Question, with my responses in BOLD:  Hi Catherine – I was hoping to pick your brain on the sidelying position. I am wanting to understand more how and when people are using this technique. The information I have received has been mixed on the safety and purpose. I saw that you mentioned it in your response so I was hoping to get your take.

We have a unit in the area that uses it for all of their babies. I have seen a lot of kids who are still being fed in this position at 3-6 months of age. This can of course be problematic – any intervention must be used by therapists with thoughtfulness and critical thinking. I suggest to parents to determine readiness after discharge to move to a more typical position by “asking” the infant during a feeding, i.e., attempt to feed the infant in the more typical position and then observe – if the infant does as well as he did in sidelying, or better, in terms of feeding quality (based on stress signs specific swallowing and breathing, or lack thereof, which they have learned before discharge), then try changing to that position for feedings. If the infant does not do as well quality-wise with feeding, he is “telling you” he is not ready for the change in position. I find that about a month after discharge is a good time to “ask” the infant. Just basing it on age is not useful as age itself has little relevance to the prerequisites for a more challenging position, developmentally, posturally and swallowing-wise. We had one child that appeared to have asymmetrical facial features and in the end determined it was from always being fed in that position with a hand on his face and sleeping in that position as well. Those problems may have been co-occurring versus due to use of sidelying –I have not had that happen—but we (ST, OT in NICU) also reinforce thoughtful variety in infant experience. Variety is the key for infant’s at all ages – non-feeding times need to offer a variety of sensory-motor/postural experiences critical for motor learning.

I have been looking into the reasoning they provide families, and it is that food can then pool in the cheeks instead of the throat, to give more time to swallow, and because it’s “beneficial”. My concerns come into play in these areas: 1. Neonates don’t have buccal cavities because of sucking pads Most preterms do not have sucking pads, as they are believed to develop at approximately 36 weeks in utero. Regarding “pooling in cheeks” I don’t think that is good either. 2. Pooling anywhere is concerning, especially when you have significant respiratory concerns and are learning to coordinate the suck/swallow/breathe yes nothing should “pool”; it implies pathology 3. Possible muscle asymmetry created I have not seen this happen as noted above, with the right sensory-motor “environment”, both for feeding and non-feeding times 4. Losing focus on the underlying reason why eating is difficult and pushing before a baby is really ready. Sidelying itself does not push a baby to eat before he is ready, caregivers do. For me, use of sidelying has nothing to do with intake or pushing a preterm to feed. If I determine a preterm is ready to initiate nipple feeding (based a variety of critical domains assessed), I will typically utilize inclined sidelying (i.e. head higher than hips) as a supportive intervention.

I am completely open to learning, but just haven’t gotten much feedback from the professionals I have asked about them “why” of doing it and for which populations they are using it. I have been told my one that she uses it only with older infants that are struggling and by another that she only uses it in a temporary, transition role for 2-3 days for babes that are struggling with still after use of pacing and the slowest flow nipple. I cannot speak to their rationale but only mine, based on my clinical experience with breast and bottlefeeding of preterms, my NDT training, the literature and reflective thinking. I’ll try to hit the key points given the limited space and time. I offer more detail and problem-solving when I teach (see website below). (1) It affords more ease of anterior-posterior rib cage movement (so less effort for the preterm’s musculoskeletal system); (2) It increases lung compliance and decreases airway resistance (per work by Mary Massery, PT and Donna Frownfelter, PT who focus on breathing) (3) It decreases work of breathing due to requiring less anti-gravity movement during breathing (compared to semi-upright or cradled) (4) Makes it easier to maintain head and trunk alignment (5) Provides increased ability to generate subglottic pressure, as opposed to when upright; this may functionally assist effectiveness of cough, if indeed a cough is required, and the infant generates one (6) Bolus flow is less adversely affected by gravity as it can be in semi-upright), which can likely reduce potential for bolus misdirection (7) It is very similar to the cross-cradle position for breastfeeding, which is our benchmark for optimal oral feeding experiences (8) Clark et al, 2007 noted better oxygen saturations and less HR variability with use of sidelying with preterms (8) Suzanne Thoyre PhD at UNC-Chapel Hill, one of my colleagues, is currently studying sidelying with preterms, contrasted with cradled in arms position and semi-upright position; thus far the data are overwhelmingly supporting better state regulation, better swallowing and better physiologic stability with sidelying. (9) I have noted clear improvements in the swallow in Radiology with sidelying as compared to semi-upright with preterms.

Over the last 27 years in the NICU, I have found sidelying, along with slow/low flowrate and co-regulated external pacing, to be one of the most critical interventions to support positive and safe feeding experiences with preterms.