Developmental Milestones and Appropriate Feeding Choices

Table 1

Developmental Milestones and Appropriate Feeding Choices

Feeding Change / Developmental Indicators
Addition of pureed foods and/or infant cereal given with a spoon / ·  Infant can sit with support and ahs neuromuscular control of the head and neck.
·  Infant can take food without choking or gagging.
·  Infant can indicate desire for food by opening the mouth and leaning forward.
·  Infant can indicate satiety by learning back and turning away.
·  Strong extrusion reflex has faded, and infant demonstrates ability to swallow non liquid foods, to transfer food from the front of the tongue to the back, and to draw in the lower lip as the spoon is removed.
·  Infant exhibits beginning of up and down chewing movements as opposed to sucking movements with the mouth.
Addition of first finger foods: large foods that won’t break into small pieces. / ·  Infant can sit independently and maintain balance while using hands to reach and grasp objects.
·  Infant grasps large pieces of food such as think dry, infant toast, in a palmar grasp.
Addition of cup feeding / ·  Infant exhibits ability to control size of sip and to manipulate liquid bolus to back of mouth and swallow without choking or gagging.
Addition of foods with increased texture and flavor / ·  Infant shows ability to manipulate food in the mouth with definite chewing movements.
·  Begins side to side, lateral tongue movements
Addition of smaller, softer finger foods / ·  Development of pincher grasp that allows infant to pick up foods between thumb and finger.
Transition to soft table foods / ·  “Munching” type of chewing
·  Improved ability to manipulate tongue and food bolus

Table 2

Hunger and Satiety Behaviors of Infants

Developmental Sequence Signals / Hunger / Satiety
Early Infancy / ·  Fussing
·  Makes sucking movements and sounds
·  Mouthing
·  Turns toward nipple and has rooting behaviors / ·  Draws away from nipple
·  Falls asleep
·  Chokes or coughs
·  Spits up
·  Averts gaze
·  Lack of facial expression and decreased muscle tone
Early Mid Infancy / ·  Hand-to-mouth
·  Leans forward and reaches out to breast or bottle / ·  Releases nipple and withdraws head
·  Fusses or cries
·  Arches back
·  Bites nipple
·  Increases attention to surroundings
·  “Halt” hand
Mid Infancy / ·  Vocalizes eagerness for bottle or food / ·  Changes position
·  Shakes head
·  Keeps mouth tightly closed
·  Hands become more active
·  Pushes or pulls away
Late Infancy / ·  Points or touches spoon or feeder’s hand / ·  Spits or sputters with tongue and lips
·  Hands bottle or cup to feeder
·  Crawls away

Feeding Assessment Checklist

Adapted from the work of Robin Glass, MS, OTR and Lynne Wolf, MOT, OTR, 1994

ü  Note state before, during and after feeding

ü  Can infant be brought into appropriate state for feeding? What works? How much assistance is needed?

ü  Does infant exhibit stress before, during or after feeding?

ü  Are reflexes that allow infant to locate and obtain food (rooting and sucking reflexes) and protect airways (cough and gag) expressed?

ü  Is there cough during feeding? When does it occur?

ü  Does the infant exhibit hypersensitive, hyposensitive, or aversive behavioral response to oral tactile input?

ü  Is feeding position optimal for this infant?

ü  Evaluate functions of each of the oral structures.

ü  Is infant capable of appropriately timed and organized suck, swallow, and breathe?

ü  Are breath sounds noisy during or following feedings?

ü  Are signs of increased respiratory effort observed during feeding?

ü  Does infant exhibit signs of fatigue before adequate intake has been achieved?

ü  Does infant demonstrate clear cues about feeding readiness and satiety?

ü  Does caregiver attend to cues given by infant?

ü  Does caregiver demonstrate affection during feeding?

