Assessment of Feeding Performance

State Control

A continuum of states of consciousness, ranging from deep sleep though awake states to crying has been described. The optimal state for feeding is an awake, alert, or active state, although some infants can feed adequately in a drowsy state. State control difficulties may be components of a variety of medical conditions. Assessment of state should be a routine part of feeding assessment and should include the following

  • Note infant’s state before, during, and after feeds.
  • If at any point the infant is not in an appropriate state, note if infant can be brought into an appropriate state.
  • Note what techniques are successful and how much assistance the infant needs to maintain appropriate state for feeding.


The feeding process places many demands on the infant. These demands may be internal, such as increased respiratory and digestive functions, or external, such as oral-tactile experiences during feeding or variations in ambient temperature, noise, or light. If these demands are beyond the infant’s adaptable capacities, the infant may respond with behaviors that reflect stress. If stress cues are noted before, during, or after a feeding, the source of the stress needs to be identified and modified. Examples of potential sources of stress:

  • Environmental: bright lights, noise, TV, distracting movements of siblings or others
  • Feeding related: liquid flowing too fast or slow, distracting movements of feeder
  • Internal discomfort: gastroesophageal reflux, desaturation, increased work of breathing

Infant Stress Cues

State and Attentional
  • 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
  • Sighing
  • Yawning
  • Sneezing
  • Sweating, (diaphoresis)
  • Hiccuping
  • 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

Responses to Tactile Input

Oral Reflexes: Oral reflexes can be either adaptive (assist the infant in locating and obtaining food, e.g.: rooting reflex and sucking reflex) or protective (keep airway free of foreign material or expel it as it enters the airway, e.g.: cough and gag). Expression of reflexes such as rooting and sucking can change depending on infant’s level of hunger or state of alertness and assessment should take this into account.

Assessment of cough during feeding is especially important in preterm infants. If cough occurs during sucking and swallowing it may indicate material crossing near or entering the airway as it descends through the pharynx. If coughing is observed during sucking pauses, or after feeding, it may indicate material ascending into the pharynx from gastroesophageal reflux.

Behavioral Responses to Tactile Input: During feeding the infant accommodates to a wide variety of tactile stimuli within the mouth as well as external stimuli from the touch of the feeder’s hands on the infant’s face or the touch-pressure of being held. The infant must perceive the tactile input appropriately to produce the appropriate motoric responses for feeding.

Preterm infants may perceive tactile input as stressful and may respond with a variety of stress reactions as described above. Early NICU experiences may have included negative and aversive stimuli to the oral-facial area. The infant may have been unable to engage in normal, pleasurable, oral exploration because of motoric immaturity or delay, intubation, or lack of experience. A pattern of learned negative or aversive behaviors that persists beyond discharge may develop.

Referral to a feeding therapist for a structured evaluation of tactile responses may be indicated for clear delineation of the threshold beyond which the infant has an inappropriate behavioral response to tactile input.

Feeding Position

An optimal position for young infants is characterized by orientation around midline, neutral anterior-posterior alignment of the head and neck, neutral alignment or slight flexion of the trunk, and flexed hips and knees.

When the feeding position is not satisfactory, the underlying factors affecting the position should be identified to develop appropriate positioning techniques. A frequent example is the preterm infant who extends, becomes hypertonic during feeding, and is difficult to hold in the optimal feeding position. This infant may be using neck extension to maintain a patent airway, may be showing a stress reaction to the tactile or gustatory aspects of feeding, or may have abnormalities of the central nervous system.

Oral Motor Control

Assessment of specific function of oral structures is most effective if the infant sucks on the examiner’s gloved finger. A wide variety of oral motor difficulties may be observed in LBW infants. Many problems are due to a lack of positional stability. Full-term infants are born with a substantial amount of subcutaneous fat and well defined fat pads in the checks. The tongue fills the oral cavity and is in physical contact with all the surfaces of the oral cavity. Additionally, at birth, the term infant has a strong physiological flexor tone that, combined with the exoskeleton, provides a stable base for the oral structure. In contrast, the premature infant has less muscle bulk and poorly developed tendons and ligament structures as well as less body fat. There is decreased opposition of the tongue to the surfaces of the oral cavity and reduced flexor tone through the head and neck with neck hyperextension. Lack of positional stability may lead to abnormal oral motor patterns, some of which may continue post discharge.

Examples of more common oral motor difficulties:

  • Tongue-tip elevation: the tip of the tongue is held firmly against the hard palate behind the upper alveolar ridge, potentially interfering with nipple insertion.
  • Tongue retraction: The tongue sits back in the mouth, well behind the alveolar ridges causing poor contact between the tongue and the nipple to stimulate appropriate tongue movements. Strong neck hyperextension can contribute to tongue retraction by pulling the tongue back into the mouth.
  • Tongue protrusion: The tongue pushes outward instead of moving in the normal wavelike anterior-posterior pattern. The tongue may compress the nipple, with little suction generated, leading to inefficient sucking. This pattern may be seen in infants who have sucked on endotracheal tubes and those with low tone.
  • Excessive Jaw Excursion: The jaw moves in a greater range than expected and the movement is poorly graded. Tongue contact on the nipple may be poor, diminishing both compression and suction. Lip seal can also be compromised, further impairing sucking

Pediatric Articles Dr Widodo Judarwanto (pediatrician)

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