Feeding Assessment in Infants

Case Study

Kay Thurston, MS,CCC/SLP,CLC

Objectives

Discuss components of an optimal observation of feeding skills

Discuss factors that complicate feeding assessment

Identify feeding skill sensitive questions to ask the family

Identify when it is appropriate to refer an infant for more in depth evaluation

Discuss swallow evaluations

Prerequisite Skills for oral feeding

“Intact anatomy and physiology, intact

sensory and tactile systems, adequate

muscle tone and postural support of the

oral, pharyngeal and respiratory systems,

stable autonomic nervous system,

adequate state regulation and enough

energy to support the entire process.”

Alexander 1993

Why is feeding so often difficult?

Developmental skill

Dependent on the opportunity to participate in developmentally appropriate activities

Interdependent on motor skill acquisition

Dependent on medical stability

Caregiver regulated moving to self regulated in the first year of life

Requires active reciprocal communication between partners

Factors that complicate feeding

assessment Timing

◦ Infant state

◦ Infant schedule

◦ Infant willingness to participate

◦ Primary caregiver schedule and availability

Emotion

◦ Feeding emotionally charged

◦ Family often feels isolated and alone, judged,

and sense of failure

Factors that complicate feeding

assessment Complicating this sense of judgment, is your

need to ask a great deal of questions -which has potential to compound emotions

◦ Medical history

◦ Feeding history

◦ Typical days schedule

◦ Foods offered

◦ Amount eaten

◦ Where they eat

◦ Preferred foods

◦ Rejected foods

Feeding Assessment Tools

Feeding individualized and complex

Oral motor skill development highly variable

Need to consider within medical, developmental and cultural context

Difficult for standardized tests to accommodate all of these variables

Many are checklists or are subscales of a test

Many require training and certification

Formal Feeding Assessments

Published Evaluations - Infant Specific

NOMAS – Neonatal Oral Motor Assessment Scale – Palmer, Crawley & Blanco. 1993

PIBBS - Preterm Infant Breast-feeding Behavior Scale – Nyqvist, Rubertsson, Ewald & Sjoden. 1996

EFS - Early Feeding Skills Assessment for Preterm Infants – Thorye, Shaker & Pridham. 2002

Feeding Flow Sheet –Vandenberg. 1990

Infant Feeding Evaluation – Swigert. 1998

Feeding Readiness Scale – Ludwig & Waitzman. 2007

Formal Feeding Assessments

Infant/Child Evaluations

Clinical Feeding Evaluation – Wolf & Glass. 1992

Developmental Pre-Feeding Checklist – Morris & Klein. 1987

NCAST Parent – Child Interaction Feeding Scales - 2009

SOMA – Schedule for Oral Motor Assessment -Reilly, Skuse & Wolke. 2000

Oral Motor Feeding Rating Scale – Jelm. 1990

Brief Assessment of Motor Function: Oral Motor Scales – Sonies, Cintas, Parks, Miller & Gerber. 2007

Memorial Outpatient Feeding Clinic

Approach Multidisciplinary team

◦ Developmental Pediatrician

◦ Dietician

◦ Occupational Therapist

◦ Speech Language Pathologist

Comprehensive Evaluation

Trained with Dr. Kay Toomey

◦ Sequential Oral Sensory Approach – SOS

Five Basic Questions

Is the feeding safe?

Is the feeding

efficient?

Is the feeding

developmentally

appropriate?

Is the feeding

pleasurable?

Does this child need

further evaluation?

Prior to Assessment – Optimal

Scenario

Gather and review medical information

◦ Discharge summary from NICU

◦ Medical records

◦ Growth charts

◦ Therapy treatment notes

◦ Pediatrician office visit notes

Prior to Assessment - Reality

Often minimal information available

Use what know to consider likely

scenarios

◦ Diagnosis

◦ Report from other treating therapists

◦ Report of family concerns

◦ Report of gross/fine motor skill development

Feeding Assessment Components

Family Concerns

Medical History◦ Pregnancy/birth history

◦ NICU

◦ Nutritional status/regime at discharge from hospital

◦ Surgery/readmissions/illnesses since discharge

◦ Medications/allergies

Developmental History◦ Developmental milestones

◦ Developmental interventions/support since discharge from hospital

◦ Current developmental therapies

Feeding Assessment Components

Nutritional History

◦ Nutritional plan at discharge from hospital

◦ Formula changes

◦ Current nutritional plan, formula/preparation

◦ Growth chart

◦ Typical day schedule of foods offered, amount

accepted

◦ Review of foods accepted/rejected by food

groups

Feeding Assessment Components

Oral Mechanical Observation◦ Optimal if done prior to feeding

◦ Assess oral structures, symmetry

Feeding Observation◦ Observation infant feeding during evaluation

◦ Typical foods offered by caregiver

◦ Novel foods by caregiver, therapist

◦ Oral motor skill assessment

Sensory Observation◦ Ability tolerate sensory input

food on hands, face, active engagement

◦ Caregiver tolerance for sensory input

Feeding Assessment Components

Motor observation

◦ Postural stability over all

◦ Postural stability as related to feeding

◦ Tone/motor patterns

Speech Language Observation

◦ Social interaction

◦ Communication with caregiver, parent and novel adults

Summary

Recommendations

Feeding Assessment

Infant Liquid Feeder

Bottle, bottle, nipple!

You must understand

how bottles/nipples

differ from one

another

To accurately assess

infant liquid feedings

Make appropriate

recommendations

Bottles and Nipples

Number of different bottles and nipples overwhelming for parents!

New bottles and nipples all the time.

Advertisements in parenting magazines.

Vast array at grocery store, Target and Babies R Us.

Stay up to date what is available in your area◦ Ease of obtaining

bottle/nipples

Guidelines for Nipple Selection

Nipple efficiently, without burning calories or exhausting infant.

Nipple safely, without compromising physiologic stability.

Developmentally supportive

Enhance Parent success

How do nipples differ?

