Weaning your premature baby: When is the right time?

It can be confusing working out whether your baby is at the right age for weaning.  Should you go by corrected age, or uncorrected?  What if your baby has developmental delays, or additional medical needs?

The short answer to ‘when do I wean my baby’, is ‘when they are ready’.  In many ways, this is the same advice as for any baby.

I have seen some advice out there suggesting that premature babies should be weaned at 4 months.  I have never been able to find any evidence for this, but I imagine the reasoning is the idea that there is a sensitive period for learning the skills of dealing with solid foods, and that premature babies cannot lose time.  This means that children are most able to learn to deal with solids within a certain time frame, and likely to find it more dfficult after this.

This is true, to an extent, and we will talk about this more in future posts.  However, like so many things in a child’s development, you cannot make them ready for the next developmental stage, and we can create problems if we push too fast.  Following through on the principle of cue-based feeding that we discussed around introducing oral feeds, we can use the same principles to think about weaning.

So when is your baby developmentally ready?

Babies who are weaning are learning how to chew.  This involves skills of the jaw and tongue.  These jaw and tongue skills are fine motor skills, requiring a lot of coordination.

Your baby will not be ready to develop the fine motor skills they need in their mouth for chewing until they have an underlying amount of stability in their body.  The easiest sign to look out for is that they are starting to sit.

When they start to be able to reach for things, and move them around, in the sitting position, this is a sign that they can both sit and do something else at the same time, which is essentially what we are asking them to do with their mouth.

So as a general rule, sitting is a good indicator of weaning readiness.  This still applies, even if your child is developmentally delayed.  Until your child is sitting, they will not be able to develop their chewing skills, and so they are unlikely to be able to move beyond pureed (smooth) foods.

But…….

The other consideration here is the introduction of flavours.  In some ways, this is the more important consideration in the first instance.  Children who cannot sit are unlikely to be able to make the transition onto more complex textures BUT the period of time during which you can establish tolerance of diferent flavours is somewhat limited.  Of course, we can learn to like new flavours during our whole lifetime, but the period between about 6 months and about 18 months is really important.  After this time, many children go through a typical developmental phase of ‘fussy eating’ ( which I will write about), and it can be much harder to establish newer foods.

So, my advice ……

  • As a rule, look for sitting, and reaching whilst sitting as indicators of readiness for weaning
  • However, if your child is slow to develop these skills, then focus on the introduction of a wide range of flavours through purees.  Do not aim to progress onto more complex textures until your child has developed their gross motor skills.

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. 

 

 

 

 

Weaning your premature baby: what skills does your baby need to learn?

It can be confusing working out the best way to introduce solid foods to your premature baby.  There is a lot of advice available, from Professionals and friends and family ,but the truth is that the research isn’t yet definitive.  This means that advice can be dififcult to apply to your baby.

Over the next few posts we’re going to be breaking down weaning in a bit of detail, so you:

  • can make decisions about when to start weaning
  • can make informed choices about what approach to take to introducing solids
  • have tools for managing common difficulties
  • understand when to introduce different textures

As a Speech and Language Therapist, I am not trained to offer advice on food from a nutritional  perspective, and so I won’t be going into detail about nutrition considerations.  For general nutrition advice, please talk to your Health Visitor, or Dietitian if you have one.  I also recommend this Facebook group, https://www.facebook.com/groups/weenourish/  , led by a Canadian Dietitian called Caitlin Boudreau.

What is weaning, anyway?

Like most things in your child’s development, moving onto solid foods might seem like something that just happens, and that is simple.  But in reality, the many milestones your child accomplishes all the time are all complicated, with a series of steps and skills to conquer.

From a Speech Therapist’s perspective, weaning involves (at least) two main skills:

-Learning about different flavours (establishing a range of foods)

-Learning to chew (moving on to different textures)

Together, understanding these two areas of development will help you to make decisions about when to start weaning, and how to progress it.

