Feeding your premature baby-Getting started with oral feeding- Positioning for feeding

There are a few ways that we can influence how successful our baby is likely to be when orally feeding.  It is important to note that we cannot make a baby feed successfully.  Only your baby can tell us when the right time for them will be.  What we can do, is:

  • Introduce feeds at the right time for your baby
  • Only fed your baby when they are showing the right cues for this feed
  • Make the task of feeding easier in subtle ways that will make learning to feed a little bit less effortful.

One of the things we can do is by varying our feeding position.  I am going to talk here about one of the main positions that we recommend for helping establish oral feeds, but it is important that you take your own baby into account, because each baby is different.  Even if you do not end up using this position, you can adapt the principles to support your baby.

The position we are going to talk about is elevated sidelying.  This is technically more of a bottle-feeding position, but it is similar to breastfeeding positions, albeit the baby lies in a different orientation to your body.

What does it look like?

In elevated sidelying, you will usually need a pillow for your legs, and a footstool.  It is very important that you are comfortable,as well as the baby!

      • Sit yourself comfortably, with your feet up on the footstool.  Put the pillow on top of your things.
      • The baby lies away from you on its side, along your legs, with its head towards your knees, and its bottom against your body.
      • You hold the bottle to the baby’s mouth with one hand, and use the other hand and arm to support the baby along their back.


Why is elevated side lying a good position?

  1. It gives babies as much support in their body as we can

When we feed orally, it is easy just to focus on the baby’s mouth and what is happening there.  However, your baby’s skills in their mouth are very closely related to what is happening in the rest of their body.  If we hold babies in ways that make them work hard to maintain their body position, then they have less ability and energy to concentrate on what is going on in their mouths.

Term babies have fat pads in their cheeks that help them to stabilise around a bottle or breast nipple.  Premature babies do not have these, and so their mouths are also more ‘wobbly’ and this will make generating suction more difficult.

Elevated sidelying means that the baby is getting a lot of support from your lap and the cushion.  The hand you have at their back is also offering support in ways that will allow you to respond as they need to move and adjust.

2. The position is best to help your baby’s breathing and heart rate. 

Compared to other positions, research indicates that this position maintains your baby’s oxygen levels more successfully and was associated with less variation in heart rate.  This is likely to reduce their chances of becoming stressed during feeding.

3. Keeps them as safe as possible

If your baby gets more milk than they can handle from the bottle, then it is likely to run away out of their mouth to the side.  This might not appear to be a good thing, but when we feed in a reclined position, gravity will tend to take the milk to the back of the mouth.  If your baby cannot cope with the volume, reclined feeding is more likely to make them feel overwhelmed, to be aspirated and to result in stress cues.

When milk comes out of the side of the mouth, it gives us important information about how well a baby is coping, and we are not increasing their risk.

4. Lets you see the baby

You should always do elevated sidelying in a way that let you see your baby’s face.  This is important for observing their cues.  The hand behind them also lets you get feedback from what you can feel.

Don’t be afraid to talk about different feeding positions, for breast or bottle feeding, with nursing staff, and/or your Physiotherapist or Speech and Language Therapist.

Posts from Find the Key Speech Therapy are intended for information.  They are not intended to, and cannot take the place of advice from an appropriately qualified Speech and Language Therapist who knows your child.  Find the Key Speech Therapy does not take responsibility for the use of any advice without appropriate professional guidance. 



Feeding your premature baby: Breastmilk as medicine

I am deviating slightly from my planned post as I was on a course this week to brush up my knowledge and skills around breastfeeding.  I am pleased to say that more and more of the premature babies are coming to me and still breastfeeding, or trying to.  In the past it was more usually the case that I would find when taking the background to a case, that breastfeeding had been started and then stopped before a baby reached me, often on medical acvice.  This is less often the case now.  I think that this is partly owing to Speech and Language referrals being made earlier in the service I work in (hooray!), and partly because of an increasing understanding of the amazing potential of breastmilk as medicine for our tiniest babies.

This is by no way to implythat breastmiilk is the only way forward.  As someone who works with babies and children with massive feeding challenges, I have long since subscribed to the ‘fed is best’ philosophy.  Guilt over feeding is something I would gladly see an end to.  But it is a real pleasure to be able to help Mothers who want to to be able to keep breastfeeding.

In addition, in the very vulnerable premature baby population, breastmilk really does have some pretty amazing properites, in comparison to even the most specialist preterm formulas (and thank goodness we have those).

