Common Concerns With Infant Feeding and Swallowing: A Q&A With Robin Glass, MS, OTR, IBCLC

Robin Glass is an occupational therapist and lactation consultant at Seattle Children’s with over 40 years of experience. She also holds a clinical faculty appointment in the Occupational Therapy Program at the Department of Rehabilitation Medicine at the University of Washington. In addition to her patient care on the Infant Team serving inpatient and outpatient infants <1 year old, she is a national and international speaker on infant feeding and swallowing. She has numerous publications, including the seminal book Feeding and Swallowing Disorders in Infancy: Assessment and Management with co-author Lynn Wolf. She was a 2015 recipient of the National Association of Neonatal Therapists Pioneer award and received the 2018 Dr. Nancy Danoff Spirit of Service award from the Breastfeeding Coalition of Washington and Nutrition First.

Primary care providers (PCPs) frequently encounter questions from parents regarding their infants’ feeding. PCPs also observe issues with growth that may result from feeding difficulties. In a brief office visit, providers may find it challenging to identify infant feeding and swallowing disorders. In this article, Seattle Children’s occupational therapist and lactation consultant Robin Glass addresses common concerns PCPs might see related to infant feeding and swallowing difficulties and describes methods of evaluation and treatment. She also offers guidance on referring to a Seattle Children’s specialist.

Q: What is an infant feeding and swallowing disorder?

In 2019, Goday and others published a conceptual framework for pediatric feeding disorders (PFDs) due to a lack of universally accepted definition. PFDs are defined as impaired oral intake that is not age appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. This disorder can be acute, that is less than 3 months duration, or chronic, that is longer than 3 months duration. A new ICD-10 code “pediatric feeding disorder” was developed. This framework highlights the complex and multifactorial nature of feeding/swallowing for all ages but especially for infants.

Q: How do I identify whether the infant is having feeding and swallowing difficulty?

The first important consideration is the way you question the parent about their infant’s feeding. Typically, when asked “how is feeding going?’ parents will immediately reply “fine.” A better approach would be to ask “is feeding going the way you expected?” This would be a novel question, causing the parent to think for a moment and a more realistic answer may be given. As a provider, you can then follow up with more questions about what is not going as expected. This will be a more efficient way of identifying feeding problems. Parents should be reasonably confident identifying when their baby is hungry and satiated. There should be minimal coughing/sputtering while feeding. Feedings should be mostly pleasant for parent and baby. If parents express frustration, feel stressed or are physically and emotionally exhausted by feeding their baby, a feeding problem exists.

Q: What about growth velocity: weight loss or excessive weight gain?

While growth parameters are important, normal anthropometrics do not mean there are no feeding/swallowing difficulties. Infants can have severe feeding/swallowing disorders and continue to have normal growth. If the parents are reporting any difficulties with the process of feeding, a feeding problem exists and referrals for evaluation and treatment are indicated. Parents may be doing everything in their power to maintain their baby’s growth including round the clock feedings, sleep/dream feedings or force feeding. Overfeeding resulting in spitting/vomiting or excessive weight gain, may indicate a parent who has no other strategies for comforting their baby except for feeding or a parent who is overly concerned about intake or weight gain. In terms of whether a feeding problem exists, adequate weight gain is one of the least important symptoms. Watchful waiting as the infant struggles with slow or suboptimal weight gain can result in a deterioration of the feeding interactions, causing secondary feeding problems and undue delays in referrals. Understanding the functional feeding and swallowing issues and feeding interactions should be your focus irrespective of the growth velocity.

Certainly, growth velocity is important particularly if the baby is beginning to show growth faltering. PCPs may encourage the parent to feed the baby more frequently or offer more volume per breast or bottle feeding. On the surface, this is a reasonable recommendation. Close follow-up of this family will be needed, however, to ensure this seemingly logical suggestion does not raise parental anxiety to a level that pushing the baby to feed occurs. In some cases, this seemingly mild suggestion can be the inciting factor for the development of feeding refusal/aversion (this will be discussed in a separate section).

Q: Where do I start with referrals for a baby with feeding/swallowing difficulties?

A clinical feeding evaluation is the best place to start the workup of an infant with suspected feeding/swallowing difficulties. At Seattle Children’s the Infant Team provides comprehensive evaluation and treatment of these infants on an outpatient and inpatient basis. The Infant Team is composed of occupational, physical and speech therapists with specialized expertise in infant feeding/swallowing disorders. Several of these therapists are also certified lactation consultants (IBCLC). A comprehensive feeding/swallowing evaluation will look at the infant’s oral control, oral-facial anatomy, swallowing integrity and safety, respiratory and cardiac support for feeding and behavioral/interactive components of feeding.

