Some Common Feeding Problems for Low Birth Weight Infants

My baby falls asleep when I feed her. She doesn't seem to have the energy for feeding.

This is a fairly common problem in the first weeks at home for some babies. It will take some patience to get through this period. The solution will depend on the reason for the problem. Here are some possible reasons and potential solutions for a baby's lack of energy for feeding.

• Baby isn't able to maintain oxygen status while feeding. Some infants become hypoxemic during feedings even though they can maintain adequate oxygen status at other times. These infants might benefit from supplemental oxygen during feedings, or from "pacing" to allow feeding breaks to maintain adequate oxygen status.
• Baby is overwhelmed by too much surrounding activity while feeding. Sleep is a coping mechanism for some infants who are easily overwhelmed. Feedings in the hospital are often done in a quiet, dark setting, and nurses are able to attend to the infant's state without normal household interruptions. At home caregivers are likely to have multiple responsibilities; there may be noise from television, radio, other children, pets, visitors, or household appliances. The caregiver may be anxious about the infant's intake. Possible solutions include environmental measures to decrease exposure to light, noise, and movement while feeding, household support for the caregiver, and parental guidance about the importance of both infant and feeder "state" during feedings.
• Baby isn't able to take very much at each feeding. Small babies have a very limited stomach capacity. This problem can be approached with changes in schedule to provide smaller, more frequent feedings or concentration of formula or breast milk. Please see section in increasing formula concentration.
• Feeding is very hard work. For infants with lung disease or difficulties coordinating sucking and swallowing, mealtimes can be very tiring. Infants might benefit from pacing as described above, supplemental oxygen during feedings, or concentration of formula.
• Baby isn't getting enough total formula or breastmilk in a 24-hour period. Some babies are easily fatigued because they have trouble getting enough energy from food, and a cycle of inadequate intake and low endurance for feeding can begin. Depending on the reason for inadequate intake solutions might include concentrating formula, smaller more frequent meals, or tube feedings.
• Baby just isn't interested in feeding or appears not to have much of an appetite. Some infants seem to fall into this category. However, this conclusion should be reached only when other possibilities have been ruled out. In this case, parental support for dealing with this challenging problem should include matter-of-fact, firm encouragement of adequate intake.

My baby gets really upset when I try to feed her. Feeding doesn't seem to bring her any pleasure, and she fights it.

This is a problem that needs to be attended to immediately because some fairly serious causes should be ruled out. There are several possibilities to consider here.

• Gastroesophageal reflux with or without aspiration should be explored and treated if necessary.
• Some preterm infants associate feeding with the unpleasant things that happened to and around their mouths early in their lives. Some infants can move beyond this stage with consistent efforts from caregivers to make feeding a pleasant time. Force feeding is never an effective solution. A more structured approach may be required for some infants to gradually desensitize them to oral feeding. Feeding therapists can help to develop an individualized program.
• The flow of milk from the bottle or breast may be too rapid, or too slow. A change of bottle nipple type or change in the size of the hole in the nipple may help with this problem. Some breastfed babies do better if the milk let-down has been established when they are put to breast; the initial volume of milk that follows let down overwhelms others. Individual experimentation is usually needed to establish the right solution for any one infant.
• It may take time to establish a pleasant feeding relationship. For infants who have been hospitalized for long periods of time, it may take a while for caregivers and infants to learn together to make feeding work. This can be a challenge, and families will benefit from encouragement and support.

My baby coughs and gags when I feed her. Sometimes this even leads to spitting up.

• Infant has trouble coordinating suck-swallow-and breathe. A program of pacing the feeds until the infant has the neurological maturity to take over this function may be helpful. Parents should work with a feeding therapist to set up a program.
• The infant may tire at the end of the feeding and lose ability to coordinate suck-swallow-breathe. In this case, pacing so that the infant doesn't get as tired as above or smaller more frequent feedings may help.
• Milk may flow too rapidly from the bottle or breast. Changes in the nipple type or size of the hole may help. Breastfed babies may need to be put to breast after letdown has occurred.

My baby gets really frustrated when I put her to my breast. She really seems to prefer the bottle.

The infant may be frustrated if the mother has a limited milk supply. Mother's milk supply should be assessed and interventions to increase supply such as more frequent nursing or more frequent use of the breast pump may be helpful.

An infant may also experience difficulty "latching on." This may be due to fullness of the mother's breast, neurological problems of the infant, or characteristics of the maternal breast such as flat or inverted nipples. A lactation specialist referral will be helpful in this case.

It is important to remember that, especially when they first come home, most low birth weight infants are nutritionally vulnerable. They have limited reserves of fat, protein, and other nutrients. They are easily tired. They need to be adequately nourished in order to recover from the problems caused by being born early and small. Despite the importance of breastfeeding for these babies, it is more important to make sure that they remain as well-nourished as possible. Breastfeeding at the breast only may not offer the child optimal nourishment if the baby isn't capable of getting adequate energy and nutrients. Please see section on breastfeeding for information on supplementing breastmilk.

Some solutions that have worked for some mother/infant dyads include:

• Feeding at the breast first when the baby is most vigorous and hungry
• Or conversely, if the baby is so hungry that he will have no patience for the breast, giving a small amount of milk in the bottle and then putting to breast when the baby has calmed down
• Exposing the baby to the pleasures of being securely held against the mother's warm skin during non-feeding times
• Helping the mother to stay calm when the baby gets upset at being put to the breast
• Working with a lactation consultant who can watch the interaction when the baby is put to breast and work with the mother to come up with individual solutions
• Using a supplemented nursing system, feeding tube at the breast or other lactation aids

I try to follow the schedule set up in the hospital of feeding my baby every 3 to 4 hours, but I can't seem to get her to take the amount of formula or breast milk that she took in the hospital.

This baby may be sleeping longer than 3 to 4 hours at night. In this case, something needs to be done to make up the missed night feeding. The question of waking a preterm baby up for regular feedings at night is open to several interpretations and should be approached on an individual level. A sleepy baby may not be in an appropriate state for feeding, and families are likely to be in great need of nighttime sleep to cope with the challenges of the baby during the day. On the other hand some infants will not ingest enough breastmilk or formula to grow if they are allowed to sleep for much longer than 4 hours. Sometimes it is helpful to try a modified demand schedule where the caregiver regulates the timing of the feeding and the infant continues to regulate the volume at each feeding. Increasing the frequency of feedings during the day may allow the infant to sleep a little longer during the night and still have an adequate intake.

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