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Feeding – the journey to feeding your baby

  • Now that your baby is staying on Butterfly ward, you may be wondering how you can get involved to support their feeding. It may have been your goal to breastfeed, but this may seem an enormous challenge if your baby is unable to feed due to their medical condition, surgery or prematurity.

    The journey to achieving oral feeding can appear to be a long one, however, there are lots of activities you can participate in as part of your baby's feeding team.

    The team

    There are a variety of staff to support you and your baby in the journey to oral feeding. The most important member of this team is YOU. You can help your baby make a good start with feeding. The earlier you get involved and the more you participate, the safer and more secure your baby will feel during feeding. Being fed by the same consistent carer makes Butterfly more like home for your baby.

    There are a variety of different Butterfly staff who will work alongside you to help you gain confidence in feeding your baby. These include:

    • Nursing staff: provide regular training and support at every feed should you need it. They will assist you to assess your baby's readiness for feeding and help you work out if your baby is coping during feeding.
    • Lactation Consultant (LC): sasists with breastfeeding, expressing and storing your breast milk
    • Speech pathologist: assesses your baby's feeding and teaches you ways to feed your baby safely
    • Dietitian: Supports your baby's growth and nutrition
    • Occupational therapist/physiotherapist: assists you to position your baby comfortably and safely for feeding
    • Doctors: will work with you and your baby to set goals and decide on a daily feeding plan 

    Cue based feeding

    Cue-based or baby-led feeding describes feeding that is guided by your baby's cues and not the volume of milk taken. Starting a feed in response to hunger cues is cue-based feeding. Stopping a feed and providing a break in response to disengagement cues is cue-based feeding. Ceasing a feed and settling to sleep in response to fullness cues is cue-based feeding. Cue-based feeding assists your baby to transition from nasogastric tube (NGT) feeding to oral or suck feeding and helps to prevent oral aversion. Oral aversion is when your baby dislikes being touched around the face or mouth or dislikes oral feeding. This can occur if babies are forced to feed or have negative experiences associated with feeding, their face or mouth. Volume-driven feeding focuses on how much your baby is fed and does not take into account the engagement or disengagement cues that signal hunger, fullness or the need for a break.

    Parent training packages about feeding your baby are available and are conducted by Butterfly staff. They are designed to give you the confidence and competence to assess your baby's readiness to feed, and to conduct cue-based breast and bottle feeding. The training is designed to increase your participation in feeding your baby and will help prepare you for going home.

    Breastfeeding and expressing on Butterfly

    Breastfeeding can take time to establish, even if your baby is born normally and goes straight to the breast in the birth suite. Mothers of babies who come to Butterfly face extra barriers to establishing breastfeeding. This can be due to having a baby who is unwell, being separated from the baby, being ill themselves, having had an c-section, or just the anxiety surrounding the whole situation. A NICU in a maternity hospital provides mothers with the continuous support of midwives and lactation consultants around the clock, and the babies are still near their mothers. However, having your baby transferred to a children's hospital can leave you feeling a bit lost and even more anxious. Expressing breast milk for your sick baby is something only you can do, and it is not just valuable but often essential that a sick baby receives breast milk and not formula.

    At RCH we aim to support and help you to overcome these barriers. We want to help you give your baby breast milk right from the start, continue to maintain a supply of breast milk throughout your baby's stay with us, and progress to breastfeeding before your baby goes home. Ask your bedside nurse to call the lactation consultant (LC) when you first come to Butterfly to discuss your personal needs as soon as possible.

    There is an LC available on the ward most days who can help facilitate expressing or feeding, is able to discuss expressing and storing your breast milk, and can explain the supports that are available to you. Breastfeeding is affected by the maturity, size and health of any infant, so advice and help will be tailored to your individual baby's needs.

    If you are separated from your baby because you have had a c-section and have had to stay in the maternity hospital while your baby comes to us, or are ill yourself so cannot visit, we will enlist the help of your partner or another family member to bring your expressed colostrum or milk over to Butterfly so that your baby can receive it as soon as possible.

    Depending on your health and the availability of rooms, we will offer you a room in our Postnatal Mother's Unit (see the My Room section of the Butterfly tab in My RCH app for more information) so that you can stay at RCH and be nearer to your baby. In the meantime, ask the midwives at your maternity hospital to help you get started with hand-expressing, as the earlier you start the better your milk supply will be. If your baby is not yet able to have any food, we will freeze what you have expressed until he or she can start feeds. Try to look after yourself and not neglect your own health, as tiredness, pain, dehydration and stress can all affect your milk supply.