In the office visit you may identify issues that you think are related to swallowing dysfunction. Referral for an instrumental swallowing evaluation — either a videofluoroscopic swallowing study (VFSS) or FEES — however, is not the appropriate first step. A clinical feeding/swallowing evaluation will be able to more clearly identify the nature of the feeding problem and whether an instrumental swallowing assessment is needed. When a referral on an infant <12 months comes into Seattle Children’s, it may typically be triaged to begin with a clinical exam. Having a clinical feeding/swallowing evaluation first improves the yield from any instrumental exam to follow. In the clinical evaluation the exact nature and timing of the swallowing difficulty can be identified so the instrumental exam is streamlined. Often swallowing treatments can be implemented from the clinical exam as a short-term solution, with efficacy confirmed later by instrumental exam as needed. Wait times for a VFSS can be lengthy, and this can delay diagnosis or unintentionally reinforce ineffective or detrimental interventions while waiting for the VFSS. Additionally, from the clinical evaluation it often becomes apparent that the feeding problem is actually unrelated to swallowing, and treatment of those other issues can begin.

Some infants may also be referred to other specialists such as Pulmonary, GI, or Otolaryngology. Having a clinical feeding/swallowing evaluation towards the beginning of the workup may provide valuable data to those specialists.

Q: What happens during a videofluoroscopic swallowing study?

The VFSS provides further information regarding the infant’s swallowing integrity by providing a real-time view of swallowing function under x-ray. The baby will ingest barium contrast by bottle, cup or spoon or a cookie mixed with barium. Breastfed babies will need to be bottle fed for a VFSS with extrapolation of results to breastfeeding. For both the breast-fed and bottle-fed baby, therefore, the clinical feeding/swallowing evaluation will provide data on whether the feeding/swallowing performance on the VFSS was a reasonable representation of typical function.

During the VFSS, observations are made about swallow integrity, including the presence and timing of aspiration as well as the effects of fatigue on the stability of swallowing performance. An important component of the VFSS is exploring treatment methods should swallowing dysfunction be observed. These treatments can include changes in feeding position, changes in temperature such as chilled liquids or alterations in consistency of foods or liquids. Thickening liquids is a common treatment strategy to treat aspiration during the swallow. Commercially available thickeners are used. If thickened feedings are indicated, the feeding therapist will contact you for approval. As a PCP you will be aware of any gastrointestinal vulnerabilities that would preclude using thickeners.

If your patient is referred for a VFSS, it would be helpful to preapprove the use of thickeners if medically safe should they be recommended as a swallowing treatment after the VFSS. Rice cereal is no longer used for thickening. Cereal results in uneven liquid flow, adds unnecessary calories and carbohydrate load, cannot thicken breast milk and has been linked to arsenic exposure.

Q: What can I do in the office for parents’ common feeding concerns?

Bottle feeding issues: With the tremendous number of bottle/nipples available and manufacturers all claiming theirs is the best — “most like the breast,” “anticolic” — it is no wonder that parents are confused. Most bottle/nipple manufacturers have varying nipple speeds, and parents may be unsure about where to start or when to advance. While having a range of flow rates available is important for babies, there is no standardization between manufacturers on nipple flow rates. The “#1 or slow” nipple in one product line can be extremely fast when compared to a different product line. It is hard for the average consumer to get information to assist in making a reasonable decision.

The best nipple/bottle for a baby is one that matches the infant’s sucking mechanics, supports an infant’s suck/swallow/breathe coordination and allows for efficient feeding. To help parents, observe a sample of bottle feeding. Within the first year, a normal sucking rate is one to three sucks per one swallow. If the baby has more than four sucks per swallow, the nipple may be too slow for the baby and/or the baby has oral motor control issues such as decreased strength of suck. A baby with decreased sucking strength might benefit from a slightly faster-flow nipple; however, there is the risk that this increase in nipple speed will result in problems coordinating sucking, swallowing and breathing.

The nipple flow rate should allow the baby to smoothly intersperse breaths within the suck/swallow cycle. The breaths should be big enough so the baby does not become breathless while drinking or become tachypneic during the sucking pauses. If the parent reports concerns of coughing/choking while bottle feeding, check that the parent is not using too fast flow a nipple or they have advanced nipple speeds prematurely.

