High Suck/Swallow Ratio
- > 2 sucks/swallow
- inefficient, feed > 30 min. and get fatigued
- risk for aspiration because spillage
- weak suck = less than normal bolus size
Modifications:
- change to faster flow
- resistive sucking to make suck stronger (slight pull on bottle while ground self on baby)
- cheek support (for weak suck)
Prolonged Sucking/Feeding-Induced Apnea
- long suck/swallow bursts w/o stopping to breathe
- “difficulty pacing” sucking and swallowing w/ breathing
- more @ beg. of feeding
- primary causes: immaturity (not ready for PO), respiratory
Modifications:
- pacing (stop after 5 sucks/5 seconds)
- decrease flow rate of nipple
External Pacing
- forcing into immature sucking pattern
1) tip bottle down
2) roll over to gum line (breaks neuro pattern)
3) remove bottle
Short Sucking Bursts
-
Disorganized Sucking
- uneven and disorganized burst/pause pattern and S:S:B pattern
- coughing and choking frequently
- *high risk for aspiration b/c of oral discoordination
- possible causes: general neurologic deficits, mild respiratory problems, incompatible nipple flow rate
Modifications:
- external pacing
- decrease flow rate of nipple
- sidelying position
- swaddle, provide borders
- modify external stimulation
- provide rhythmic rocking
Anterior loss of liquid during sucking
- consider a slower flowing nipple
- cheek support
Poor State Regulation
- modify external environment
- swaddle, provide borders
- positioning
- NNS
- rhythmical movement
S/S of Aspiration & Referral for MBSS
- coughing/choking (rarely in infants under 1 month)
- wet breath sounds
- “crackles” during exhalation
- throat clearing
- stressful facial expression
- pulling back of head & arching into extension, but infant may still stay latched & be sucking
- pulling off nipple, w/ possible head turning or crying/fussing
- color changes around lips or face
- rapid breathing (tachypnea)
- decreased O2 saturation
- frequent sneezing
- constant low grade fevers
- URI/pneumonia
- red flag: frequent need for nebulizer or other pulmonary treatments
Rooting Reflex
elicited: when oral area is touched, turn head in direction of touch and vigorously open mouth
purpose: allows infant to locate source of food
integrated: by 3-4 months
Sucking Reflex
elicited: light touch to lips or tongue from nipple or finger initiates sucking response
purpose: insures infant will obtain nourishment
integrated: by 3-6 months *an infant younger than 3-4 months w/ strong sucking reflex cannot always cease sucking on nipple when overwhelmed
Gag Reflex
elicited: infants- mid-tongue area; older baby/adult- posterior tongue or pharyngeal wall area
purpose: to protect the person from ingesting items that are too large for the digestive tract or protect the airway from blockage *if not present in infants, doesn’t necessarily mean shouldn’t suck liquids
integrated: present through adulthood
Tongue Thrust Reflex
elicited: when contact made to infant’s tongue or intraoral cavity
purpose: protective response that prevents anything other than nipple in infant’s mouth
integrated: by 4-6 months
Transverse Tongue Reflex
elicited: by touching/stroking the lateral borders of the tongue, causes tongue to lateralize to direction of touch, should be equal bilaterally
purpose: aids in development of lateral tongue movement during eating of solids
integrated: under volitional control by 6-8 months
Phasic Bite Reflex
elicited: rapid, rhythmical up and down movement of the jaw for a bite-and-release pattern (no lateral movement)
purpose: aids in development of chewing
integrate: by 7-8 months (to a more mature biting pattern)
Neurodevelopment Progression of Sucking Response
- 15-18 wks: sucking seen in utero
- 28 wks: sucking seen in extrauterine environment (disorganized & random w/ no coordination of breathing)
- 32 wks: beginning to see S:S:B coordination (inconsistent & random)
- 34-35 wks: established coordinated sucking & breathing pattern
- intro of oral feedings typically by 32-34 wks.
Components of Sucking
- suction (- pressure)= jaw/tongue depresses, creating negative space which draws milk out of nipple
- compression (+ pressure)= tongue pushes against nipple; increased compression on breast vs. bottle
- burst= S:S:B (1-2:1:1)
- pause= still latched, just breathing
Mature Sucking Pattern (NS) - Normal
- 10-30 sucking cycles per burst
- continuous sucking burst
- S:S:B (1-2:1:1)
- “catch up” breaths during pause period
Immature Sucking Pattern (NS) - Normal
- 3-5 suck:swallows/burst
- respirations only during pause periods (equal duration as suck/swallow burst)
- *normal sucking pattern for pre-term infants
NNS - Normal
- purpose=state regulation, satisfy sucking desire, exploration
- rhythm= repetitive pattern of equal bursts & pauses
- *rate= 2x as fast as NS (2 sucks/second)
- suck: swallow = 6-8:1
- NOTE: can use NNS as therapy tool
*sign baby is neurologically intact: sucking rate change from NNS to NS
Guidelines for PO Readiness
•32-34 weeks GA
•gaining weight w/ tube feeding
•
Differences in Anatomy
- sucking pads (cheeks)
- larger tongue (relative to oral cavity)
- smaller jaw (relative to oral cavity)
- velum & epiglottis touching til ~ 6 mos. (nose breathers, valve for airway protection)
- epiglottis shorter, narrower, softer, 45’ angle/horizontal (nose breathers, valve for airway protection)
- larger head (compared to body)
- weak head & neck muscles
- larynx & hyoid bone more anterior & higher (airway protection, little laryngeal elevation to swallow)
- swallow reflex at valleculae (precise timing & speed of swallow-shorter pharynx, swallow triggered @ lower level)