    Butterfly has breast pumps available for every mother, or you can bring your own if you prefer. If your baby is going to be staying with us for a while, it will be best if you either buy your own pump or hire one, as you will need to express overnight and when at home, not just when you are here visiting the baby. In order for your milk supply to meet the needs of your baby you need to express 8 - 10 times in each 24 hour period, including overnight, just as if you were actually feeding the baby. The LC or bedside nurse will assist you with setting- up the breast pump and show you how to clean the equipment you use. In the first few days, until your milk starts to come in, you may be hand-expressing. We will show you how to do this and check your technique. We will also discuss ways of increasing or maintaining your supply, what to do if you experience problems, and how to store your breast milk and transition to breastfeeding.

    We have a freezer for storing small amounts of EBM, but space is limited. If your space in our freezer is full, it is important not to bring extra EBM in from home but to leave it in your own freezer.

    Hand hygiene is very important if you are expressing, and especially if you are hand-expressing. There are sinks in every room and hand sanitising gel at every baby's bedside so that you, and anyone helping you, can clean your hands every time before you start.

    If you smoke or take recreational drugs, are on prescribed medications for an illness of your own, take over-the-counter medications for hay fever or a cold, etc., or take alternative medicines such as vitamin or mineral supplements, it is best to let us know. In that way we can discuss with you what is safe or what alternatives can be explored.

    Our aim is to support your breastfeeding efforts and your own goals with how you wish to feed your baby.

    The following links have additional information and support about breastfeeding and expressing:

    Australian Breastfeeding Association: A community based self-help group offering information, counselling, and support services on breastfeeding issues. 24-hour breastfeeding helpline 1800 686 268.

    RCH Kids Health Info fact sheet: Breastfeeding a baby in hospital.

    RCH Kids Health Info fact sheet: Breastfeeding a baby at The Royal Children's Hospital.

    Nasogastric tube (NGT) feeding

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    Breast and bottle feeding require a baby to have a coordinated action of sucking, swallowing and breathing. Babies then have to work to digest the milk. This is hard work for many of the babies on Butterfly. To assist your baby to feed, breast milk or formula may need to be given through a nasogastric tube (NGT).

    ...

    The length of time a baby may need NGT feeding varies. NGT feeding provides your baby with the nutrition they need while giving them the time they need to develop and learn the skills required to feed orally (suck feed). Your baby will learn these skills at their own pace. There are many parts of your baby's NGT feeding routine that you can assist with. Ask your nurse when you can give your baby NGT feeds. You can also learn to identify whether your baby is showing signs of readiness to feed orally.

    NGT training

    The specific steps required to give your baby an NGT feed have been included in a training package specifically designed for you as parents and carers. This training package aims to teach you the knowledge and skills you need to be competent and confident giving NGT feeds to your baby. You will be mentored through the training by the Feeding team (see above). Once you feel you have the confidence and skills, you are encouraged to give NGT feeds to your baby as part of their daily feeding routine. You will get to know your baby and their signals of hunger and fullness. You will see whether they are alert enough for feeding and activities like sucking their dummy, or whether they are feeling tired and need a break. You will come to understand how well your baby copes with feeding, and finally whether your baby is ready to try oral feeding. At any stage along the feeding journey, you are encouraged to ask questions and discuss your observations of your baby with the Butterfly staff. Describing what your baby likes and doesn't like during feeding is invaluable when staff have to assist and feed your baby.

    Bottle feeding

    Occasionally breastfeeding is not possible for mother, baby or both. In the event that breastfeeding is not possible, Butterfly staff will discuss introduction and transition to bottle feeding. Bottle feeding, like breastfeeding, is an opportunity for interaction and loving contact between baby and carer. Your baby may receive both NGT feeding and bottle feeding while they grow and mature and develop oral feeding skills.

    Sepal bottles have been designed through consultation with RCH staff, and are the bottles that are used on Butterfly. Extra small (XS) and small teats (S) are used, and can be either slow or extra slow, which describes how fast the milk flows out. The bottles are used once and are then placed in a recycle bin. Different to most baby bottles, the bottle cap and teat are one piece. Sepal bottles are available at the Equipment Distribution Centre at RCH and can be purchased for use at home. Alternatively, you can provide your own bottles and teats in preparation for going home. It is recommended that these be trialled in Butterfly before you leave.

