Learning how to safely breastfeed or bottle-feed is one of the most challenging tasks that we ask of our babies in the NICU. Many babies that are preterm or hospitalized are not able to safely eat by mouth until much later in their hospital stay. For example, maybe your baby is still too young or is currently requiring too much oxygen for them to safely coordinate their ability to suck, swallow, and breathe. So, what can you do in the meantime to promote early feeding development and promote positive associations with breastmilk or formula?

What is pre-feeding?

Pre-feeding is a set of skills your baby can practice in order to prepare for breastfeeding and/or bottle-feeding. Babies who are in the hospital experience stressful procedures every day to care for them.

Pre-feeding should be an activity that you and your baby can enjoy without any stress or discomfort.

The goal is to offer positive stimulation to your baby’s sensory system. There are two main skills that can be targeted.

• The ability to tolerate touch and smell
• Sucking and tasting breastmilk or formula

How to get started?

Make sure your baby is at least 28 weeks gestational age.

Most of the current research supports starting pre-feeding between 28-32 weeks gestational age. Pre-feeding skills can be practiced on all babies regardless of what kinds of respiratory support they require (intubated, CPAP, nasal cannula) or how their nutrition is being offered (orogastric tube, nasogastric tube, gastrostomy tube).

Disclaimer: It’s important to always consult with your baby’s medical team and feeding therapist prior to initiating pre-feeding activities. This education should not be construed as medical advice.

Create a calm and quiet environment.

⦁ Keep lights dim during care times
⦁ Keep voices low before, during, and after offering pre-feeding activities
⦁ Swaddle your baby with their hands near the middle of their body and near their face 

Look for signs that your baby is ready.

⦁ Stable heart rate, oxygen and breathing  
⦁ Calm, alert, and organized state (not crying, arching, or stressed).
⦁ Bringing hands to mouth
⦁ Rooting (turning towards a source of touch to the mouth/cheek)

Look for signs that your baby is NOT ready.

⦁ Decreased oxygen or heart rate
⦁ Increased breathing rate
⦁ Gagging or pushing pacifier out with tongue
⦁ Pursing lips shut (in a kiss face)
⦁ Arching their back
⦁ Turning away from gentle touch to their lips/cheek
⦁ Painful facial grimace or eyebrow raise
⦁ Splaying hands (hands in stop sign)

You may also be interested in:

10 UNEXPECTED WAYS YOUR NICU BABY IS TELLING YOU THEY ARE STRESSED

My baby looks ready for pre-feeding. Now what?

Your baby is constantly changing and developing while in the NICU. They may be asleep during some feeding times and wide-awake during others. That is why it is important to check in with your baby each time you practice pre-feeding.

The best part about pre-feeding is that you can meet your baby where they are on any given day.

Below are the components of pre-feeding listed in order from easiest to hardest skills to practice.

⦁ Breastmilk or formula on cloth – Place 2-3 droplets of your breastmilk or your baby’s formula on a small cloth that can be placed by their head during their tube feeding.

⦁ Skin-to-skin or Kangaroo Care – If your baby is sleepy, offer skin-to-skin contact by holding your baby on your chest while their tube feeding is being delivered.

⦁ Sucking on mother’s empty breast or pacifier – If your baby is awake and showing feeding cues (rooting when you gently stroke their lips or cheek), this is a great time to practice sucking while their tube feeding is offered.

You can either pump prior to pre-feeding sessions to have your baby practice latching to breast or you can use a pacifier to practice sucking. In some NICUs, when mothers practice having their baby latch to their empty breast, it is called “nuzzling.”

⦁ Milk drops – If your baby has latched to a pacifier or empty breast and is sucking, grab a 1ml syringe and ask your nurse to fill it with breastmilk or formula. You can offer up to 1ml of breastmilk or formula by dropping one droplet at a time into the corner of your baby’s mouth with a 1ml syringe. It is important to only offer one drop at a time and to allow your baby time to suck on the pacifier prior to offering the next drop. Check in with your baby every time you offer a droplet.

If they start showing signs of stress (pushing out the pacifier, pulling away, pursing their lips), stop offering the drops. Go back to just offering the dry pacifier or empty breast. If your baby continues to suck and seems to enjoy the droplets, keep going until you have reached 15 minutes of active sucking or your syringe is empty.

Why is this so important?

Research shows that practicing pre-feeding skills during the hospital stay helps NICU babies learn to enjoy feeding. By exposing babies to some of these experiences early on, we can prevent stressful experiences when our babies start trying to breastfeed and bottle-feed.

Research also shows that pre-feeding practice can increase the use of breastmilk at discharge from the hospital, reduce the time it takes for babies to take all of their nutrition by mouth, reduce the risk of feeding trouble at home, and help babies go home from the hospital sooner.

Pre-feeding is a wonderful time for you to bond with your baby and learn how they communicate comfort and stress. Enjoy this time getting to watch your baby grow and practice new skills!