Avoiding Oral Aversion in the NICU

Sandy Sundquist Beauman, MSN, RNC-NIC / February 2017


Eating is a pleasurable experience for most of us. Many of our favorite social events, holidays, activities, and even TV shows center around it (Chopped and Diners, Drive-Ins and Dives are some of my favorites!).

Think of your most treasured childhood memories – many involve food, I’m sure. Things like a tasty cookout at the beach, ice cream on a hot day alongside friends and family, and your grandmother’s green chili, or tamales, or macaroni.

But considering our NICU patients, we must realize there will be possible future food-related challenges for them.

Infants who spend their earliest days in the NICU often have oral aversion, which can make eating an unpleasant experience. How does this happen, and how can we prevent it?

Why does oral aversion occur?

Oral aversion happens due to unpleasant oral experiences, and results in a hyperactive gag reflex and touch aversion.1 For sick or premature infants, consider the multiple procedures involving the mouth: Some are intubation, oral feeding tube passage, oral and endotracheal suctioning, force feeding, or pacifiers or nipples with an unpleasant or strong taste, for example.

Other conditions can contribute to oral aversion, such as gastrointestinal reflux, congenital diaphragmatic hernia and tracheoesophageal fistula, all of which involve esophageal dysmotility.

How can we reduce oral aversion in the NICU?

Some negative oral experiences cannot be avoided, like an endotracheal tube. This should not be compounded by other negative oral experiences, but rather counteracted by positive experiences.

Oral care with colostrum and soft swabs, gentle suctioning while providing containment, and possibly sucrose, will help avoid a negative response. Gentle passage of oral feeding tubes is also important in avoiding negative oral experiences. Moistening the tube before passing it, having the infant suck on a pacifier so that it passes easier, and providing sucrose for the passage of the tube are all measures that can help.

Finally, unpleasant feeding experiences will lead to oral aversion as well. Many of us know someone who could get any baby to eat. But is the baby really eating… or is the nurse pouring the feeding into the infant? The pushing of the nipple, manipulation of the mouth and cheeks, and often gastric reflux as well, may make feeding time unpleasant.

Feedings should be given according to the infant’s cues, and not our time clock. Cue-based feedings are given when the infant exhibits signs that he/she is ready to eat, and not when the caretaker is ready. Furthermore, when the infant gives cues that they are done eating, the feeding should be stopped rather than trying to force the infant to finish.

Feeding maturation is a result of developmental changes and experiential learning. In other words, infants must have practice at feeding in order to become adept at it. Some infants are ready for oral feeding at early gestational ages, while others are not until almost term gestation. Factors that affect this readiness are severity of illness, prematurity, neurologic abnormalities, and development of oral aversion.1

We must realize that, contrary to what many of us may have learned early in our NICU career, coordination of suck, swallow and breathe does not magically occur at 34 to 36 weeks. For some infants, this happens much earlier, with successful breast feeding having been reported as early as 26 weeks gestation and some infants able to successfully nipple feed as early as 32 weeks gestation. However, in order to implement oral feeding at these early gestational ages, careful assessment is required with each feeding. Infant cues must be observed to indicate the infant is ready to feed orally, and oral feeding stopped when the infant indicates he/she is no longer engaged in the act of feeding. There are several feeding readiness scales and cue-based feeding protocols available.2-6

Treating the oral aversion is sometimes necessary when physical conditions exist that lead to oral aversion. In extreme cases, infants will become bradycardic or apneic when anything touches their lips.  Perhaps you’ve seen this in your own practice. You place a finger on their lips or drip a little milk onto their lips and they turn away, cry, turn blue or become distressed in other ways. The process to correct this, if it can be done, takes a long time.7

Many of these children continue to have sensitivities and eating problems into childhood, and perhaps even into adulthood. Avoiding this sensitivity, when possible, is certainly preferable. We’d all like to see our tiny charges grow strong and healthy, and to someday have memorable food experiences that bring them joy.


  1. Gardner, S & Goldson E. The Neonate and the Environment: Impact on Development.  In Gardner, S. L., Carter, B. S., Enzman-Hines, M. I., & Hernandez, J. A. (2011). Merenstein & Gardner’s handbook of neonatal intensive care. Elsevier Health Sciences. Pp270-331.
  2. White, A., & Parnell, K. (2013). The transition from tube to full oral feeding (breast or bottle)–A cue-based developmental approach. Journal of Neonatal Nursing, 19(4), 189-197.
  3. Ludwig, S. M., & Waitzman, K. A. (2007). Changing feeding documentation to reflect infant-driven feeding practice. Newborn and Infant Nursing Reviews, 7(3), 155-160.
  4. Newland, L., L’Huillier, M. W., & Petrey, B. (2013). Implementation of cue-based feeding in a level III NICU. Neonatal Network, 32(2), 132-137.
  5. Kinneer, M. D., & Beachy, P. (1994). Nipple Feeding Premature Infants in the Neonatal Intensive‐Care Unit: Factors and Decisions. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 23(2), 105-112.
  6. Waitzman, K. A., Ludwig, S. M., & Nelson, C. L. (2014). Contributing to Content Validity of the Infant-Driven Feeding Scales© through Delphi surveys. Newborn and Infant Nursing Reviews, 14(3), 88-91.
  7. Seabert, H., Eastwood, E. C., & Harris, A. (2004). A multiprofessional children’s feeding clinic. The journal of family health care, 15(3), 72-74.


About the Author

Sandy Sundquist Beauman has over 30 years of experience in neonatal nursing. In addition to her clinical work, she is very active in the National Association of Neonatal Nurses, has authored or edited several journal articles and book chapters, and speaks nationally on a variety of neonatal topics. She currently works in a research capacity to improve healthcare for neonates. Sandy is also a clinical consultant with Medela. You can find more information about Sandy and her work and interests at https://www.linkedin.com/in/sandy-beauman-0a140710/.