Table 3

Infant Stress Cues

State and Attentional / Motoric / Autonomic
·  Irritability
·  Crying
·  Frenzy, inconsolability
·  Rapid state changes
·  Sleeplessness, restlessness
·  Drowsy alertness
·  Strained alertness
·  Panicked alertness, hyperalertness
·  Diffuse sleep or awake states
·  Staring
·  Frequent gaze aversion
·  Strained fussing or crying
·  Silent crying / ·  Motoric flaccidity: trunk, extremities, face
·  Motoric hypertonicity
·  Hyperextension of the legs
·  Hyperextension of the arms and hands
·  Truncal hyperextensions (arching)
·  Hyperflexions (fetal tucking, fisting)
·  Facial grimacing
·  Frantic, diffuse activity
·  Frequent twitching / Moderate stress
·  Signing
·  Yawning
·  Sneezing
·  Sweating (diaphoresis)
·  Hiccupping
·  Tremoring
·  Startling
·  Gasping
·  Straining
Major Stress (when seen with feeding)
·  Frequent or prolonged coughing
·  Spitting up
·  Gagging, choking
·  Color changes, cyanosis
·  Respiratory pauses
·  Irregular respirations

Assessment of Feeding Interactions

Caregiver Responsibilities:

·  Recognize and respond to the infant’s cues and respond in a contingent manner

·  Sooth or quiet a distressed infant

·  Demonstrate warmth and affection toward infant and communicate a positive feeling tone

·  Foster cognitive growth through touch, movement and talking

·  Delay stimulating or responding until the infant signals readiness

Infant/Child Responsibilities

·  Send clear cues to the caregiver, including:

o  Display of some tension at beginning of feeding and decrease in tension once feeding has begun.

o  Have periods of alertness during the feeding

o  Older infants cue the caregiver for interaction through vocalization and smiles

o  Cue the caregiver of need for a break or rest.

·  Respond to the caregiver’s attempts to communicate and interact

·  Stop crying when the caregiver attempts to sooth

·  Look in the direction of the caregivers’ face than the caregiver talks

·  Mold into the contours of the caregiver’s body

·  Suck and make feeding sounds following feeding attempts by the caregiver

·  Older infants vocalize or smile after the caregiver’s vocalization or smile

Medical and Developmental Factors that May Impact

Growth, Intake and Nutritional Needs

Condition / Nutritional Considerations
Respiratory
Bronchopulmonary Dysplasia (BPD) / ·  Increased energy needs
·  Risk for growth failure
·  Risk for feeding difficulties
·  Rick for drug-nutritional interactions
·  Recurrent illness/hospitalization
·  Risk of fluid and electrolyte imbalance
·  Osteopenia
Reactive airway disease RAD / ·  May have increased energy needs and decreased intake during respiratory illness
·  Risk for drug-nutrient interaction
Visual or Hearing Impairment
Retinopathy of prematurity (ROP) / ·  May have feeding difficulties secondary to alterations in giving and receiving feeding cues
·  May startle at beginning of feeds and have difficulties attaining state control for feeding
Gastrointestinal
Short Bowel Syndrome / ·  Nutritional implications vary with extent and site of resection. May include the following:
o  Fat malabsorption
o  Fluid and electrolyte imbalance
o  Vitamin and mineral deficiencies
Cholestasis / ·  Malabsorption of long chain fats
·  Fat soluble vitamin deficiencies
·  Possible water soluble and mineral deficiencies
·  Growth failure
Gastroesopageal Reflux / ·  Growth failure
·  Feeding difficulties/aversion
·  Anemia
Cardiovascular
Patent ductus arteriosis *(PDA)
Congenital heart disease (CHD)
Cor Pulmonale / ·  Fluid-electrolyte problems
·  Increased energy needs
·  Drug-nutrient interactions
·  Growth failure
·  Feeding difficulties
· 
Apnea/Bradicardia/Cyanosis (ABCs) / ·  May be related to feeding difficulties in some circumstances, i.e., difficulty coordinating suck-swallow-breath, choking, possible sign of reflux
Renal
Nephrocalcinosis / ·  Nutritional issues are related to degree of renal compromise
·  Acute complications include hematuria, pain, urinary tract infection
·  Persistent calcification may result in renal complications including hypertension and tubular dysfunction
·  Possible alterations in metabolism and nutritional status for: fluid and electrolytes, iron, calcium and phosphorus, and protein
Neurodevelopmental
Cerebral Palsy (CP)
Developmental delays
Motor immaturities
Learning disabilities / ·  Alterations in growth patterns
·  Inadequate intake/possible increased energy needs
·  Oral/motor/hypo or hypertonia leading to feeding difficulties
·  Drug-nutrient interactions
Nutritional
Anemia
Osteopenia
Failure to thrive
Small for Gestational Age (SGA) / ·  May have increased needs for energy for “catch-up-growth”
·  May have increased calcium and phosphorus needs
·  May have difficulties with glucose homeostasis
·  May have alterations in growth patterns.

