You have accessThe ASHA LeaderFeature1 Oct 2018

‘Mom, You Got This’

Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship.

    If a preemie could talk, what would she say to her mother during those first attempts at feeding? Maybe something like, “Mom, you’ve got this. You make me feel so safe. I like feeding with you.” Or perhaps, “Thank you for letting me be done. I am just too tired to keep eating. I need to rest now.”

    Thinking about feeding a preterm infant as a communicative interaction may not be instinctual for a new parent. Parents are likely more focused on getting their preemie to eat—and a lot. After all, the infant needs to grow and gain weight to go home. And parents may already feel tenuous about their ability to care for their infant, given that tubes, wires and monitors have prevented optimal bonding.

    Parental focus on the numbers and getting milk in can lead to feeding experiences that are not relationship-based but quantity-driven. Feeding then becomes something they do “to” their infant to get him home. The already fragile parent-infant relationship suffers.

    What builds confidence is shifting the focus to feeding quality and parents’ relationship with their infant. We get there by helping parents conceptualize feeding as a “conversation” with their infant. Our role as feeding specialists in the neonatal intensive care unit (NICU) is to guide parents to develop this “co-regulation” with their infant—this line of communication that drives feeding and, ultimately, the parent-infant relationship itself.

    With our ongoing support, parents can begin to see their relationship with their infant as the foundation for feeding. Intake is then viewed as the byproduct of a quality feeding interaction, not the feeding’s only goal. The parent-infant-relationship begins, through infant-guided feeding.

    Reality check: While this may all sound straightforward, it is, of course, anything but. In the NICU, infants may receive their first feeding via a tube—from the infant’s nose or mouth to her stomach—to deliver the mother’s breastmilk or special formulas designed to provide optimal calories.

    When infants show readiness for the first oral feeding, parents may be conflicted. Some parents describe feelings of worry, such as, “Will he choke? Will I know what to do?” Unlike heathy newborns at their first feeding, preterm infants are more at risk for choking. When an infant chokes, parents may worry about the next feeding, recalling that past incident. One mother even told me it was her fault. This highlights the complexity of oral feeding for preterm infants and the vulnerability of their parents.

    To keep the infant safe, caregivers must carefully observe and interpret the infant’s cues, and be ready to intervene quickly. These skills are complex, and parents may inadvertently feed past the infant’s “stop” signs, which can lead to physiologic instability (such as slowing of the heart rate, increased breathing effort or color change) and possibly aspiration.

    This is why it’s critical that we—professional caregivers in the NICU, including nurses, speech-language pathologists and other neonatal therapists—provide consistent guided learning opportunities for parents, using both anticipatory guidance and guided participation (more on these later). Through this structured learning, parents gain the feeding competence they must demonstrate and the confidence to finally take their tiny new family member home.

    Parental insecurity

    Long before their preemie is discharged from the NICU, parents begin judging their parental competence by their ability to feed their infant. This is an undue burden to take on, given the enormous stresses and challenges posed by preterm birth. Anxiety, depression and feelings of lost autonomy are common. Many parents experience dissonance between what they expected for their first days of parenthood and the reality of caring for a medically fragile infant.

    These new parents may also feel less confident when comparing themselves with highly trained and experienced NICU staff. And the fact is, their infants are at high risk for the onset of problems during feeding attempts: We often see irregular respirations and prolonged apneic pauses, which increase aspiration risk during sucking bursts. We may also see purposeful changes in the infant’s sucking pattern due to difficulties managing the flow of milk—difficulties that parents may not recognize. Their infant may experience unstable oxygen saturations or heart rate, disengagement, and fatigue with the challenges of feeding by mouth. Support for breast and/or bottle-feeding is crucial for positive feeding experiences.

    The more stressful the feeding experience, the more likely it is the infant will struggle with coordination of swallowing with breathing, which can pose a threat to the airway. Parents need guided learning to proactively structure feedings to prevent distress and anticipate what support their infant may need from moment to moment. This can then minimize infant stress and support safe, successful feeding (see sources below).

    NICU parents begin judging their parental competence by their ability to feed their infant. This is an undue burden to take on, given the enormous stresses and challenges posed by preterm birth.

    A complex preemie-parent ‘dance’

    This cue-based interaction—whose underpinning is “co-regulation”—forms the foundation of a lifelong caregiving dance. This feeding approach, as described in my research (see sources) includes:

    • Observing the infant from moment to moment during feeding for cues of stress versus stability specific to swallowing, breathing, physiologic stability, postural control and state regulation.