It is very common for PCPs to hear the complaint of coughing/choking during feeding that is actually due to excessively fast-flow nipples.

Parents may choose a faster-flow nipple when they have concerns about their baby’s intake and slow weight gain. Or, they may observe the baby falling asleep when feeding. Increasing nipple flow rate, however, can frequently be counterproductive. The higher flow rate may be a stressor for the baby, threatening or overwhelming their swallowing and breathing. Babies are able to decrease their strength of suck to help manage the high flow and/or may begin to refuse to feed. If the parent has difficulty finding the appropriate bottle/nipple, a feeding evaluation would be useful to identify oral motor and swallowing issues that may be affecting bottle/nipple selection.

Information about current bottle/nipple systems and their relative flow rates can be found at Pados, B.F., Park, J., and Dodrill, P. 2019. Know the Flow: Milk Flow Rates From Bottle Nipples Used in the Hospital and After Discharge. Adv Neonatal Care 19, 32-41.

Another issue related to bottle feeding is the breast-fed baby who refuses to take a bottle when the parent is going back to work. Sadly, there is no “magic” bottle that will guarantee a smooth transition, and many babies are tenacious about preferring the breast. That said, it is worth trying various nipple shapes, as one may be appealing to the baby. When breastfeeding is well established, beginning after 6 to 8 weeks of life, the family can offer one bottle several days per week to establish a bottle habit. Even starting bottles ahead of return to work, however, may not ensure the baby will continue to take a bottle. Having a second adult if available, who is not the breastfeeding parent, may help the baby accept a bottle. Sometimes, having the breastfeeding parent out of the room can improve a baby’s acceptance of a bottle. If the baby continues to refuse, the PCP can problem-solve with the family. Knowing the number of hours the baby will be in childcare and exploring other alternatives to offering liquids by bottle may be a short-term solution. For example, a baby may be able to take breast milk from a cup or spoon. The infant may be able to eat table or baby foods until they can nurse again. Some babies will reverse-cycle and awaken more at night to feed. Despite parent fears, many babies and childcare providers can work this situation out when given time.

Breastfeeding difficulties: Common concerns regarding breastfeeding difficulties relate to persistent nipple pain, difficulty latching to the breast, long breastfeeding sessions or the baby who falls asleep at the breast. Similar to other feeding/swallowing issues, a comprehensive assessment will identify the root of the problem. The ideal situation is to have a lactation support person in your office to see parents with breastfeeding issues or to refer to a community or hospital-based lactation consultant for this assessment.

If you have time within the visit to observe a breastfeeding, you may be able to offer some basic advice. When observing a breastfeeding, the baby should be well supported during attachment to the breast with head, shoulders and hips aligned. If there are problems with latch, compressing and shaping the breast so that the jaw and tongue slide more easily underneath the breast may be helpful. During attachment, the baby’s head should be tipped slightly backwards and leading with the baby’s chin. It is more important that the lower lip should be flanged outwards, although for an optimal latch, both lips should flange.

Observe the baby’s level of engagement in feeding. A baby who appears hungry then immediately falls asleep at the breast is communicating the breast is not providing adequate milk flow. That baby is tuning out and cuddling. Babies should be active feeders at the breast for most of the feeding. There should be a clear differentiation between eating and comfort nursing. The latter is itself an important activity; however, in the context of feeding difficulties the baby will need to be fully fed first. The baby who becomes fussy before latching or is consistently unsettled at the breast is also communicating that the breast is not satisfying their needs. More detailed assessment of breastfeeding and the adequacy of the milk supply is warranted.

Nipple pain and latch problems share similar underlying etiologies. A baby may have a shallow latch secondary to inadequate mouth opening during rooting, or inadequate suction strength to pull the nipple/areola deeply enough into the mouth. Looking at the shape of the nipple when the baby comes off the breast gives clues about the quality of the latch. If the nipple is compressed or has a ridge across the nipple or is shaped like a lipstick, the baby has an improper latch. The baby may be using a predominantly compressive sucking pattern, creating nipple pain and trauma. While this can be secondary to oral motor difficulties, a more common issue is a tongue tie (ankyloglossia/tethered oral tissue). The diagnosis of a tongue tie is not solely based on visual inspection of the frenulum. Rather, it involves identifying both the structural limitations and, most importantly, combined with the presence of functional feeding difficulties. Skill is required to make this diagnosis. Release of tethered tissue is only one part in the rehabilitation of breastfeeding difficulties. Most often, the dyad requires treatment from a lactation consultant and/or feeding therapist in order to change motor patterns and use the new tongue range of motion the infant achieves. Most providers who perform frenotomies require a breastfeeding dyad to be involved with lactation providers before and after release. Practitioners who perform frenotomies as a major part of their practice will be best at identifying both the need for frenotomy and performing a complete release of all tethered tissue. Practitioners who only occasionally perform frenotomies or who don’t routinely collaborate with lactation consultants and/or feeding therapists may not provide optimal care for your patients.