Material

Shape

Flow rate

Size

Material

Rubber Nipples

◦ tan color

◦ variable texture

◦ tend to have a taste

◦ generally softer -

faster

◦ collapse easier

Silicone Nipples

◦ clear

◦ firmer

◦ generally slower

◦ less likely to collapse

Nipple Shapes

Orthodontic Nipple

◦ larger surface

◦ easily collapses

◦ unpredictable flow

◦ promotes flat tongue

Straight Nipples

◦ tongue cups nipple

◦ Lateral margins tongue lift/curl

◦ flow predictable

◦ less likely to collapse

Flow Rate

Flow rate should match infant ability to efficiently

feed without compromising physiological stability

Preemie nipples - traditionally they were made to flow fast – red nipple◦ Newer premature nipples actually designed to give smaller

bolus per suck – may have single hole

Dr. Brown’s premature nipple

Cross Cut nipples – unpredictable and usually fast◦ Require infant to have strong enough suck to pull open

cross cut

◦ Thickened feedings

◦ Never manually create a cross cut by cutting nipple Destroys integrity of nipple, cannot standardize cut

Flow rates

Variable flow nipples – typically for thickened feedings

◦ Differ by how you can adjust flow rate

turning nipple to different position

clicking nipple to different position

◦ Shortest line or slowest flow usually faster than standard nipple

◦ Never manually create variable flow -compromises integrity of nipple, cannot standardize cut

How fast does it flow?

Size

Match to the infant’s mouth.

Fill the oral space without compromising airway

Standard vs. wide base

◦ increased sensory input

◦ assist with organization

Standard Nursery Nipples

Shape easy to match

Disposable

Standard shape

rubber

One time use only

General flow rates

◦ Clear rim - standard

◦ blue – controlled flow

◦ green – slowest single

hole

Readily Available Bottles

Dr. Browns bottle◦ interior chamber

◦ cleaning concerns

◦ helpful for infant swallow air/GER

◦ Premie nipple, Ycut

◦ Graduating flow rates

Advent ◦ silicone

◦ broad base

◦ may be helpful for infant breastfeeds best

◦ Variable flow, increasing flow rates

Readily available slow and variable

rate nipples

Slow Flow

Silicone

Firm

Deliver smaller bolus

size per suck

Consider if infant

eager but very

sloppy/spitty

May tire with effort

Variable Rate

Usually silicone

Increase flow by

turning nipple in

mouth

Consider if feeds

thickened

Slowest rate faster

than standard nipple

Cleft Palate Nipples/ Bottle Systems

Mead Johnson◦ Fits any standard nipple

◦ Pliable, easy to squeeze

◦ Nipple with bottle narrow often too long, x-cut, unpredictable flow

◦ Works well with NUK upside down

◦ Good starting bottle

◦ Relatively inexpensive

◦ Order by phone, internet and ship to home

Pigeon Bottle

Children’s Medical Ventures

Large rubber nipple

One way valve

Fast flow may be too much for premature or fragile infants

Expensive

Instructions in Japanese

Bottle is hard to squeeze

Haberman Bottle Systems

Medela

Available in regular and mini

Silicone

Variable flow rate

One way valve

Squeezable reservoir tip

Expensive

Look different

Bionix Controlled Flow Baby Feeder

Bionix Medical

Multiple flow rates

◦ 0 no flow – 5

Premie or standard nipple

Adjustable during feeding

Expensive 12/$299.99

Multiple parts

Cleaning concerns

Difficult to assemble

There’s not a perfect bottle!

The Baby controls sucking and breathing.

The feeder can affect change in the flow rate or bolus size.

A premature infant’s feeding success is often a reflection of their brain maturation and not the nipple.

Medically fragile infants benefit from feeding assessment and close monitoring to determine appropriate nipple system.

Infants with structural abnormalities also benefit from close monitoring to determine best nipple system. Growth may change relative shape of cleft and impact efficiency.

Infant: Pre-solids feeding assessment

Keep in mind 5 questions throughout observation◦ Safety, efficiency,

pleasure, appropriateness, need for further evaluation

First determine family/caregivers concern

Why and by whom were they referred for a feeding evaluation?

Infant Assessment – Family

Interview Ask open ended questions

Reassure family that you are not judging

them

Remember feeding is highly emotional, be

prepared for tears, anger, grief

The family may still be recovering from

lengthy stay in NICU

The family may be emotionally, physically

and/or financially exhausted

Infant Assessment Family Interview

History

◦ Pregnancy – “Tell me about your pregnancy”

Complications

Medications

◦ Delivery – “ Tell me about your baby’s birth.”

Term or preterm

Birth weight

Did your baby need to stay in the hospital?

Infant Assessment family interview

History

◦ NICU – “Tell me about your babies stay in the

NICU.”

How long did your baby stay in the NICU?

Did your baby need help breathing in the NICU?

How long was your baby on the breathing machine?

Tell me about feeding in the NICU.

How was your baby feeding when you were

discharged from the hospital?

When did your baby feed best?

Infant Assessment Family Interview

History◦ Health since discharge from the hospital

◦ “Tell me about your babies health since you came home from the NICU.” Surgeries

Re-admissions

Illnesses

Testing

◦ “Does your baby take any medications?”

◦ “Does your baby have any allergies?”

◦ “Is your Dr. happy with your baby’s weight gain?”

◦ “Tell me about your baby’s daily schedule. “ Does he nap during the day?

Sleep all night?

Infant Assessment Family Interview

Developmental History◦ Tell me about your infant’s strengths

◦ Tell me about your infant’s challenges

◦ Does your infant participate in any developmental therapies?

Nutritional History◦ Tell me about your baby’s feeding when he came

home from the NICU. Formula

Preparation

Schedule/volume

Bottle/nipple type

Infant Assessment Family Interview

Nutritional History – Tell me about your baby’s feeding now.

◦ How has your baby’s feeding changed since you were discharged?

Formula changes, schedule changes, volume changes

◦ What formula is your baby on now?

◦ Issues with vomiting, diarrhea, constipation or skin rashes?

◦ How do you prepare your baby’s formula?

◦ How much milk does your baby take in his bottle?

◦ How long does it take for your baby to finish a bottle?

Infant Assessment Family Interview

What kind of bottle and nipple is your baby using now?

◦ Have you tried other bottles or nipples?

◦ Look at the nipple!

Shape, size, material, condition

If they are using an unusual bottle/nipple find out how/why they started to use it.

◦ Describe a typical day’s schedule

◦ Does your baby enjoy his bottle?

◦ When does he feed best/worst?

◦ Tell me about your baby’s weight gain.

◦ Is your Pediatrician concerned about your baby’s weight gain?