Keep an eye out for upcoming posts where we will talk more about this subject, and in the meantime, you might find these older posts helpful

 

 

Feeding your premature baby: Pacing oral feeding

One of the skills that babies need to develop is their suck-swallow-breathe co-ordination.  This skill is something that develops with maturity, and not practise, which is one reason why we have to chosoe our starting point for oral feeding very carefully.

Sometimes at the beginning of oral feeding, babies need some outside help to manage the co-ordination of these skills.  This is particularly true of bottle-fed babies.  When babies exert pressure on a bottle teat, milk comes out.  At the beginning of a breastfeed, it takes time for milk to flow.  To an extent, the breast and baby adapt to each other in ways that the bottle does not.  So we need to step in and make sure that we are doing this job for the bottle-fed baby.

Sometimes, babies start to suck and cannot stop.  They suck and swallow, suck and swallow, but they don’t stop to breathe.  At some point the brain recognises this as an emergency situation and they will breathe in.  In the meantime, their oxygenation levels have dropped, and their body will repond as if to an emergency.  Monitors will go off, and all-in-all this is a very stressful experience.  In addition, if they breathe in with milk in their mouth, then they may aspirate milk (breathe milk into their lungs).

We want to avoid this situation if at all possible.  Remember, finishing the bottle at this stage is not the aim, developing skills at the appropriate rate for the baby is.

Some babies find co-ordination difficult through the whole feed, but most commonly, it is the beginning part of the feed that is the issue, where the baby is most hungry and least able to regulate the amount of flow coming from the bottle well.

External pacing is a strategy that helps us manage this situation.  It involves counting a set number of sucks (I often start with three), and then dropping the bottle teat beneath the level of the baby’s mouth.  They may keep sucking for a little while, but usually they are prompted to stop sucking and breathe.  After a few minutes of this, you can experiment with giving your baby back a little more control of the co-ordination experience.  You will probably find, as the baby gets more experience, that you are having to pace them for less and less of the feed, as they mature in this skill.

If your baby is just not stopping sucking, you can actively break their suction on the teat by rolling the teat to the side of the mouth, or even removing the bottle.  This is the least preferred option as it is likely to frustrate the baby who is probably really hungry, and they will have to organise themselves onto the teat all over again.

You can combine strategies to support your baby, for example, pacing and positioning, as discussed in a previous post.

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- 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. 

Feeding your premature baby: Ready to get going, now what? Feeding cues

In previous posts we’ve talked about ways that we can understand whether your premature baby is ready for oral feeding, and how to support them if they are not.

Now we’re going to focus on the next stage, when we start to offer your baby oral feeding opportunities.  It is important to think about this stage as a separate stage to establishing oral feeding.  This stage is for learning and practising skills.  There will not be an emphasis on them supporting their own nutrition yet, that’s what their NG or other feeding tube is for.

In the next few posts we’re going to explore ways that your baby communicates to you that they are ready for a feed, ways they tell you they need a break, and some things that will help them to get the best out of a feed.

Today’s post is about feeding cues.  These are behaviours that babies show when they are getting ready to feed.  They are one aspect of the important skill of being able to ‘read the feed’, that is, understand what our babies are telling us when feeding.

In the past, babies were woken on a set routine to be fed.  This increases their chances of having a poor feeding experience, which increases their chances of developing avoidance behaviours around feeding.  In addition, a tired baby is unlikely to be at their best when trying to co-ordinate their suck-swallow-breathe cycle, which puts them at increased risk for aspiration (milk entering the airway and lungs), which can lead to infection.

dontwakethebaby

One of the jobs of babies is to sleep, especially premature babies whose brains and bodies have not finished developing.  Waiting for feeding cues before oral feeds means that babies are likely to be at their best and most alert for attempting feeding.

Feeding cues are split into early, mid and late cues.  The ideal is that we catch babies early, before they start to become agitated, when it will be harder for them to focus on their feeding skills.

The cues are below.

https://www.breastfeedinginsheffield.co.uk//wp-content/uploads/baby-feeding-cues.jpg

Try watching your baby and see if they are showing any of these cues before you start an oral feed.  In our next post we’ll be covering signs that our babies might show us that tell us they need to stop feeding.

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.