Progression to oral feeding in preterm babies

DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment

Table 1: Breastfeeding assessment

Score	Category at 10 min	Action
A	Offered breast: not interested, remained sleepy	Full top-up (preferably EBM)
B	Interested in feeding: licking and nuzzling, but does not latch	Full top-up (preferably EBM)
C	Latches, has few sucks then comes off breast repeats pattern for several minutes/falls asleep within few minutes of latching	Full top-up (preferably EBM)
D	Latches, starts sucking and swallowing but: sucking is shallow for most of feed (>2 suck/sec) short sucking bursts long pauses (mum feels need to encourage to restart sucking)	Half–full top-up (preferably EBM) – depending on weight gain, milk supply and wet and dirty nappies If receiving phototherapy/excessive weight loss – give full top-up
E	Latches well Rhythmic sucking and swallowing (see below) Feed duration 5–10 min	Half top-up (preferably EBM) consider not topping-up if mother is available for next feed If score A–E at next feed: offer top-up feed as indicated above If receiving phototherapy/excessive weight loss – give full top-up
F	Effective latch and rhythmic sucking and swallowing (see below) Duration 10–40 min/breast >1 breast may be taken	Second breast can be offered, but no top-up required provided: wakes naturally to feed ≥8 times/day expected number and colour of wet and dirty nappies gaining weight (weight check every 48 hr) milk supply increasing

Signs of effective breastfeeding

Effective latch
- latches within few seconds of trying, with wide open
- mouth
- no nipple pain after 10–20 sec
- chin pressed against breast
- head tipped back slightly, nose lightly touching breast
- some areola seen above top lip, but not below bottom lip
- rounded cheeks (not sucked in)
- remains attached throughout feed
- nipple looks rounded (not pinched) at end of feed
Rhythmic sucking and swallowing
- rapid sucks (≥2 sucks/sec) at first, slowing to regular bursts of rhythmic sucking
- deep jaw drops (1 suck/sec) before brief pause for most of feed
Eyes open at start of feed
Remains calm and relaxed as feed progresses
Baby removes self from breast when no longer wants milk, and looks relaxed and sleepy

BOTTLEFEEDING

Table 2: Bottle feeding assessment chart for babies receiving special/transitional care

Score	Category at 10–20 min	Action
A	Offered bottle, reduced signs of feeding readiness, with signs of avoidance behaviours and is sleepy	Full NGT feed top-up Focus on supportive interventions to prepare for bottle feeding
B	Latches onto teat and starts to suck, but has difficulty co-ordinating swallow with breathing, loss of milk despite careful pacing Demonstrates signs of avoidance behaviours and/or falls asleep	Full NGT feed top-up Focus on supportive interventions to prepare for bottle feeding
C	Latches onto teat and beginning to demonstrate short sucking bursts, e.g. 2–3 suck:swallows per burst with frequent long pauses to breathe Shows signs of avoidance behaviours and fatigue within 10 min of bottle feeding opportunity. Bottle feed discontinued	Offer NGT feed top-up with remaining volume left from bottle feed
D	Latches well to teat, sucks with an emerging and maintained rhythmical suck/swallow/breathe pattern for the first part of the bottle feed Starts to show signs of fatigue and avoidance behaviours within 10–15 min of bottle feeding opportunity. Feed discontinued	Offer NGT feed top-up with remaining volume left from bottle feed
E	Latches well, with co-ordinated, strong and maintained suck/swallow/breathe pattern (see Co-ordinated sucking/swallowing and breathing) - within 20 min of bottle feeding opportunity No signs of fatigue or avoidance behaviours observed – beginning to show maturation of bottle feeding skills	No NGT top-up feed needed Shows early feedingreadiness cues ≥8 times/day and is gaining weight

Supportive interventions to prepare for bottle feeding:

Skin-to-skin contact
Positive touch
Mouth care with EBM
Non-nutritive sucking
Held in a feeding position during NGT feeds

Early feeding readiness cues:

Stirring
Mouth opening
Turning head/rooting
Stretching
Hands to mouth

Avoidance behaviours during bottle feed:

Finger splay
Back arching
Grimace/startled look
Disengages
Cry
Change in saturations and heart rate
Drooling
Loss of tone
Colour change to face, lips, nose/finger tips

Co-ordinated sucking/swallowing and breathing

Able to maintain consistent latch around teat and minimal milk loss observed
Maintains pattern of 3–5 suck-swallows followed by a breath, with occasional long pause
Returns to sucking in a pattern of short series of suck-swallow bursts and brief pauses for breathing

Supportive interventions during bottle feed

Responsive feeding following feeding readiness signs and offering external pacing as led by baby
Elevated side-lying feeding position
Slow flow teat

See Guideline Supporting Information