Interventions trialed – increasing calories

Infant Feeding Assessment

Feeding Observation Infant appearance

during interview

Motor development

Tone

◦ Over all

◦ Facial

Social interaction with family and novel adults

◦ Communication style

◦ Tolerance of novelty

Infant Feeding Observation

Watch during feeding -

Tone/Motor skills Developmentally appropriate?

Supports offered by caregiver?◦ Positional changes

◦ Postural supports

◦ Swaddling

◦ Chin/jaw supports

If supports not offered gently suggest them –you may find out

why family does not use them

Infant Feeding Observation

Gentle suggestions -

I’m noticing that Baby Jon is having a hard time keeping his body in an organized position for feeding

I wonder if we swaddled him if he would have more energy available for nippling?

You may discover important information

Infant Feeding Observation

Social Interaction Infant cues and caregiver response

Hunger cues present Obvious or subtle

Engagement during feeding◦ Verbal

◦ Tactile

◦ Eye contact

Stress/distress cues during feeding◦ Obvious or subtle

Infant Feeding Observation

Facial tone

Facial symmetry

Oral exam if not done before◦ Presence of clefts

◦ Ankyloglossia

Oral Movement patterns◦ Non nutritive

◦ Nutritive suck

Suck/swallow ratio◦ Immature

◦ Emerging

◦ mature

Infant Feeding Observation

Respiratory patterns

Color

State/alertness

Assess for changes during and after feeding

Want to ask if this feeding is typical

If not how is it different

Infant Feeding Assessment

Is the feeding safe?

Has the child had a previous swallow?

If so what were the recommendations?

Have there been any changes to plan?

Changes to medical status?

Infant Feeding Assessment

Is the Feeding Safe?Is there any evidence or history of dysphagia?

If the infant is on thickened feedings ask how his

feedings are prepared

◦ “Tell me how you make your Baby’s milk.”

Look at the formula/milk before watching a feeding.

◦ Does it appear to be the correct thickness?

What nipple is the infant using – has it been altered in

any way?

◦ Look at the nipple

◦ Check the rim for identifying information

Observe infant closely during feeding for both overt and

subtle signs of swallowing issues

Infant Feeding Assessment Warning

Signs

Overt or obvious

Choking

Gagging

Coughing

Refusing to feed

Wet vocal quality

after feeding

Physiological

instability

Infant Feeding Assessment

Warning signs

Subtle cues during

feeding

Watery eyes

Eyebrow raising

Hyper-alert look

Nasal flaring

Color changes

Sudden state/tone

changes

Infant Feeding Assessment

Warning SignsOther subtle

cues/patterns

Ongoing need for supplemental oxygen

Increasing oxygen needs

Frequent illnesses

Poor weight gain

Refusal to feed

Taking minimal volumes

Sleepy baby

Is the feeding safe?

If you are concerned about the safety of

the feeding, why?

Is the infant demonstrating subtle or

overt signs of distress?

Is this typical of all feedings?

Do changes in flow rate, positioning

improve coordination?

Infant Feeding Assessment

Is it efficient?

Observe infant face and body

Is feeding effortful?

Suck/swallow ratio

◦ Change from NNS

Anterior leakage

Respiratory changes

State changes

Is the feeding efficient?

How much tension is

on the nipple?

How long does a

typical feeding take?

Does the infant

require stimulation

or cueing to finish?

Is the infant

gaining weight?

Is the feeding efficient?

If the infant is “sloppy” or “gulpy”

Look at flow rate

May need slower nipple

Positional support – consider swaddling, sidelying, or upright

If the infant is working too hard for a minimal volume or feeding is lengthy

Look at flow rate, nipple material

Consider postural support

Is there excessive jaw excursion?

If the feeding is thickened may need variable or fast flow nipple

Is the feeding efficient – special

considerations Cleft palate – size and shape of cleft may

change with anatomical growth

Nipple baby used in hospital may not be appropriate now

Goal is the same, most efficient transfer of fluid without compromising stability or exhausting infant

◦ Appropriate weight gain

First examine the nipple they are currently using

Is the feeding efficient – special

considerations Oral exam noting

size/shape/extent of the cleft

Observe infant feeding with their nipple

If the infant is very sloppy the flow may be too fast

If the infant is working too hard the flow may be too slow, the nipple may be too small

Infant Feeding Assessment

Is it developmentally appropriate?

What is the infant’s chronological age?

What is the infant’s adjusted age?

What is the infants developmental age?

Do the infant’s oral skills match adjusted or developmental skills?

If not why?

◦ Medical status

◦ Limited experience

Infant Feeding Assessment

Is it pleasurable? What is the infant’s state

at the beginning of the

feeding?

Does the infant’s

behavior change during

the feeding?

After how much

volume?

What is the infant’s state

at the end of the

feeding?

Infant Feeding Assessment

Is it pleasurable?

What is the infant’s

state at the end of

the feeding?

◦ Satiated or exhausted

Does the infant

appear engaged?

Is the infant an active

participant in the

feeding?

Infant Feeding Assessment

Is it pleasurable?Active Participant

Demonstrate hunger

cues

◦ Rooting, mouthing, fussing

Open mouth with

tongue down

Lean into bottle

Maintain flexed posture

Hands to midline

Infant Feeding Assessment

Is it pleasurable? Signs of pain or

discomfort during feeding?

◦ Head bobbing

◦ Repeated swallowing

◦ Gurgly sound

◦ Arching

◦ Pulling away from the bottle

◦ Disorganization

◦ Vomiting

Infant Feeding Assessment Is it

pleasurable? What is the infant’s

overall presentation?

◦ Fussy

◦ Irritable

◦ Stressed

◦ Hungry then satisfied

◦ Relaxed

◦ Drowsy

◦ Exhausted

Infant Feeding Assessment

Is it pleasurable?

What is the overall

presentation of the

infant’s caregiver?

◦ Stressed

◦ Relaxed

◦ Engaged

◦ Overwhelmed

◦ Exhausted

Infant Feeding Assessment

Is it pleasurable?

If it is not

pleasurable, why?

Consider position or

handling changes

Consider nipple

changes

Consider postural

changes

Consider scheduling

changes

Infant Feeding AssessmentDoes this infant need further evaluation?

Answer the first four questions-

1. Is the feeding safe?

2. Is the feeding efficient?

3. Is the developmentally appropriate?

4. Is the feeding pleasurable for infant and

caregiver?

Infant Feeding AssessmentDoes this infant need further evaluation?