    • Modifying the feeding approach through individualized interventions contingent on the infant’s cues to help the infant maintain or regain stability.

    Learning this dance is far from straightforward for new parents of preemies. The learning curve for mothers can be steep, as they report this is novel territory. Most healthy newborns feed readily and don’t require such parental skill. Given this complexity, it’s important that we individualize parental guidance, homing in on:

    • Interpreting the meaning of infant communication, adaptive feeding behaviors and stress responses.

    • Problem-solving cues of engagement versus disengagement.

    • Making modifications for postural support and optimal suck-swallow-breathe coordination.

    • Providing opportunities for rest and deep breathing to promote respiratory reserves.

    Through structured learning, parents gain the feeding competence they must demonstrate to finally take their tiny new family member home.

    Types of guidance

    So how do we SLPs successfully individualize parental guidance in the NICU? In my experience, two methods of structured participatory learning are essential: anticipatory guidance and guided participation.

    Anticipatory guidance

    Depending on their professional expertise, SLPs may also be certified lactation consultants. When bottle feeding or breastfeeding starts, parents learn along with the SLP and/or lactation consultant. This may involve guiding the breastfeeding experience using the infant’s readiness and behavioral cues. It may involve listening and watching as the SLP bottle-feeds the infant while describing the infant’s behaviors, interpreting the infant’s subtle communication and using those communicative cues as a guide.

    The SLP helps parents explore reasons for the behavior and potential interventions. Using this anticipatory guidance, the SLP models interactive problem-solving while the parent learns along with the SLP.

    In this guided problem-solving context, parents learn to take their infant’s perspective and to titrate interventions based on infant communication. During co-regulated feeding, the SLP:

    • Provides supportive, swaddled side-lying to optimize tidal volume, alignment and midline.

    • Offers opportunities for deep breathing and brief resting periods.

    • Decreases the flow of milk by using a nipple with a slow, controlled flow rate.

    • Provides co-regulated pacing by imposing pauses in sucking that avoid uncoupling of swallowing and breathing.

    • Responds to loss of flow at the lips with rest periods that allow for reorganization of infant swallowing function.

    • Supports state regulation through gentle, thoughtful re-arousal or calming using deep-pressure tactile/vestibular input.

    • Decreases feeding demands at the earliest signs of disengagement, responding to infant communication.

    Here are three examples of SLPs using anticipatory guidance to help parents problem-solve while the SLP is feeding their infant. Guidance is individualized based on the developing skills of the parents and their infant.

    • “Did you see how Savannah pushed the nipple out with her tongue? She might be telling us she needs more time for breathing, or maybe she has a burp. Let’s first see what happens if I just give her time to breathe. Then, if she doesn’t open her mouth to start sucking again, we’ll see if she has a burp. Maybe that is why she is choosing not to open her mouth.”

    • “When I stroke Jake’s lips, he can tell us if he is ready to suck by opening his mouth and latching on to the nipple. If I just put the nipple in, he might think, ‘I’m not ready. Why didn’t you ask me?’”

    • “When the milk is splashing out of her mouth, Elizabeth might be trying to tell me her mouth is too full. I think I’ll give her a brief break from sucking, to clear her mouth, and then offer the nipple again. There. I think she liked that. What do you think, Dad?”

    Feeding skills are complex, and parents may inadvertently feed “past the infant’s stop signs,” which can lead to physiologic instability.

    Sometimes preterm infants may, despite interventions, get into trouble. SLPs may also misread the infant’s communication when the SLP is feeding the infant. As SLPs model this type of expert problem-solving, it is appropriate for parents to see the SLP struggle in the face of real difficulty. This teaches that even experts stumble.

    For example, the SLP might say, “I thought he could take one more suck since he wasn’t splashing milk out, but I missed that he was starting to blink. I bet he was trying to tell me he needed a break to breathe. I think if I watch his eyes more, that will help me understand. Let’s see.” The SLP explores what happened, what was learned, what to do next, and what, perhaps, to do differently. The parents make connections about what they are coming to know about their infant’s feeding needs.

