Question: Our health care system is looking at the pros/cons of administering maternal breast milk swabs vs drops via syringe to early preemies and other infants who are intubated. I am aware that the use of syringe is recommended for initial colostrum, but I question if this is a safe practice beyond that phase. Our feeding educators and micro-preemie champions feel that best practice is to administer swabs vs syringe, which is difficult to control. I would appreciate your thoughts and references on this matter.

Catherine’s Answer: The benefits of EBM from the first moments of extrauterine life have been well-documented. That said, some of the applications of this concept are somewhat worrisome and need to be grounded by our understanding of swallowing physiology, its emergence in the setting of prematurity, the impact of an ETT and the co-morbidities that co-occur for preterms and sick newborns who require neonatal intensive care. I have seen commentary from a therapist on social media saying, ” We start as young as 24 weeks. 0.2 mL”    While we know the fetus at 24 weeks of life is swallowing amniotic fluid for motor learning in the intrauterine environment, the extrauterine environment cannot provide the same underpinnings when a caregiver delivers fluid, even with the best of developmentally supportive infant-guided care. 

The complex and precarious nature of the swallow-breathe interface in these fragile infants is not always fully understood, so the need to pause and fully consider the risk-benefit ratio for such an intervention at that particular time in the infant’s recovery may not be fully appreciated. If there is an ETT in situ, then it may act, as our ENTs say, as a potential conduit for the milk drops (and EER/LPR for example) to invade the airway, silently or symptomatically. I would suspect that syringe delivery of a bolus would pose a greater risk, but no one to my knowledge has studied that question.

That does not mean pacifier dips or milk drops aren’t a valuable intervention, but timing and readiness are key considerations for any intervention available to us. I use it often in the NICU to promote both neuroprotection, motor learning for swallowing (often truncated by limited intrauterine learning secondary to preterm birth) and underpinnings for future PO attempts (so incorporate organized root-to-latch sequence, resting, and co-regulated pacing). Even for sick newborns with co-morbidities that predispose then to feeding/swallowing problems, this has clinically appeared to be quite helpful for the infant and as a learning process (via guided participation) for families in preparation for offering an infant-guided approach to PO feeding. 

I hope this was helpful. As we both know, there are rarely black and white answers to our clinical questions. They require thoughtful deliberation and critical thinking to minimize risk for these most fragile of our patients.