Remember the first four questions.

Were you able to change the answer to

any of the questions during the

evaluation?

Do you feel you can facilitate

improvement/changes?

Safety

If you are concerned for the safety of the feeding - REFER for further evaluation

Explain your concerns to the family◦ Be specific, give examples of infant “red flag”

behaviors

Inform the Pediatrician

Be succinct and explain exactly what you observed during the feeding ◦ When did the infant demonstrate difficulty Beginning, middle, throughout feeding, at the end

Subtle or overt cues – describe them exactly

Medical status alerts

Efficiency

If you are concerned about the efficiency

of the feeding – weight gain - what is

impacting infant ability take sufficient

calories without expending more?

Is this something you can change?

◦ Bottle/nipple

◦ Positional supports

◦ Swaddling

◦ Schedule changes

Efficiency

Can you verify infant current caloric intake?

Determining if it is sufficient for growth?

◦ Dietician

If it is not sufficient the infant may require an increased calorie formula. This requires coordination with the infant’s primary care physician. Do you have a relationship with Pediatrician?

◦ Dietician support

Efficiency

Do you have supports needed to monitor weight gain?

◦ WIC

◦ Pediatrician

◦ Dietician

◦ To appropriately monitor weight gain you need frequent weight checks on the SAME scale

If you do not have adequate support to monitor weight gain, caloric intake, and formula modifications, this infant requires further evaluation.

Efficiency

If the infant is consuming adequate

calories without significant energy

expenditure, there may be other factors,

medical issues, that are impairing growth

and infant ability to thrive.

This infant requires further evaluation.

Is the Feeding Developmentally

Appropriate? Do the infant’s oral feeding skills appear

consistent with overall developmental level?

If not, what seems to be inhibiting infant oral skills?

◦ Medical status

◦ Respiratory status

◦ Mismatch between infant cue and caregiver response

◦ Lack of skill building opportunity/experience

Is the Feeding Developmentally

Appropriate?

Is this something you can address in

therapy?

◦ Demonstration developmentally appropriate

skill building experiences

◦ Positional supports

◦ Bottle/nipple changes

◦ Caregiver education

Is the feeding pleasurable

Is the feeding pleasurable for both infant and caregiver?◦ replicable

Is the infant actively involved in the feeding?◦ Alert and intentional - not distracted

◦ Interactive with caregiver

If not, why?

Is the caregiver calm, relaxed and responsive?

If not, why?

Is there something you can change/teach/modify to improve feeding experience? ◦ Postural changes

◦ Scheduling changes

Video Infant feeding

Feeding Assessment Part Two

Infant/Child Solid Feeder

Infant/Child Solid Feeding

Assessment

Five basic questions are the same:

1. Is the feeding safe?

2. Is the feeding efficient?

3. Is the feeding developmentally appropriate?

4. Is the feeding pleasurable for both infant and caregiver?

5. Does this infant require further evaluation?

Infant/Child Solid Feeding

Assessment – Parent Interview

Parents with older infants often VERY frustrated

◦ Isolated

◦ Feelings of failure

◦ Fear of judgment

◦ Threat of hospitalization

Caregivers problem solve

◦ Short term solutions/success

Imperative that you reassure families you are asking questions to guide assessment NOT to assign blame!

Infant/Child Solid Feeding

Assessment – Parent Interview

Determine Parent primary concern with feeding first

Obtain Medical, Developmental history as before

Detailed Feeding history is important◦ Breast or bottle fed

◦ How infant fed initially

◦ Initial Problems feeding Frequent emesis, fussy/crying

Happy or colicy baby

Diarrhea or constipation issues

Skin rashes/dryness

Sleeping/nap patterns

Infant/Child Solid Feeding

Assessment – Parent Interview Changes to bottle/nipples since discharge

◦ Reason for changes

Changes to formula

◦ Reason for changes

◦ How change made – gradual or sudden

Solids

◦ Age first presentation

◦ Where infant seated for solids

◦ Infant acceptance of solids

Infant/Child Solid Feeding

Assessment- Parent InterviewTypical days schedule of meals/snacks

Time meal/snacks offered

What is offered Be specific not just “crackers” ask for types

Graham, saltine, ritz, etc.

If cheerios will child eat any type of cheerios?

Will child eat all brands – name brand, generic, homemade

What is eaten

What is refused

Amount eaten

Who is present during meal/snack

Infant/Child Solid Feeding

Assessment – Parent InterviewTypical schedule of meals/snacks

◦ Where is the child seated for meals?

◦ Where is the child seated for snacks?

◦ How long do meals last?

◦ How long snacks last?

◦ Is food available other than at meals/snacks?

◦ How does caregiver know when the infant/child is hungry?

◦ Distractions used or available during meals/snacks?

Infant/Child Solid Feeding

Assessment – Parent Interview

What liquids does the child drink other than his milk/formula?◦ How much other liquids

◦ Are liquids available throughout the day or only at meal/snack times

◦ Bottle, cup, sippee, breast

What is the infant/child’s sleep schedule◦ Naps during the day

◦ Sleep through the night

◦ Food available during the night, how often, how much

Infant/Child Solid Feeding

Assessment – Parent Interview Useful to run through food groups

Asking about foods in each of three groups

◦ Carbohydrates – bread, pancake, waffles pasta, rice, hot/cold cereal, crackers, cookies, tortilla, chips

◦ Protein/Milk – meats, beans, hummus, peanut butter, milk, yogurt, ice cream, pudding

◦ Fruit/Veggies – baby food and regular, raw or cooked, whole, smashed

Infant/Child Solid Feeding

Assessment – Parent Interview Final question – Are there any other

foods or liquids that we haven’t talked

about that your child eats on a regular

basis?

Consider parent information

Are patterns emerging?