So, with thanks to Ali White, Infant Feeding Advisor,  of  ‘Heart of England NHS Trust’, an acronym of the ‘BIG’ benefits of breastmilk over formula for premature babies:

  • Brain
    • Improved cognitive development
  • Immunity and anti-inflammatory
    • Reduced risk of inflammmatory conditions ( such as Retinopathy of prematurity), and of all types of infections
  • Gut
    • Reduced risk of NEC (Necrotising enterocolitis), a very nasty disease of the bowel that can kill premature babies
    • More easily digested than formula
    • Promotes growth of the gut lining
    • Supports the development of friendly bacteria, specific to the environment that Mum and baby find themselves in

Breastmilk really is superior to even the best formulas on the marker, and every drop a Mum can provide for her baby is very precious.  It can be difficut to maintain breastfeeding in the difficult circumstances of a special care environment, when it can be so far away from the ideal situation to promote breastfeeding.   Even if you do not want to, or can’t produce very much breastmilk, the first colustrum from your breasts is an amazing immune system support for your baby.  Ask your unit staff for advice on maintaining milk production and supporting breastfeeding, if you want to provide this excellent medicine for your baby. Even if it is not your intention to breastfeed long-term, it is something really positive you can do for your baby in the early stages.  Depending on your staff’s experiences, they may be more or less confident about giving you advice.  Ask to see your unit’s breastfeeding advisor, if they have one.

Posts from Find the Key Speech Therapy are intended for information.  They are not intended to, and cannot take the place of advice from an appropriately qualified Speech and Language therapist who knows your child.  Find the Key Speech Therapy does not take responsibility for the use of any advice without appropriate professional guidance. 


Feeding your premature baby: Getting Started with Oral Feeding- Stress Cues

When a baby is learning how to feed, it is important not only that we respect their feeding cues, but also that we understand when they are telling us that they need a break.

Feeding is a complex set of skills that require a high level of coordination.  If our babies are finding learning to co-ordinate difficult, or finding it tiring, then they will experience feeding as stressful.  Stressful feeding experiences are more likely to lead to aspiration (milk going down into babies’ airway and/or lungs), and to lay the groundwork for feeding tube dependency or feeding aversions.  These difficulties can be difficult to remediate, and are often easily avoided if we ‘read the feed’ well.

So what can we look out for when feeding our babies at this stage?

Firstly, it is a good idea to observe your baby before each feed.  You need to get a feel for what your baby looks like before the feed, because looking for some signs, such as colour changes, will be relative to whatever they looked like when they started.

Look at your baby’s colour, and general happiness being handled and alertness before you start.  This should all be taken into account, alongside their feeding cues.  If your baby appears sleepy or irritable before a feed, it might be that an oral feed is not the best idea.

Specific things to look out for:

  • Becoming irritable whilst feeding
  • Grimacing or signs of stress in the face. This can be quite subtle in a small baby, just a forehead wrinkle or similar.
  • Crying whilst feeding
  • Colour changes when feeding- this might be going pale, or getting red in the face. This can eb quite subtle
  • Desaturations which may set off the machine monitoring your baby.
  • Appearing to be tiring
  • Splaying out fingers or arching their body (this is a ‘startle’ response)
  • Hiccups


Desaturations on the monitor are a late sign.  If you are watching your baby carefully, you will usually see the signs of stress before the monitor picks them up, so watch your baby more carefully than the monitor.

A baby who is regularly setting off the monitors whilst feeding may well require a Speech and Language Therapy assessment.

Signs of stress during a feed may indicate that a baby is struggling to co-ordinate all their feeding skills, or that milk is ‘going down the wrong way’ (being aspirated).  These are signs that a baby need a bit more help from you, and you will find some ideas on how to help coming up in future posts.

However, signs of stress during a feed may not necessarily suggest that it is the feeding that is not going well.  Many babies have the basic idea of feeding, but may not be able to co-ordinate at the beginning of a feed when really hungry or may tire over a feed.  In addition, oral feeding may trigger reflux, or make them fill their nappy.  They may have taken in some excess air that they need to bring up.  They may not be able to coordinate all these things as well as their emerging feeding skills.  With time and maturity, these things will improve, and it is our job to make sure that the baby gets enough practise, but is not overwhelmed by the task of oral feeding.

It is important to respect a child’s stress cues by giving them a break from feeding, or even by stopping the feed and completing it with a tube feed.  Whatever the underlying cause of the stress cue, if we continue to feed then we are likely to be teaching them that feeding is unpleasant, and that we don’t listen when they communicate.

Posts from Find the Key Speech Therapy are intended for information.  They are not intended to, and cannot take the place of advice from an appropriately qualified Speech and Language therapist who knows your child.  Find the Key Speech Therapy does not take responsibility for the use of any advice without appropriate professional guidance.