Transitional Feeding

Jae Kim, MD, PhD

This is my first entry to the Medela Neonatal Perspectives blog. I am thrilled to be able to contribute to this blog that allows me to connect with the neonatal community at large on topics of importance to the vulnerable infants we take care of. The first topic I wanted to cover is that of transitional feeding, the process when infants are learning to take on the developmental challenge of oral feeding after a prior period of only enteral feeding by oro- or naso-gastric tube feeding.

Preterm infants born before 34 weeks of gestation are typically not ready to suck at all or have effective sucking behavior. Sucking and swallowing are complex coordinated activities that come into place at specific developmental windows. (Commare & Tappenden, 2007) Swallowing requires the coordination of about 50 different muscle pairs in the head and neck.(NIDCD website: Dysphagia)

The ultimate goal for any infant, including those born preterm, is to establish exclusive breastfeeding with their mothers. However, there is an enormous initial challenge to provide mother’s own milk as mothers of preterm infants are more disadvantaged in producing enough milk herself. (Henderson, Hartmann, Newnham, & Simmer, 2008)Enteral tolerance is the most important hurdle as infants who can establish early enteral feeding adjust and have better growth. Getting infants to have a positive oral feeding experience is crucial to getting infants home in a timely manner and for establishing good feeding behavior to achieve the often lofty goal of successful breastfeeding from their mothers.

The establishment of early oral feeding is aided by several key influences:

1.     Skin-to-skin care (SSC)

2.     Early non-nutritive suck training

3.     Early oral feeding

Skin to skin care

Also known as kangaroo mother care, SSC care is an important bonding exercise for the mother-infant pair. The benefits of SSC in healthy newborns is well described and include more effective breastfeeding, stabilization of infant physiology such as temperature and metabolic function, and improved maternal-infant bonding.(Moore, Anderson, Bergman, & Dowswell, 2012)The preterm infant has similar gains in areas of improved breastfeeding, cardiorespiratory and temperature stability,sleep organization and duration of quiet sleep, neurodevelopmental outcomes, and modulation of pain responses.(Jefferies, Canadian Paediatric Society, & Newborn, 2012) More often than not, mothers have not had an opportunity to truly hold their sick infant for weeks after giving birth to their child. Bringing the mother/infant dyad physically together is a critical first step to setting the best stage for future oral feeding and breastfeeding.

Early non-nutritive suck training

Non-nutritive sucking on a pacifier or mother’s empty breast is an excellent way to train an infant to develop appropriate suck and swallow patterning.(Fucile, Gisel, McFarland, & Lau, 2011)Provoking the suck response with tactile stimuli is a powerful way to improve the coordination and development of the mature sucking pattern. In addition evidence suggests that these stimulated activities might have a positive effect on long-term neurodevelopmental outcomes.(Poore, Zimmerman, Barlow, Wang, & Gu, 2008)

Early oral feeding

Early oral feeding is best attempted under the guidance of a trained occupational therapist or experience neonatal nurse. Small volumes of milk feeding are best delivered in a controlled manner. Aspects of feeding can be divided and graded into several feeding parameters defined by the acronym, CRAMPS:

C oordination (poor latch, disorganized oral suck and swallow mechanics, milk dribbling out of mouth)

R eflux (pre-regurgitation swallowing, regurgitation or spit up, vomiting and/or signs of aversion, fussiness, apnea, etc.)

A version (infants turn away from nipple or show negative signs with feeding)

M aturity (infants are not waking for feeds, show disinterest in feeding)

P acing (infants have not learned to take pauses after a series of suck/swallow)

S tamina (infants tire after a short period of time, may be accompanied by changes in other parameters such as coordination and pacing)

Current methods to provide controlled oral feeding include finger feeding with feeding tubes, syringe feeding directly into the side of the mouth followed by pacifier use, or controlled and paced bottle feeding by experienced feeders.


The transitional feeding period is an exciting time to finally get preterm infants to their last major milestone before hospital discharge. Oral feeding can be aided by several key experiences by the infant including SSC, early non-nutritive suck training and assisted early oral feed training.


Dysphagia. Website- NIH Publication No. 10-4307. October 2010.

Commare, C. E., & Tappenden, K. A. (2007). Development of the infant intestine: implications for nutrition support. Nutr Clin Pract, 22(2), 159-173.

Fucile, S., Gisel, E. G., McFarland, D. H., & Lau, C. (2011). Oral and non-oral sensorimotor interventions enhance oral feeding performance in preterm infants. Dev Med Child Neurol, 53(9), 829-835. doi: 10.1111/j.1469-8749.2011.04023.x

Henderson, J. J., Hartmann, P. E., Newnham, J. P., & Simmer, K. (2008). Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women. Pediatr, 121(1), e92-100. doi: 121/1/e92 [pii]


Jefferies, A. L., Canadian Paediatric Society, Fetus, & Newborn, Committee. (2012). Kangaroo care for the preterm infant and family. Paediatr Child Health, 17(3), 141-146.

Moore, E. R., Anderson, G. C., Bergman, N., & Dowswell, T. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev, 5, CD003519. doi: 10.1002/14651858.CD003519.pub3

Poore, M., Zimmerman, E., Barlow, S. M., Wang, J., & Gu, F. (2008). Patterned orocutaneous therapy improves sucking and oral feeding in preterm infants. Acta Paediatr, 97(7), 920-927. doi: APA825 [pii]


About the Author

Jae Kim is an academic neonatologist and pediatric gastroenterologist and nutritionist at UC San Diego Medical Center and Rady Children’s Hospital of San Diego. He has been practicing medicine for over 23 years both in Canada and the USA. He has published numerous journal articles, book chapters, and speaks nationally on a variety of neonatal topics. He is the Director for the Neonatal-Perinatal Medicine Fellowship Program at UC San Diego and the Nutrition Director of an innovative multidisciplinary program to advance premature infant nutrition called SPIN (Supporting Premature Infant Nutrition, He is the co-author of the book, Best Medicine: Human Milk in the NICU. Dr. Kim is a clinical consultant with Medela, Inc.