◦ Continued reliance on liquids for nutrition

◦ Preferences for certain textures

◦ Preferences for temperatures

Infant/Child Feeding Observation

Observe Caregiver feeding child

Goal is to observe typical

meal/interaction

◦ Usual feeding place and position

◦ Familiar foods

◦ Normal feeding time if possible

Observe both infant/child and caregiver

behaviors

◦ Reciprocity and engagement

Infant/Child Feeding Observation

Infant observations◦ General tone

◦ Oral structures

◦ Developmental level

◦ Manipulation of food

◦ Postural stability

◦ Social engagement

◦ Communication ability

Caregiver observations◦ Social interaction

◦ Supports provided

◦ Cueing provided

◦ Tolerance level for mess

Infant/Child Feeding Observation

Generally start in highchair with solids first

Caregiver feeding typical foods

Observe infant oral motor skill and behavior◦ Anticipation – active opening mouth, leaning into

◦ Tongue lateralization – emerging or mature

◦ Chewing – anterior or on molar pads

◦ How does the infant/child manipulate food Whole hand, single finger

What does child do with food

◦ Tolerate sensory input

◦ How does posture change overtime

Infant/Child Feeding Observation

Match between infant behavior and caregiver response

◦ How does caregiver tolerate “messy” eating

Use of modeling, reinforcement and distractions

◦ Does the caregiver attempt to re-engage child in feeding

Model real eating, pretend eating

◦ How does the caregiver interact with child

◦ Caregiver body language/facial expression

Infant/Child Feeding Observation

Novel Food Presentation

Further assess infant oral motor skill development

Determine if infant ready for next step

Assess -

Spoon Feeding – does infant anticipate spoon,

opening lips, lean into, accept

Hard Munchable – acceptance, tongue movement,

oral exploration, fun dipper

Meltable Solid - acceptance, biting central or lateral,

tongue movement patterns

Infant/Child Feeding Observation

Novel Food Presentation

Family/ Caregiver

Education

Demonstration

strategies to advance

skills

Spoon Feeding –

lateral presentation

facilitation active lip

closure

Infant/Child Feeding Observation

Novel Food Presentation

Hard Munchable – oral

exploration not

consumption

Facilitation of tongue

lateralization

Handy dipper for

purees

Child directed with

modeling

Infant/Child Feeding Observation

Novel Food Presentation

Hard Meltable – oral

exploration and

consumption

Facilitation of

munching/biting

Tongue lateralization

Also handy dipper

for puree

Child directed with

modeling

Infant/Child Feeding Observation

Liquid Assessment last

Begin with child’s typical bottle or cup

Observe oral motor skills, efficiency transfer

Introduce novel container

Further assess infant oral motor skill

develoment

Willingness accept new container

Demonstration/Family caregiver education

Cup

Honey Bear

Infant/Child Feeding Assessment

Answering the questionsIs the feeding safe?

Concerns for solids, liquids or both?

What happened that raises a safety issue?

Is choking/coughing self protective?

Are foods being offered at home developmentally appropriate?

Is there a mismatch between expectation/diet offered and skill level?

Interventions trialedhelpful or not

Infant/Child Feeding Assessment

Answering the questionsIf there is a mismatch between oral motor

skill level and diet, can the infant/child eat

appropriate foods safely?

Family/caregiver education

Developmentally appropriate diet

Recommendations to increase caloric

density in accepted foods

Strategies/Activities to facilitate oral skill

building

Safety Concerns

Explain your concerns to the family

Be specific and give examples of infant behavior

Coordinate with primary care physician

Be specific, provide examples ◦ Airway/structural anomalies, vocal cord function

◦ Swallow concerns or Reflux/Vomiting

To evaluate structure – ENT referral

To evaluate safety of swallow◦ Recommendation for swallow evaluation

◦ Be aware of different diagnostic tests

◦ Modified Barium Swallow, Video Swallow

Modified Barium SwallowPurpose: evaluate safety and

efficiency of swallow

The infant/child is seated upright in a tumbleform.

Orally fed barium mixed with glucose water.

Orally fed food with barium mixed in or frosting

Variety of nipples, cups, bottles

Alter consistency of barium

Alter position of child

Upper GIPurpose: evaluate the anatomy of

esophagus and stomach, may identify GER

Infant/child given barium to drink

Positioned in supine, turning to each side during procedure

MAY be able to visualize swallow if fed orally

Abnormal feeding position

Unable to assess compensatory strategies

◦ Position changes

◦ Diet modifications

Fiberoptic Endoscopy

Invasive procedure

Scope passed

through nares and

visualizes vocal cords

Able to assess

anatomy before and

after the swallow

Following swallow assessment

Results of study must be weighed

Compensatory strategies trialed

Reassessment

Normal MBS means that infant was safe at

that moment

◦ Ongoing concerns warrant further evaluation

Abnormal MBS much more predictive

◦ can be a first sign neurological concerns

Is the feeding efficient?

Is the child gaining weight?

Is the current schedule of meals/snacks and food provided offering appropriate calories?

◦ Family limiting

◦ Self limiting

Is there something else impacting child’s ability to maintain nutritional needs appropriately?

◦ Postural supports

Is the feeding developmentally

appropriate? Do the infant/child’s oral feeding skills

appear commensurate with developmental

level?

If not why?

◦ Self limiting experiences – GER, Sensory

◦ Family limiting – lack of experiences, cultural diet

differences or perception of child as too fragile

◦ Mismatch between developmental skill and foods

offered

Chronological age vs developmental age

Is the feeding pleasurable for both

infant/child and caregiver? Active participation by

both infant and caregiver

◦ Willing interaction/trust building

◦ No coercion, hiding food or force feeding

◦ No distraction with non food objects

◦ No fake eating

If not why?

◦ Mismatch between expectation and skill level?

◦ Sensory/GER learned experiences

Does this infant/child need further

assessment? If feeding is not safe – REFER

If feeding is efficient and child is not gaining weight - REFER

If feeding is not efficient and you do not have supports to assess caloric intake, caloric needs, monitor weight gain, or make specific recommendation to increase calories in currently accepted foods – REFER

If feeding is not pleasurable can you identify the reason? For example negative experiences pairing pain with feeding due to GERD?

Does this child need further

assessment?

If the feeding is not pleasurable and you

suspect ongoing issues with pain or

discomfort with feeding – REFER

Feeding assessment with partially or

non - orally fed infant/childPrior to assessing infant oral skills it is imperative to

have the following:

Thorough understanding infant/child’s past and present medical status

Reasons for ongoing supplemental nutrition

Opportunity to examine previous swallow evaluations, feeding clinic recommendations

Support of family and Physician

Self awareness◦ Your skill level

◦ Comfortable stretch of skills with support vsoperating in the dark

Assessment with partially or non-

orally fed infant/child

Go Slow!

