Problem Solving: Adaptive behavior during feeding in the NICU

QUESTION: I am posting this for a colleague that works in our NICU department, we’d appreciate any insight you might have!

“Can there be significance to infant’s with tongue tip elevation as the preferred position while at rest?  We currently have two infants on our NICU caseload that consistently hold this position.  It is interfering with feeding as the infants both root but will infrequently bring their tongues down for nipple acceptance.  They are both from a twin gestation and were born between 28-30 weeks.  Neither have an oxygen need.  Any thoughts?”

This is an adaptive or compensatory behavior often seen in preterms, especially those born <28 weeks, but even in late preterms. It is associated with increased WOB and/or an increased respiratory rate. One of my favorite neonatologists, Dr. Ragatz, who was my mentor almost 30 years ago, loved to “think along with” me about how respiratory co-morbidities affect breathing. As a marathon runner, too, he concurred with me on this. Placing the tongue tip on the alveolar ridge provides the infant with  a point of stability for the tongue, and has an  impact on many of the muscles of the head/neck, including those that stabilize the shoulder girdle. This biomechanically creates the feeling of a more open airway.  No one has studied this phenomenon but a pulmonologist and several skilled neonatal OTs and PTs have agreed with this hypothesis. Our infants find ways to help themselves without someone telling them; this is an example, as is the spontaneous use of pursed lip breathing by preterms who need to blow off C02; adults with COPD are often taught this by RTs. Dr. Ragatz found it fascinating that what he reported experiencing while running the Boston Marathon was what we see some of preemies do.

When we see this behavior, it is communication to us that the infant is choosing to pause his sucking to breathe. And so we respect this, allow him the pause as long as he wishes, letting him signal his readiness to return to sucking via his active rooting on the nipple which is kept touching the corner of his lip during the pause. We then create a feeding “environment” that reduces his need to recruit this adaptive behavior. We do this by utilizing a swaddled elevated sidelying position, a slower flow nipple, and contingent co-regulated pacing to support a frequent series of deep breaths.

Think about the infant’s behavior not as “interfering” with feeding, but as the infant guiding you as the caregiver. When feeding the infant is perceived and valued as a relationship between the infant and the caregiver, the feeding experience builds trust and positive sensory-motor learning for the infant. This is the way we improve post-NICU feeding outcomes and support the parent-infant relationship in ways that have long-lasting effects.

I hope this is helpful.


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