For more information see the Academy of Breastfeeding Medicine position statement on ankyloglossia.

Noisy breathing and stridor: To understand the correct starting point when parents report these concerns, the PCP should differentiate between whether the baby is showing stridor or upper airway congestion. Stridor is a high-pitched sound heard as the baby breathes. It is most typically heard on inhalation, although biphasic stridor can sometimes be observed. A baby with upper airway congestion may sound like they are breathing through mucus in their throat or have a chronically stuffy nose. Sometimes, babies will have clear breath sounds at baseline, but develop congestion during and/or after a feeding. This observation would be suspicious for swallowing difficulties, although it can also be observed during a silent gastroesophageal reflux (GER) episode.

If stridor is observed, the age of the baby and effects on feeding should be considered. With idiopathic or congenital laryngomalacia, stridor will worsen from birth through the first 6 to 8 weeks of life and improve typically over the next 6 to 8 months of life. Less common in the healthy term infant is stridor secondary to vocal cord dysfunction. The PCP should observe whether the baby is able to coordinate sucking, swallowing and breathing when feeding with stridor on either the breast or bottle. For bottle feeding, a slower-flow nipple, external pacing and/or feeding in side-lying may improve coordination. For breastfeeding, using a laid-back nursing position may be helpful to assist with flow control. Removing the baby from the breast during a brisk or forceful let-down may improve coordination. Beginning nursing on the “lower-flow” breast could also be helpful. Identifying whether there is oversupply of breast milk and offering strategies to carefully lower supply can also be helpful. It is crucial, however, to differentiate between oversupply and/or fast let-down versus a baby who has primary incoordination of sucking, swallowing and breathing and is not able to tolerate even an appropriate flow rate.

If simple feeding strategies are not effective for the baby with stridor, two types of referrals are indicated: one for a clinical feeding/swallowing evaluation to deal with the feeding issues and another to Otolaryngology for diagnosis of the underlying condition. While additional referrals to specialists might also be indicated, the PCP should approach these feeding issues in a step-wise fashion to avoid overmedicalizing the infant and avoid costly, family-stress-provoking and difficult-to-coordinate care.

If a baby is showing upper airway congestion either all the time or increasing with feeding, further clinical feeding/swallowing evaluation is indicated. The waxing and waning congestion may be a sign of swallowing dysfunction with pharyngeal penetration, silent microaspiration during the swallow or nasopharyngeal reflux during swallow. Following a clinical feeding/swallowing evaluation, a baby with these symptoms may likely need a VFSS. Making both referrals at the same time will be helpful, although the clinical evaluation will occur first. Upper airway congestion midway between feedings could also be a sign of GER. The clinical feeding/swallowing evaluation will help direct the flow of further workup, although simultaneous referrals to other specialists such as Gastroenterology for gastrointestinal issues, Pulmonary for breathing issues, or Otolaryngology for structural airway issues can be made.

Feeding reluctance/refusal/aversion: Parents often bring concerns regarding their baby’s unwillingness to feed, whether by bottle or breast. They describe the baby will arch, cry or keep their mouth closed when the parent tries to initiate feeding. Parents may also describe the baby gives mixed hunger signals or no hunger cues at all. The parent may begin to offer a feeding, the baby may at first begin to feed then quickly actively or passively stop feeding. Parents may also describe the only time the baby will feed well is when they are very drowsy or asleep. The situation can deteriorate to the point where the baby will no longer feed when awake, and the parent spends the day trying to put the baby to sleep or awaken them slightly for a feeding.