Feeding can be fatal

Assess infant status

at rest

◦ Secretion management

◦ Respiratory rate

◦ Need for oral suction

◦ Spontaneous mouthing

◦ Oral reflexes

Feeding Assessment with partially or

non - orally fed infant/child

Assess infant status

with non nutritive

experiences

◦ Changes in oral

secretions

◦ Secretion management

◦ Respiratory stability

◦ Infant interest in

mouthing/sucking

◦ Developmental level

Feeding Assessment with Partially

Orally fed Infant/Child

Assess infant with

minute tastes

◦ Secretion management

◦ Respiratory changes

◦ Suck/swallow ratio and

coordination

◦ Willingness to accept

food/liquid

Feeding Assessment with Partially or

non – orally fed infant/child

The same questions apply -

Is oral feeding safe?

Is the feeding efficient?

Is the feeding developmentally

appropriate?

Is the feeding pleasurable?

Partially or non oral feeder

Is the feeding safe? If the feeding does not appear safe is it –

◦ Liquids

◦ Solids

◦ Both

Why does it appear unsafe?

◦ What is the child doing?

Result of oral motor skill development, mismatch skill/diet, swallow function?

If swallow function - REFER

Partially or non oral feeder

Is the feeding efficient? If the feeding is not efficient why not?

◦ Postural control/stability

◦ Rate of presentation

◦ Oral motor skill/function

◦ Medical status/stability

◦ Caloric density of foods offered

Can you address this in therapy?

If the feeding is not efficient and you do not have supports to make changes and monitor growth - REFER

Partially or non oral feeder

Is the feeding pleasurable?

If the feeding is not pleasurable why not?

Are there any foods/liquids the infant enjoys

and eats willingly?

Is the infant behavior self protective?

Is the infant behavior learned response to

pain? Swallow dysfuntion?

If you suspect the infant continues with

significant pain paired with feeding - REFER

Partially or non oral feeder

Is the feeding developmentally

appropriate?

Are oral motor skills commensurate with developmental level?

If not what is preventing child from developing oral skills?

◦ Medical status/stability

◦ Lack of skill building experiences

◦ Caregiver limiting

◦ Infant self limiting

Is this something you can address in therapy?

Assessment with partially or non –

orally fed infant/child

Often the most appropriate

recommendation for an infant that has

never orally fed is a referral to a Feeding

Clinic for comprehensive evaluation.

Feeding Assessment -Take Home

Feeding/Oral Motor Assessment is complex

Requires detailed information from caregiver

◦ Medical and developmental history

◦ Daily schedule

Observation of typical feeding

Observation of novel feeding

Evaluation of child’s developmental level

Awareness/sensitivity to cultural differences

and family goals

Video of Spoon, finger feeding

Malia Case Presentation

Medical History

Fetal tachyarrhythmia at 29weeks (HR240) Non Immune Fetal Hydrops Atrial Flutter Mother admitted to hospital 2 weeks prior to

delivery◦ Maternal steroids◦ Digoxin and flecainide therapy – HR improved several

days prior to delivery◦ No improvement in hydrops

Urgent C section at 31 weeks ◦ Decreased fetal movement ◦ Biophysical profile 2/10◦ Fetal bradycardia with uterine contractions

Delivery

Apgars 2/4/6

Birth weight 2900g – 6lb 4oz

◦ Estimated real weight 4lbs

Severely hydropic and depressed at birth

No respiratory effort

Difficult to visualize airway due to profound swelling

Bilateral thoracentesis

Traumatic intubation

Low HR requiring chest compressions

NICU Course

Bilateral Chest Tubes

Assisted ventilation x 14 day

Thrombus R atrium

Wolff-Parkinson-White Syndrome

Stage III ROP – requiring bilateral laser surgery

HUS/MRI – stable cystic changes bilateral caudate head

Feeding in the NICU

History weak voice with only minimal improvement

Demonstrated readiness cues at 34 weeks gestation◦ attempting breastfeeding first

Ongoing physiological instability at breast or bottle

ENT consult 5/21/2010 revealed vocal fold damage◦ Left arytenoid cartilage dislocated (resulting in L cord

immobility) surgically repaired

◦ R mid vocal cord damage

◦ Unable fully occlude airway

Feeding

Video Swallow 5/24/2010 in L sidelying position

◦ Aspiration of thin

◦ Safe on nectar thick in left sidelying with slow flow

nipple

Unable to maintain all nutritional needs orally

Gastrostomy tube 6/23/2010

Discharged at 80 DOL, 42 weeks

◦ Nippling small volumes 20-25%

Feeding Clinic Follow Up July 2010

Chronological age 3 months Corrected age 3 weeks Social and interactive infant Gaining weight Combination Gtube/Oral feedings

◦ Six feedings of 105ml/day

Oral Feedings continue nectar thick Recipe family using providing insufficient

calories – did not account for gel thickener displacement

Increased GER symptoms ◦ Frequent gagging, retching and vomiting during gavage

feeding or oral feeding

Feeding Clinic Recommendations

Continue nectar thick

Provided with correct recipe to adjust for addition of non nutritive gel thickener

Continue offer oral feeding first

◦ emphasis on pleasurable oral intake

Reassess swallow function following ENT follow up appointment

Transition to 7 feedings daily

◦ Smaller volume every 3 hours

◦ Manage infant symptoms of GER

Developmental Follow Up August

Chronological age 4 months

Adjusted age 1 month 3 weeks

Socially interactive

◦ Smiling, visually attentive

Delayed Motor Development

◦ Unable turn head fully to left

◦ Limited tolerance prone positioning

◦ Unable lift head from surface in prone

◦ Increased tone and tightness in lower extremities

Developmental Follow Up - August

Ongoing GER symptoms

Requires venting throughout oral feedings

Mother feeding in sheepskin covered bouncy seat to assist with upright positioning, decrease emesis

Limiting time or experience in any other position

Variable oral intake

Recommendations

Home Program developed and given to family

◦ Supervised time in prone, modified prone for GER

◦ Gentle stretches to cervical spine

◦ Activities to increase active head turning to left

◦ Activities to encourage active kicking

◦ Review of GER positioning

Follow up in two months

Developmental Follow Up October

Chronological Age 6months Adjusted age 4 months

Very social and engaging –reciprocal smiling, cooing

Decreased GER symptoms

Increased oral intake -nippling most

Tolerating prone - lifting head

Rolling

Continue mild tightness in LE but increased play and exploration with feet

Continue mild cervical tightness

Recommendations

Continue follow in IDAC at nine months

Feeding Clinic Follow Up in one week

Continue home activities to encourage

◦ Tummy time prone positioning

◦ Rolling to each direction

◦ Head turning to each side

◦ Sidelying for toy play

Feeding Follow Up - October

ENT re-evaluation September results -

Improvement, but still some visible cord damage

Cleared for initiation of trials of thin and reassessment of swallow function

Infant willingly accepted viscosity change without signs of aspiration

◦ Initially decreased thickness to ¾ strength nectar

Initiating spoon feeding

Swallow Reassessment October

Chronological age six

months

Adjusted age four

months

Infant nippling all

Successfully

transitioned to ¾

strength nectar

Spoon feeding purees

Swallow Results

Infant positioning with L lateral neck flexion and R rotation, resists positioning in midline – protective?

