Transition to breast/bottle feedings: the premature infant

Premature infants present a nutritional challenge to the health care provider for a variety of reasons: reduced gastric capacity, poorly integrated intestinal motility, limited digestive capabilities, neurobehavioral immaturity and limited ability to take feedings by mouth. There is often a prolonged need for oro-gastric/nasogastric supplementation until nipple feedings can commence. Neurobehavioral organization is essential for a smooth and gradual transition to full nipple feedings. This article describes the expected progression of behavioral competencies as reflected in recognizable infant cues which can be identified by care providers to facilitate an optimal feeding interaction. The essential components of nutritive sucking, including the integration of suck-swallow-breathe, are detailed. Common problems with their warning signs and methods of prevention are described. Specific recommendations to limit hypoventilation during feedings are discussed, as well as optimal route and rate of delivery of milk. Prefeeding techniques used to arouse the infant to best performance are delineated including state modulation, correct positioning and oral motor stimulation. The second half of the article focuses on the breast-fed premature infant and includes information on maternal markers for success/failure, a detailed discussion of lactogenesis and the establishment of lactation, and specific recommendations for maintaining lactation in the absence of a suckling infant. Practical guidelines based on neurobehavioral development are provided for facilitating the transition from gavage feeding to nursing. Common concerns encountered at discharge are reviewed, including those parameters which require continued healthcare supervision.