These are symptoms of feeding reluctance/refusal or feeding aversion. These babies are demonstrating what is described as conflicted feeding behaviors. There is a misalignment of the balance for autonomy and control within the feeding relationship. For babies, refusal to feed is a learned, acquired response to being pressured or pushed to feed. Parents may not be actively force feeding their baby, but they override the baby’s communication or cues and continue to try to feed the baby when the baby is saying, no. Thus, the parent is putting pressure on the baby even when it is subtle. Babies who feel stress and pressure to feed can develop conflicted feeding behavior. Many of these babies will act hungry but refuse to feed either actively or passively. Conflicted feeding behaviors typically will develop around 6 weeks of life or slightly later. At that age, the baby is developing memory for objects and their function and can make associations between an object (breast or bottle) and how they felt the last time they interacted with that object. At about 6 weeks, the baby is learning their behavior can control others’ behavior through an interactive social smile. These two cognitive concepts — memory of object functions and controlling external behavior — make it possible for the baby to perceive pressure and to communicate their feelings about feeding.

The predominant etiology of feeding refusal is an imbalance and disruption of the locus of control for feeding away from the baby and assumed by the parent. Frequently, there is an inciting factor; however, the feeding problem is only observed once the feeding behaviors begin. For example, the baby might be gaining weight slowly and concern is raised over weight gain. A baby may have a negative event while feeding such as a choking event, GER or excessive flow rate from breast or bottle. Former premature infants are especially vulnerable for the development of feeding refusal/reluctance from being pushed to discontinue nasogastric (NG) tube use prior to discharge from the neonatal intensive care unit (NICU). Sometimes feeding refusal can develop from swallowing difficulties. Irrespective of whether there is an inciting factor, the feeding refusal/reluctance becomes the feeding problem, and the feeding relationship will require treatment. Even if swallowing difficulty or GER is treated, the feeding interactions will not improve unless the underlying locus of control issues are balanced. In my treatment of these cases, I emphasize to parents that in order for a baby to say yes to feeding, they also have to be able to say no to feeding. Unless the baby holds both ends of the power dynamics, the feeding relationship will not improve and the baby will refuse to eat.

Sometimes feeding reluctance/refusal can take the form of distracted feeding behavior. As a PCP, when you hear a parent report the baby is a distracted feeder, a sleep/dream feeder, eats for a short amount of time despite having access to milk or does not appear settled while feeding, there is a high probability the baby is developing feeding reluctance/refusal and there are disruptions in the feeding relationship. This baby and family should be referred for a clinical feeding/swallowing evaluation and treatment to identify the underlying components. Unfortunately, parents are increasingly using devices such as phones, tablets or TV to increase their baby’s oral intake. This can stem from parental anxiety regarding growth velocity or other issues but is an external form of pressure to eat. A baby should have an internal drive to eat, and if external methods are required, such as distraction, a feeding problem exists.

There are treatment models that can be very effective in improving feeding interactions, developing appropriate locus of feeding control and increasing intake. The treatment focuses on developing a more responsive feeding environment between the baby and parent, while giving the babies’ agency over their feeding. During this treatment program, there is no focus on daily intake goals or discussion of weight gain. As part of the feeding treatment program, parents are given clear guidelines on how and when to offer feedings and when to stop feeding attempts at the first sign of refusal. Feedings can be spaced at three- to five-hours intervals to build an intensity of hunger that allows the baby to experience self-directed hunger relief. The more intense hunger combined with responsive feeding management allows the baby to have agency over the feeding process and begin to feed. The baby can then actively start feeding as they learn their communication — yes or no — will be honored. Another component of this type of treatment is supporting and identifying parental anxiety and fears about feeding. Becoming attuned to their own fears allows the parent to more appropriately respond to their baby. This type of treatment typically involves three to four weeks of intense work, with stabilization of growth and feeding interactions occurring over the next six to eight weeks.

Making Referrals for Infant Feeding/Swallowing Evaluations at Seattle Children’s

Referring using the Access portal in EPIC or Care everywhere:

1. The order set for an infant feeding/swallowing evaluation is “Ambulatory feed/swallow evaluation and treatment all ages.”
2. If a VFSS is also desired, a second order using the same order set will be used, but check the box on the order for “VFSS.”
3. Having two separate orders improves the speed of processing and scheduling. It typically takes two to four days to triage the orders before scheduling begins.

Referring by fax:

1. Fax number: 206-985-3121
2. Fax the NARF (new appointment request form). Make sure all patient details are included: patient DOB, diagnosis, reason for referral and parent contact information. The triage and scheduling process will be delayed if the PCP needs to be recontacted to obtain all information.
3. If also wanting a VFSS, use two NARF forms — one for the clinical exam and one for the VFSS.
4. When faxing a NARF, it typically takes two to three days for processing and two to three days to triage the order and then scheduling will occur.