Problem-Solving with Catherine

Question: I work in EI, in a primary-service provider, parent-coaching model doing home visits, and am considering taking courses to get an Infant/Toddler Mental Health certificate. Since strong relationships really provide the foundation for so many early communication foundations, I think this would be a beneficial area in which to learn more, but would love some feedback/input from other SLPs in the EI world.

Answer: I agree that the parent-infant relationship is best used to guide and inform our SLP practice, whether it’s supporting early communication in EI, or indeed in the NICU, while supporting the early communication that takes place first through the feeding relationship. Feeding isn’t a task of course, it is, when it is at its best, relationship-based.

As an NICU SLP, this is the heart of my daily practice as I empower parents to understand their infant’s communication during feeding, and let the infant guide them in providing a positive safe feeding experience. I call this “infant-guided” feeding. It fits so well with the concept of infant mental health, I thought I would share it with you.

Interaction between infant and parent is the mechanism through which the infant’s development ultimately occurs. Feeding is not solely a task of nutritional intake, but also has many social correlates in infancy and throughout the lifespan. Interaction during infant feeding aids the development of social interaction, communication and being responsive to others among both parents and the infant. Parents of healthy term infants regulate the environment and any stressful events for the infant through bonding and attachment. This “dance of attachment” between parents and the infant creates a blueprint for the infant’s future well-being, including brain development, nervous system regulation, ability to manage stress and sense of security. In the NICU, however, parents may experience the loss of their own homeostasis due to the stress of having a preterm infant. Parental anxiety, depression, and the sense of a loss of autonomy are common. The dissonance between the parents’ expectations and the reality of parenting an infant born early is often particularly stressful. Parents may perceive themselves as outsiders in the NICU and there may be difficulties for parents in developing relationships with their infant and staff. Therefore, empowering parents in the NICU is very important.

Research has shown that the ability to feed well is closely related to the caregiver’s ability to understand and sensitively respond to the infant’s physiology and behavioral communication. Depending on the perspective of the professional caregiver, however, feeding may be viewed as either supporting the infant in a positive learning opportunity or as emptying the bottle. Infant cues of stress may not be recognized by professional caregivers who remain focused on “getting it in” the infant. They may feed past the infant’s communicative “stop signs” in an effort to assure volume is ingested, using well-intentioned strategies that actually result in stress for the infant and often, incoordination. These volume-driven strategies, may include: increasing the flow rate to empty the bottle, which can cause the infant to “fight the flow” to breathe; prodding the infant, which takes away the infant’s active sensory-motor control over feeding, and delivers unanticipated flow into the infant’s oral cavity and/or pharynx; putting the infant’s head back to use gravity to help empty the bottle, which increases risk for bolus misdirection and airway compromise; unswaddling the infant to “keep him awake”, which actually takes away critical postural support for the swallowing mechanism. The infant may be expected to continue feeding, despite subtle signs of physiologic instability, behaviors that suggest swallowing and breathing are starting to uncouple, for example: drooling, gulping, nasal flaring and blanching, the lack of a regular series of deep breaths, chin tugging, and changes in eye gaze pattern. Communicative signs of disengagement may not be given meaning. These signs may include pushing the nipple out, pulling off the nipple, no active rooting or sucking, arching, shutting down/inability to re-alert, or purposeful use of a weak suck on the infant’s part to signal a preference for return to only pacifier sucking. If the role model provided for parents is volume-driven, parents may see their role as emptying the bottle or “getting it in” the infant. They may not correlate feeding behaviors with co-occurring physiologic instability, may not identify adverse events as problematic, and may not recognize and respond to infant “stop signs” during feeding. They may learn to view feeding a something they do “to their infant” not “with their infant “. Reducing stress for the infant promotes neuroprotection and reducing stress empowers the parents.

Parents observe and learn they can communicate back and forth with their infant during feeding, and that this conversation allows their infant to guide them. This co-regulated approach to feeding recognizes the impact of the caregiver on the infant’s experience of feeding and views the infant as a co-regulatory partner with his own agenda and emerging feeding skills. This co-regulation between parent and preterm becomes the foundation for strong parent-infant attachment and is formed most often during feeding experiences in the NICU. When the unique behavior of an infant is understood as a communicative attempt, and parents know how to respond to it effectively, feeding is both more successful and less stressful, and the attachment relationship tends to strengthen, while parental anxiety tends to diminish. Infant-guided feeding early on is the foundation for a strong parent-child-relationship that supports long-term positive outcomes a cross so many domains.

I hope this is helpful to embracing infant-guided feeding as a critical component of infant mental health. As you are able to incorporate this perspective into your work, both infants and caregivers benefit.

Catherine S. Shaker, MS/CCC-SLP, BCS-S