Gaining and Growing: Assuring Nutritional Care of Preterm Infants in the Community

Developmental Approach to Feeding Low Birth Weight Infants

 Table of Developmental Milestones and Appropriate Feeding Choices
 Hunger and Satiety Cues


Most infants follow a fairly predictable pattern of development. The standard advice about feeding infants in the first year of life is based on that pattern of development. Preterm infants may not necessarily reach developmental milestones at times predicted for full-term infants, and routine advice about advancing feeding skills and adding solid foods may not apply to low birth weight infants. It makes sense to consider an individualized or "developmental" approach to feeding advice for these infants in the first year of life.

An excellent approach to nutritional guidance for full-term infants is found with other anticipatory guidance on the Bright Futures Website. Guidelines and recommendations should be based on the child's developmental level, instead of only on her chronologic age.

In focus groups, parents of very low birth weight infants often spoke of the consequences when community health professionals misunderstood the developmental approach. An infant who was born at 28 weeks, is chronologically 4 months old when he is only 1 month old corrected age (see section on calculating corrected age). Nevertheless, parents of very low birth weight infants were frequently told that it was time to introduce solid foods to infants at this age. This is especially problematic when one considers that many low birth weight infants are slower to reach developmental stages even if corrected ages are used for comparison.

Parents often report that their low birth weight infants have difficulty transitioning to "solid" foods or that feeding difficulties persist into the second year of life (See What Parents Tell Us). We may be able to reduce some long lasting feeding problems by paying close attention to the readiness of each infant to advance feeding methods. This approach may prevent the "force feeding" that can occur if too much food is offered too soon to an infant who is not capable of sending clear satiety signals. It may also prevent the problem of missing developmental cues and maintaining an infant or young child on a diet that lacks texture or variety because foods were not presented when the infant was ready for them.

The table below is a tool to give developmentally appropriate advice about advancing methods of feeding and offering new foods. It is assumed that the infant will have only breastmilk or formula for the first months of life.

Table of 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 has 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 leaning 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 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 thick 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 pincer 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

Hunger and Satiety Cues

Cues that signal readiness to eat and to stop eating may be very subtle in VLBW infants when they are first discharged home. These cues usually follow a predictable sequence of development. It is worth noting that some families first encounter difficulties with feeding when infants develop sufficiently to give strong and potent satiety cues. If the infant clearly does not want to eat, but parents are concerned about inadequate intake, further assessment and referral for feeding and/or nutrition services may be helpful.

Hunger and Satiety Behaviors of Infants

Adapted from Pipes and Barnard.

Developmental Sequence Signals



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
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Page reviewed: March 24, 2015