    Sepal bottle image

    The other bottle that you may see on Butterfly is the Special Needs Feeder, sometimes called a Haberman Feeder. These bottles are often recommended when sucking strength is reduced or when the milk flow needs to be more closely controlled. The three lines on the teat reservoir represent slow, medium and fast flow. The longer the line, the faster the flow. This teat has a slit valve which opens only when your baby is actively sucking on the teat. When your baby is not trying to feed, the slit remains closed and prevents milk coming out. A Special Needs Feeder may be recommended by a lactation consultant or speech pathologist following a feeding assessment. There are a variety of other teats that can be used to assist your baby with oral feeding. Recommendations for specialised bottles and teats are made by a speech pathologist following a feeding assessment.

    Feeding care plans

    Feeding care plans are often written and displayed near your baby's cot. They notify the feeding team members of how your baby is fed and the types of strategies that are used to help your baby to feed safely and well. Careplans also state what your baby likes and doesn't like with respect to things going on around them and to them. Please contribute to and use these feeding careplans during your stay. They are updated regularly as your baby changes and grows, and also in response to changes in feeding as a result of illness, surgery or other medical interventions.

    Ways you can help your baby to feed

    Providing expressed breast milk (EBM) for NGT feeding is often your first role in the feeding team. Butterfly staff will support you with expressing and storing your breast milk (see above and the "Breastfeeding and bottles" section in My Room within the My RCH app).

    Gentle mouth care with EBM can give your baby nice taste experiences and help to prepare them for breastfeeding when they are ready.

    Skin-to-skin care helps with breast milk production and improves your likelihood of breastfeeding success.

    You can also assist Butterfly staff to make your baby's environment a great place for feeding. Your baby needs an environment that is quiet, calm and softly lit. Turning off sound on mobile phones, talking in a quiet voice and shading your baby's eyes from direct light are all ways to create a supportive feeding environment. Talking to your baby before touching and moving them also alerts them to changes in the environment that occur around feed times.

    Comfort touch is another way you can participate in NGT feeding. Comfort touch is a slow gentle way to alert yet calm your baby. It helps your baby adapt to being touched, something that will occur with more regular feeding as your baby grows older.

    Non-nutritive sucking

    You can help your baby learn to feed by providing a dummy to suck during the NGT feed. This is called non-nutritive sucking. You can also encourage sucking with empty breast contact, where the baby is supported to latch onto the nipple immediately after their mother has expressed breast milk. This links sucking with the feeling of a full tummy that occurs during and after a NGT feed.

    We use gumdrop dummies on Butterfly. The green dummy is for smaller babies and the orange dummy is for those babies born at full-term. It is important to remember to wash your baby's dummy with warm soapy water before using it and store it in a clean dry place.

    Non nutritive sucking

    It is important to give your baby lots of opportunities to suck as this assists with the development of the muscles involved in feeding and improves digestion of the feed. Sucking a dummy or empty breast contact also helps your baby learn to coordinate sucking and breathing. Sucking also assists with settling to sleep and calming during medical treatments.

    Encourage your baby to suck at the following times:

    • before a feed
    • during a nasogastric tube feed
    • during medical treatments
    • to settle to sleep

    If you have questions about dummies please ask one of the Butterfly nursing staff caring for your baby. You can also speak to one of the Butterfly speech pathologists.

    Positioning for feeding

    Holding your baby during their NGT feed helps teach them the movements and positioning that occur specifically with feeding. By moving your baby out of the cot and positioning them for feeding, you are signalling that feeding is about to occur. You can position your baby swaddled in your lap, at the breast for breast contact or do skin-to-skin care. You can discuss which position is best with nursing staff or the speech pathologist. If your baby is asleep in bed during a tube feed, you can still provide comfort touch during feeding.

    Feeding positioning image 1 COCOON - The Royal Children's Hospital
    Feeding positioning image 2 COCOON - The Royal Children's Hospital
    Feeding positioning image 3 COCOON - The Royal Children's Hospital

    Communication

    Communication during feeding is almost as important as the milk! Communication includes not only talking to your baby in a quiet speaking voice, it can also include singing, eye contact and facial expression. These are all important ways to bond with your baby and to teach your baby that feeding is a positive and enjoyable activity.

    Assessing your baby's readiness to feed

    The decision to start oral feeds is a team decision. It is based on your baby's:

    • medical status
    • ability to maintain stability with breathing and heart function
    • ability to digest the milk
    • ability to cope with the positioning and handling associated with feeding
    • ability to remain alert for feeding
    • ability to communicate hunger and fullness
    • ability to suck, swallow and breathe.