Definitions and Classification Systems

Definitions

Apnea / Apnea is a pause in breathing which may lead to changes in heart rate (bradycardia) and color changes (cyanosis).
Bronchopulmonary Dysplasia / Bronchopulmonary Dysplasia: BPD is a chronic lung disease (CLD) occurring in ≤ 5% of newborn infants. The incidence is much higher in premature and LBW infants, occurring in 38% of ELBW infants. BPD is characterized by respiratory symptoms including tachypnea, CO2 retention, need for supplemental 02, diuretics, and other respiratory therapies. Characteristic radiographic changes are evident on x-ray
Bradycardia / Decrease in heart rate
Cholestasis / Arrest in the flow of bile. In LBW infants characterized by elevation in direct Bilirubin secondary to obstruction of enterohepatic circulation and decreased bile flow. TPN Cholestasis is seen in infants receiving prolonged TPN (≥2 weeks) and may result in liver damage.
Chronic Lung Disease / Term used to describe ongoing respiratory concerns, often determined by need for supplementary oxygen therapy at 36 weeks of life.
Cerebral Palsy / Chronic, non-progressive neuromuscular disorder resulting in abnormalities of posture, muscle tone, and motor coordination.
Cyanosis / Bluish coloration of skin and mucous membrane due to inadequate oxygenation. In LBW infants may accompany apneic episodes, or may be due to alterations in cardiac or respiratory function.
Desaturation / Term commonly used for LBW infants to indicate decrease in oxygen saturation of hemoglobin.
Enteral Nutrition / Provision of nutritional needs through the GI tract. Commonly used to refer to some method of tube feeding that uses the GI tract.
Gastroesophageal Reflux / Retrograde movement of stomach contents into the distal esophagus. Sometimes seen as regurgitation/vomiting.
Necrotizing Enterocolitis / Gastrointestinal disease characterized by areas of necrosis of the small or large bowel.
Nephrocalcinosis / Deposition of calcium compounds in the kidney.
Occipital Frontal Circumference / Head circumference
Osteopenia / Decreased calcification or density of bone.
Patent Ductus Arteriosus / Left to right shunt through an open ductus (PDA) increases pulmonary blood flow and potentially contributes to respiratory symptoms (increased work of breathing, desaturations, and radiographic changes of increased lung density.
Reactive Airway Disease / Commonly used to indicate asthma type symptoms in an infant or young child. May respond to bronchodialator therapy. Often a loosely defined term as currently applied to VLBW infants.
Short Bowel Syndrome / Malabsorption resulting from anatomical or functional loss of a significant length of the small intestine. Most commonly this occurs after bowel resection in the newborn period (i.e., secondary to necrotizing Enterocolitis).
Total Parenteral Nutrition / Intravenous provision of nutrients when Enteral intake is inadequate or impossible.

Adapted from http://depts.washington.edu