Silent aspiration of nectarand honey◦ Continued to suck until

nipple removed

Able tolerate honey thick with slow flow nipple but decreased efficiency

Signs of decreased sensory awareness◦ Delayed swallow initiation

◦ Pooling in valleculae prior to swallow

◦ Aspiration during swallow

Factors Impacting Swallow Function

Premature Birth

Assisted Ventilation

Structural abnormalities

Impact of GER on swallow function

◦ Recurrent GER episodes blunting sensation

◦ Recurrent aspiration blunting sensation/awareness

Impact of anatomical growth

◦ Downward and forward position of larynx

◦ Decreasing inherent protection

Recommendations

Continue honey thick with slow flow nipple

Emphasis on pleasurable oral intake

Feeding Therapy with Speech or Occupational

Therapy

Continue with spoon feeding

Ongoing Developmental Follow Up

Feeding Follow Up – February 2011

Chronological Age 10 months

Corrected Age 8 months

Developmental skill level 6-7months

Most recent ENT evaluation January 2011

◦ Unable to evaluate vocal cord integrity/function

◦ Area edematous and inflamed – GER

◦ Increased reflux medication dosage

Social and engaging, reciprocal smiling and laughing, joint eye contact

Babbling but limited voice

Feeding follow up – February 2011

Video of Malia in high chair

Feeding Assessment Wrap Up

Was the feeding safe?

Feeding Assessment Wrap Up

Was the feeding efficient?

Feeding Assessment Wrap Up

Was the feeding developmentally

appropriate?

Feeding Assessment Wrap Up

Was the feeding pleasurable?

Feeding Assessment Wrap Up

What recommendations would you

make?

Lessons from Malia

Development is interdependent

Nutrition is primary

Never underestimate the power of an involved family and developmentally sensitive care

Even the best families are stressed and may confuse or forget the best teaching at discharge

Follow up is essential

Swallowing is complex

Silent aspiration is silent

Feeding/Swallowing

Dramatic increase feeding disorders in last decade

◦ Increased survival rates medically fragile, extremely premature infants

Typically developing children 25-25% have feeding/swallowing issues

Medically complex/developmentally delayed percentages much higher 33-80%

Risk factors for feeding/swallowing

◦ Low birth weight

◦ Medical complexity

◦ Prematurity

Thanks To:

Malia Joy and family for allowing us to

share her story.

David for technical support with PPT

Remember the goal is long term

feeding success!

Part II - Site visits

Site visits to include:

Up to 4 hours of time by 1 to 2 team members (PT, OT or ST) from Memorial Hospital for Children, depending on location and topics of interest.

Offered at any of the 20 central EI sites throughout Colorado.

One or two case studies would be presented by the local E.I. staff with either in-person (child) visit, video tape, or oral presentation. A case study form would need to be sent to the Memorial staff one week prior to the visit. This would be a problem solving/idea collaboration session, not a formal consultation. Further education on development of the infant < one year of age could be discussed.

Visits would be provided during the months of April, June or September, 2011.

Early Intervention Site Visits

Deadline for sign-up will be March 15,

2011

Cindy Gardner (Peds Rehab manager)

will be the contact person to schedule

site visits at 719-365-9637

cindy.gardner@memorialhealthsystem.co

m.

Case Review Outline(Please use as a guideline; may need additional paper for lengthy

information. Medical summaries, & results of any tests or studies are also

very helpful)

Date of Birth:

Diagnosis (if any):

Past medical history:

Birth History: (gestational age, birth weight, APGAR scores, cord pH,

complications etc)

Illnesses, surgeries, hospitalizations, therapies:

Social history: (lives with____;# siblings____;

Present status:

Sensory/Motor: (developmental milestones/test results, posture,

muscle tone, movement patterns,

sleeping patterns, tolerance to touch/movement/clothing/bathing etc)

Feeding: (typical pattern/ amount/frequency) ( difficulties, spitting up,

discomfort)

Strengths, things child does well:

Problems, things child has difficulty with:

Family’s goals for the child:

Specific interventions tried, to address the goals: (were they

successful or not?)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Discussion, recommendations/suggestions made at the time of

this case review:

Feeding Evaluation TemplateName:

DOB:

MRN:

ACCT:

Date of Evaluation:

Chronological Age:

Corrected Age:

Parents:

Physician:

Referring Physician:

Diagnosis:

______________________ was seen for a feeding evaluation. ________was brought into the evaluation by ____________________. Their concerns include______________________. ________________ was evaluated by

________________________ Developmental Pediatrician

_______________________ Occupational Therapist Registered

________________________ Speech Language Pathologist

________________________ Registered Dietician

Background:

◦ Birth history: ____ week gestation

◦ Initial Feeding History: breast/bottle fed, amounts, problems, when solids introduced

Past Medical History

Medications

Allergies

Other relevant info

Review of systems

Physical Examination

Feeding Assessment:

Current daily feeding routine

Meal Time Foods offered/eaten Drink

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Bedtime

Night feedings

Feeding Routine:

Mother’s lap/arms

High chair

Family style

Walks around

Food available all the time

T.V. on

Toys present; distractions

Other:

Naps:

◦ Time(s)/length

Night:

Sleeps through night/wakes up

Night feedings: amounts/frequency

Foods eaten at home include: C-consistently, O-occassionally, D-dropped, R-refuses

carbs protiens fruit/veggies

Bread chicken- baked apples

Waffles - nuggets oranges

Pancakes beef - hamburger bananas

Cereal - roast pears

Rice pork grapes

Noodles eggs strawberries

Chips cheese peaches

Cheetos peanut butter melons

Cookies yogurt carrots

Crackers pudding green beans

ice cream peas

mashed potato

french fries

Foods refused include:

During todays evaluation _____________ was offered the following foods. ( puree, hard munchable, meltable, hard/soft mechanical drink)

list observation infant child interaction with food spontaneously and with modeling/cueing

note oral motor development

Sensory Screen:

Motor Screen/Postural Stability:

Speech Language Screen:

Summary:

Strengths:

Challenges:

Recommendations:

Plan:

Goals:

References

REFERENCE LIST

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Bell, H.R. & Alper, B.S. (2007). Assessment and intervention for dysphagia in infants and children: beyond the neonatal intensive care unit. Semin Speech Lang. 28(3):213-222.