    Feeding is "exercise" for your baby. It places extra workload on their heart, lungs and digestive system. Your baby needs to be "fit" enough to feed orally. The medical staff caring for your baby will assess their medical status and determine if your baby will cope with the extra demands that feeding creates. Your baby needs to maintain their heart rate and breathing rate at safe levels during and after oral feeding. Doing so demonstrates that they are fit enough to cope with the work of feeding. Butterfly staff will teach you how to assess if your baby is fit and strong enough to be handled, moved and positioned for feeding, and then if oral feeding can proceed as either breastfeeding or bottle feeding. By looking at your baby's monitor, breathing pattern, alert state, colour and muscle tone, you can assess if they are ready to feed and if they are coping with the feed.

    Babies are born with oral reflexes that help them to feed. Reflexes like sucking and swallowing are designed to make feeding possible for babies. The rooting reflex is also necessary for feeding. This is when your baby turns their head, opens their mouth and lowers their tongue in response to being touched on their face or mouth. This reflex helps your baby to find the "nipple" and latch on to it for feeding. Gagging is also present and helps babies clear the material that is too large for them to swallow. Coughing helps your baby clear their airway in the event that milk has traveled in the wrong direction toward the lungs instead of down to the stomach. These reflexes need to be present for your baby to feed orally. A speech pathologist can assess your baby's oral reflexes and assist with strategies to develop them in preparation for oral feeding.

    At the time of feeding, your baby's state of alertness is also observed. Early in the feeding journey, your baby may sleep through feeds. As they grow and mature, your baby may start to stir at feed times or stir and become alert during the cares that often occur before a feed. When assessing if your baby is ready for oral feeding, they need to be mature enough to become alert and stay alert during feeds. Babies can orally feed safely while drowsy, quiet alert or active alert (see Baby cues and interactions section to review these states).

    Infant cues that are associated with feeding are hunger cues and satiation or fullness cues. Hunger cues signal when your baby is ready to feed. Satiation cues signal when they have had enough or are no longer coping with the activity of feeding.


    Hunger cues can include:

    • Stirring before a feed or at feed times
    • Increasing movements and becoming more active
    • Rooting reflex
    • Hand to mouth movements
    • Sucking movements
    • Sucking on the fingers and hands
    • Opening the mouth in response to touch 
    • Crying 

    Baby feeding cues poster

    Oral feeding requires coordination of sucking, swallowing and breathing. How well your baby maintains and coordinates these actions during the feed is a measure of the "quality" of the feed. You can assist Butterfly staff to assess your baby's quality of oral feeding by reporting your observations during a feed. If your baby is having difficulty maintaining the activity of feeding, your baby might give you a cue that indicates they need a break. These are called disengagement cues. You may also see these cues if your baby is "full" and has had enough. Disengagement cues may include:

    • Cessation of sucking
    • Closing their mouth
    • Spilling milk from their mouth
    • Turning their head away from the breast, bottle or carer
    • Putting a hand up
    • Gagging
    • Pushing the nipple or teat out of their mouth with their tongue
    • A rapid transition to sleep

    HEN

    HEN is the Home Enteral Nutrition Program. Your baby may need to go home with NGT feeding as part of their daily routine. If this happens, you will be registered with the RCH Home Enteral Nutrition Program (HEN). This is government funded and allows RCH to provide families and babies with adequate equipment and formula (if required) for NGT feeding at home. You can also continue to use expressed breast milk at home as part of HEN.

    When your baby is enrolled with HEN you will have a dietitian who will continue to review your baby and provide you with supplies. Your baby will require regular reviews to make sure they are growing well and getting enough nutrition. If your baby's main medical care is moved to another hospital, the dietitian will liaise with the new hospital to plan future HEN supplies with them. When you go home you will be given a list of equipment you will be entitled to each month, your baby's formula recipe (if required), a booklet about your baby's NGT and relevant contact numbers. Your equipment including formula (if you need it) will be delivered every two months by the Equipment Distribution Centre.

    Other feeding reviews

    If your baby is discharged home with an NGT, they will continue to receive services from RCH dietitians. They can also be seen by other feeding team members. The Eating, Drinking and Swallowing Clinic is a speech pathology-run outpatient clinic in Specialist Clinic B. Your baby may be referred to this clinic for feeding assessment and therapy to support the development of oral feeding. If your baby is transferred to another hospital, outpatient feeding services may be arranged through them. Community services are also available to support your baby with the transition to oral feeding, and these will be discussed with you by a Butterfly staff member.