TABLE 1.

Setting the Stage for Optimal Feeding Performance

Provide an appropriate setting for the observation

• Feed the infant in the quietest setting possible.

• Remove all distractions and aim for no interruptions.

• Expect to give your full attention to the infant throughout the feeding.

Select an optimal feeding:

• Ensure that the infant is hungry and in a quiet-awake state. Change the diaper, and bring the infant to an awake state before starting the feeding. Facilitate minimal expenditure of the infant's energy during the prefeeding period.

• If needed, offer nonnutritive sucking and/or visual, auditory, vestibular, and/or tactile stimulation to help the infant get organized and ready for feeding.

Assess the baseline condition of the infant

• During a calm, inactive period, when no demands are being placed on the infant and when he is not recovering from a recent change such as handling, assess the infant's baseline physiologic status: Baseline oxygen saturation Baseline respiratory rate and breathing effort Baseline heart rate Stability/variability of physiologic measures Prefeeding color Level of oxygen supplementation, if administered

Provide developmental feeding support

• Hold the infant either in your arms or semiupright in your lap with the upper body and head upright at a 45° angle to the buttocks; or feed with the infant side-lying, head higher than hips. If side-lying, have the infant face you to enable you to see stress signals.

• Facilitate neutral head-neck flexion (chin slightly tilted down, not with the head extended or with excessive flexion, which can compromise airway maintenance).

• Keep the infant's head midline (not to one side).

• Swaddle-support the infant with a blanket, elbows inside, to promote hands toward the midline/center of the body and to contain the infant. Avoid tightly swaddling the arms away from the face. Avoid losing sight of the infant's upper arms and hands, which provide important information regarding the infant's experience and energy level during feeding.

• Coregulate the feeding: Observe for stress signals and respond contingently in ways that promote self-regulation. Begin feeding by eliciting the rooting response (i.e., by stroking the infant's lips at the corners or center). This promotes the infant's active engagement in feeding, which reflects his readiness to begin feeding with adequate breathing and vigor. Lack of rooting may indicate stress and typically signals nonreadiness to initiate sucking. If the infant does not open his mouth in response to a nipple touching his lips, realert the infant, swaddle or reswaddle him to provide better support, and reassess his interest and capacity to engage in feeding. Place the nipple in the infant's mouth only in response to his cues of readiness (rooting, descending tongue). Do not urge the infant to feed. Respect his pauses in sucking, not only because they influence the infant's ability to self-regulate during feeding, but also because they influence swallowing coordination. The pause patterns that occur or do not occur reflect the infant's skill or lack of skill in coordinating sucking, swallowing, and breathing. Observe the infant's physiologic status during pauses to learn potential reason(s) for them. Do not attempt to prod the infant to continue sucking (through turning or twisting the bottle or by passively moving the infant's jaw). If the infant's breathing is calm and sleep or fatigue is suspected, do not encourage sucking, but rather provide a rest and realerting period.