Bingham, P.M., (2009). Deprivation and dysphagia in premature infants. J Child Neurol. 24(6):743-749.

Bozzette, M., (2007). A review of research on premature infant-mother interaction. Newborn and Infant Nursing Reviews. 7(1):49-55.

References Bronwen, N.K, Huckabee, M.L., Jones, R.D. & Frampton, C.M.A., (2007). The first year of human life:

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Brown, L.F., Thoyre, S., Pridham, K., & Schubert, C. (2009). The mother-infant feeding tool. Journal of Obstetrical, Gynecological, & Neonatal Nursing. 38, 491-503.

Buswell, C.A., Leslie, P., Embleton, N.D., & Drinnan, M.J. (2009). Oral -Motor Dysfunction at 10 months corrected gestational age in infants born less than 37 weeks preterm. Dysphagia. 24(1): 20-25.

Chang, Y.J. & Lin, C.P. et al. (2007). Effects of single-hole and cross-cut nipple units on feeding efficiency and physiological parameters in premature infants. Journal of Nursing Research. 15(3). 215-223.

Cho, J., Holditch-Davis, D. & Miles, M.S. (2010). Effects of gender on the health and development of medically at-risk infants. Journal Obstet Gynecol Neonatal Nurs. 39(5):536-549.

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DaCosta, S.P., Van Der Schans, C.P., Boelema, S.R., Van Der Meij, E., Boerman, M.A. & Bos, A.F. (2010). Sucking patterns in fullterm infants between birth and 10 weeks of age. Infant Behav Dev. 33(1): 61-67.

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Delaney, A.L. & Arvedson, J.C. (2008). Development of swallowing and feeding: prenatal through first year of life. Dev Disabil Res Rev. 14(2): 105-117.

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Laing, S., McMahon, C., Ungerer, J., Taylor, A., Badawi, N. & Spence, K. (2010). Mother-child interaction and child developmental capacities in toddlers with major birth defects requiring newborn surgery. Early Human Devlopment, Epub ahead of print PMID:20888152.

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References Law-Morstatt, I., Judd, D.M., & Snyder, P. (2003). Pacing as a treatment technique for transitional

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Lee, T.Y., Lee, T.T., & Kuo, S.C. (2009). The experiences of mothers in breastfeeding their very low birth weight infants. Journal of Advanced Nursing. [Epub ahead of print]. doi:10.1111/j.1365-2648.2009.05116

Lefton-Greif, M.A. & McGrath-Morrow, S.A. (2007). Deglutition and respiration:development, coordination, and practical implications. Semin Speech Lang. 28(3): 166-179.

Lefton-Greif, M.A. (2008). Pediatric Dysphagia. Phys Med Rehabil Clin N Am. 19: 837-851.

Ludwig, S. & Waitzman, K.A. (2007). Changing feeding documentation to reflect infant driven feeding practice. Newborn and Infant Nursing Reviews. 7(3). 155-160.

McCain, G.C. (2003). An evidence-based guideline for introducing oral feeding to healthy preterm infants. Neonatal Network. 22: 45-50.

McGrath, J. M., Braescu, A. V. & Bodea, M.S. (2004). State of the science: Feeding readiness in the preterm infant. The Journal of Perinatal & Neonatal Nursing. 18, 353–368.

Medoff-Cooper, B., Bilker, W. & Kaplan, J.M. (2010). Sucking patterns and behavioral state in 1 and 2 day old full term infants. Journal Obstet Gynecol Neonatal Nurs. 39(5), 519-524.

Medoff-Cooper, B. & Irving, S.Y. (2009). Innovative strategies for feeding and nutrition in infants with congenitally malformed hearts. Cardiol Young 19(2):90-95.

Medoff-Cooper, B. (2005). Nutritive sucking research:from clinical questions to research answers. Journal of Pediatric Neonatal Nursing. 19: 265-628.

References Law-Morstatt, I., Judd, D.M., & Snyder, P. (2003). Pacing as a treatment technique for transitional

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Lee, T.Y., Lee, T.T., & Kuo, S.C. (2009). The experiences of mothers in breastfeeding their very low birth weight infants. Journal of Advanced Nursing. [Epub ahead of print]. doi:10.1111/j.1365-2648.2009.05116

Lefton-Greif, M.A. & McGrath-Morrow, S.A. (2007). Deglutition and respiration:development, coordination, and practical implications. Semin Speech Lang. 28(3): 166-179.

Lefton-Greif, M.A. (2008). Pediatric Dysphagia. Phys Med Rehabil Clin N Am. 19: 837-851.

Ludwig, S. & Waitzman, K.A. (2007). Changing feeding documentation to reflect infant driven feeding practice. Newborn and Infant Nursing Reviews. 7(3). 155-160.

McCain, G.C. (2003). An evidence-based guideline for introducing oral feeding to healthy preterm infants. Neonatal Network. 22: 45-50.

McGrath, J. M., Braescu, A. V. & Bodea, M.S. (2004). State of the science: Feeding readiness in the preterm infant. The Journal of Perinatal & Neonatal Nursing. 18, 353–368.

Medoff-Cooper, B., Bilker, W. & Kaplan, J.M. (2010). Sucking patterns and behavioral state in 1 and 2 day old full term infants. Journal Obstet Gynecol Neonatal Nurs. 39(5), 519-524.

Medoff-Cooper, B. & Irving, S.Y. (2009). Innovative strategies for feeding and nutrition in infants with congenitally malformed hearts. Cardiol Young 19(2):90-95.

Medoff-Cooper, B. (2005). Nutritive sucking research:from clinical questions to research answers. Journal of Pediatric Neonatal Nursing. 19: 265-628.

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