    Guided participation

    In this next teaching phase, the parent feeds the infant while the SLP thoughtfully acts as a guide. Guided participation involves learning through collaboration with someone who knows the way. Because the SLP understands what feeding a vulnerable infant is like at its best, the SLP provides guidance and reflects out loud about what the parent is learning. Joint attention between SLP and parent regarding feeding behaviors and infant communication creates opportunities to problem-solve and explore interventions.

    The SLP comes to understand where parents are in their learning, and supplies support as needed. The parent learns to take the infant’s perspective and build a relationship through feeding. Progressing from observing to guiding the infant builds parents’ competence and confidence. Parents remark that when they heed what their infant is “saying,” they no longer feel they are feeding their infant blindfolded or are on the edge of their chair waiting for their infant to choke or turn blue.

    Here are some examples of typical guided-participation dialogue:

    • “I noticed you gave Tyler a brief break from sucking to rest. It seemed like just what he needed. How did he tell you he was getting winded? How did you know?”

    • “Grace isn’t rooting any more. I wonder why. What do you think?”

    • “What do you think he is trying to tell you?”

    Parents need to proactively structure feedings to prevent distress and anticipate what support their infant may need.

    Successful parent-infant communication during feeding helps build a lifelong trusting relationship. Watching “how-to” videos or reading printed guidelines is not enough to develop this type of dynamic skill, nor to truly get to know the infant during feeding. Guided feeding experiences—the SLP feeding while parents learn along, then problem-solving as parents feed their infant—help build and reaffirm the parent-infant relationship. Feeding becomes a pleasurable experience for both infant and parent. Parents can then truly look forward with confidence and joy to the discharge home.

    I often ask parents after feeding their infant, “If your baby could talk, what would your baby say about this feeding?” This helps them always consider their infant’s perspective. The joy on parents’ faces as they recognize their important role in the feeding experience is priceless. One father said, “I think she’d say, ‘I love when you feed me, Daddy.’”

    By working to establish successful parent-infant communication during feeding in the NICU, we can set parents and their infants on the way to a trusting relationship that can last a lifetime.


    • Cleveland, L. (2008). Parenting in the neonatal intensive care unit.Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37, 666–691.
    • Park, J., Thoyre, S., Estrem, H., Pados, B. F., Knafl, G. J., & Brandon, D. (2016). Mothers’ psychological distress and feeding of their preterm infants. MCN:.The American Journal of Maternal Child Nursing, 41(4), 221.
    • Pridham, K., Brown, R., Clark, R., Limbo, R. K., Schroeder, M., Henriques, J. … Bohne, E. (2005). Effect of guided participation on feeding competencies of mothers and their premature infants.Research in Nursing & Health, 28(3), 252–267.
    • Shaker, C. S. (2017). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part I: Theoretical underpinnings for neuroprotection and safety.Seminars in Speech and Language, 38(2), 96–105.
    • Shaker, C. S. (2017). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part II: Interventions to promote neuroprotection and safety.Seminars in Speech and Language, 38(2), 106–115.
    • Shaker, C. S. (2013). Cue-based co-regulated feeding in the neonatal intensive care unit: Supporting parents in learning to feed their preterm infant.Newborn and Infant Nursing Reviews, 13(1), 51–55.
    • Shaker, C. S. (2013). Cue-based feeding in the NICU: Using the infant’s communication as a guide.Neonatal Network, 32(6), 404.
    • Smith, G. C., Gutovich, J., Smyser, C., Pineda, R., Newnham, C., Tjoeng, T. H. … Inder, T. (2011). Neonatal intensive care unit stress is associated with brain development in preterm infants.Annals of Neurology, 70, 541–549.
    • Thoyre, S. M., Hubbard, C., Park, J., Pridham, K., &McKechnie, A. (2016). Implementing co-regulated feeding with mothers of preterm infants.MCN: The American Journal of Maternal Child Nursing, 41(4), 204.
    • Thoyre, S., Park, J., Pados, B., & Hubbard, C. (2013). Developing a co-regulated, cue-based feeding practice: The critical role of assessment and reflection.Journal of Neonatal Nursing, 19(4), 139–148.

    Author Notes

    Catherine S. Shaker, MS, CCC-SLP, BCS-S, an SLP since 1977, is the senior clinician–swallowing and feeding for acute care/inpatient pediatrics at Florida Hospital for Children in Orlando. An affiliate of ASHA Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia), she offers seminars on neonatal/pediatric swallowing/feeding across the U.S. and internationally.

    Additional Resources