Updated: Jul 2, 2020
So... we're sure you've been waiting with bated breathe to see how feeding therapy helped get Ella back on track, and her family on board with cue based/ responsive feeding. But honestly, it was not as simple as we all would have hoped. Situations like Ella's are complex, and sometimes, we don't completely "solve" the problem.
After the feeding therapist completed a thorough evaluation, it was determined that although the baby did have a prominent lingual frenulum, it was not restrictive (this is a bit of a soapbox topic for us, so we will hold back and not get into too much detail here). Was the frenulum slightly short? Yes. Was it getting in the way of tongue range of motion, strength, latch, or swallow function? The answer to this was a resounding NO. Overall, the baby's oral motor skills were appropriate to support bottle feeding and swallowing was not the problem. The only objective data collected was early shut-down response during feeding.
Falling asleep vs “shutdown”
For therapists who are new to baby feeding, there is a distinct difference between falling asleep due to fatigue and shutting down (neurologic response). In Ella's case, she demonstrated classic shut down--after about 10 minutes of guarded feeding, she would stop sucking. But once she was placed back in the crib, she would wake, cry, root, and show feeding cues. Her body was still hungry, but so stressed by the feeding experience that she neurologically shut off. Amazing to see that it only took ONE WEEK for baby Ella to learn this adaptive behavior.
So in chasing one of the why's we had an answer: Ella's poor feeding/intake was initially due, most likely, to being immature at birth, which impacted her ability to stay awake long enough to complete feeds. Then you add in the stress of being separated from mom, who is essential in those first days for co-regulation (the ability of the parent to help a baby achieve a just-right state of regulation) and then last there is dad—who was doing what he had been told in terms of walking and pushing Ella to eat, but who was having trouble getting Ella regulate because he himself was anxious and stressed. Her immaturity + losing mom as a co-regulating force + putting it all on dad who was also stressed and disregulated AND who had been given instruction to make sure baby stayed awake and ate, caused a perfect storm which appears to have led to force feeding over a period of about a week, which baby Ella responded to by going into neurologic shut down after a short period of bottle feeding to protect herself. It’s worth noting that force feeding often sounds very harsh- like the parent isn’t connected or loving. But this dad was extremely loving- he was just also extremely worried about Ella doing well and gaining weight, which led to him missing her communication and pushing her a bit too hard to eat.
Feeding therapy plan
THIS, we could work with. Luckily the baby had an NG tube which alleviated some of the pressure to keep her awake and eating past the point where she couldn’t. She also had trained nurses feeding her most of the day, who were not anxious when Ella didn’t eat, who were instructed to ONLY feed if Ella was actively showing feeding cues, and who we’re taught to carefully respect all “shut down“ cues. We transitioned Ella to a slower flow nipple so she was less overwhelmed, fed her swaddled, with her hands midline, in sidelying, and let her run the show. It took a few days, but her volumes slowly increased.
It’s worth noting that force feeding often sounds very harsh- like the parent isn’t connected or loving. But this dad was extremely loving- he was just also extremely worried about Ella doing well and gaining weight, which led to him missing her communication and pushing her a bit too hard to eat.
BUT the bigger “why” to chase was how did this come to occur in the first place? We suspected, as noted above, Ella was neurologically immature and waking for feeds was challenging. So what could the pediatrician have shared with the family that would have respected cues, helped her build neurologic maturity, while also ensuring weight gain and growth in the critical first week of life?
What pediatricians should recommend to support eating for drowsy newborns without encouraging force feeding:
Skin to skin, ALL THE TIME: Research supports that skin to skin contact (doesn't have to be with mom!) can improve state control and digestion--two of the most important necessities for waking for feeds. It also helps a caregiver start to identify feeding cues EARLY as they are literally, right in eye site. You kind of can’t help but get in sync with a baby that you’re holding super frequently on your chest. Ok so maybe “all the time” isn’t feasible. But parents need to be coached that skin-to-skin holding and learning feeding cues should take priority over many other activities in those first few weeks while feeding is getting established, especially when feeding isn’t going all that well.
If not breastfeeding, use a relatively slow nipple to respect baby's need to learn to coordinate suck-swallow-breathe. We love the Dr. Brown Preemie because they are consistent, but there are many slow flows on the market.
Use paced-bottle feeding. The lactation community LOVES this concept, but it is not talked about enough in the pediatrics and therapy world. There are tons of you tube videos (like this one here. Or just search YouTube to check out many others), but the main idea is to mimic the ebb and flow of breastmilk by providing tons of breaks for baby to rest and regulate.
One big thing we do change in regards to paced feeding though is using a sidelying position, a nice swaddle with hands at midline and chin tucked (in the video link above the babies are positioned into a semi-upright position and in at least one of the examples the baby has arms swaddled down at his sides). Sidelying position also facilitates neurodevelopmental organization and decreases the baby's energy expenditure. See the picture above for an example or check out this video of Kary explaining & demo’ing (w a doll) how to use a sidelying positioning to pace a baby.
Last, help a baby like Ella wake every 1.5-2 hours to feed by unswaddling her, removing any socks or gloves and either placing her on her back on a flat surface or gently start shifting her position on your chest to be more upright and a little less cozy. The key word here is GENTLY.
These 5 strategies, used consistently should be enough to wake even very drowsy babies and keep them on track. If this fails, this is a giant red flag that baby might be jaundiced or so immature that she needs some extra help. Talk to the pediatrician about going the NG route. Yes we know that an NG tube seems scary. But in our experience it is far superior to teaching a family to force the baby to feed (which seems to be the preferred choice of many medical professionals). We have NEVER seen force feeding go well. Sometimes it works in the short term but it ALWAYS ends up causing more harm in the long run. For example, even if the baby can eek along in the early days through force feeding, once the reflexive suck reflex integrates around 4 months, we see these older babies admitted to the hospital or referred to feeding specialists (us) for failure to thrive, bottle refusal, and poor weight gain, which is twice as challenging to solve at that point.
So baby Ella went home taking about 2 ounces a feed, gaining weight, and sleeping well. She responded well to a mix of NG support AND practice with paced, slower, cue-based feeding. a obviously though, Ella wasn’t going home with the nursing staff- so we needed to help change dad’s approach. How did we change dad's ways? Stay tuned... as we delve into how motivational interviewing comes into play with behavior change around feeding!