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

Feeding Relationship During the First Year of Life

 Referral for Further Evaluation and Treatment


In typically developing infants, feeding skills evolve so that infants become increasingly independent with advancing age. The caregiver-infant relationship involving premature infants, especially those with ongoing health problems, can be influenced by a myriad of factors, some of which include length of hospitalization, degree of social support, maternal confidence, postnatal complications, and infant temperament. Furthermore, aspiration, gastroesophageal reflux, and aversion to food and resistance to eating may complicate an infant's feeding. Chronic lung disease or congenital heart disease may cause fatigue and prevent the infant from having the energy to feed.

a) Why might a VLBW infant have difficulties with the feeding relationship?

An infant who has experienced prolonged airway intubation or tube feeding through a nasogastric tube may perceive an approach to his or her mouth or face as a potential discomfort. In addition, infants fed via nasogastric tubes early in life may have little exposure to oral stimulation. Lack of early oral sensory input and perception can lead to hypersensitivity and hyperirritability during feeding.

According to a recent study, infants who experienced prolonged intubation started breast-feeding at about twice the postnatal age of infants with short-term intubation. Furthermore, feeding score at 3 months was the strongest predictor of time intubated. This emphasizes the impact of prolonged intubation on oral motor function and feeding (Blaymore-Bier, 1993).

Infant control over his/her arousal level may impact the parent-infant relationship. Sucking can help an infant attain state organization and acts as a stress reliever for the infant. Oral-motor problems may inadvertently reduce self-regulation abilities, decreasing opportunities for parent-infant interaction. (Humphry, 1991)

Preterm infants have developmental immaturities that may contribute to alterations in feeding patterns and ability to communicate with caregivers.

Preterm infants are often found to have higher rates of "difficult" temperament in the first months of life. In a recent study, infant's birth weight and the baby's temperament at 4 months were predictive of mother-infant interaction with their preterm infants. However, by 8 months, the infant's birth weight was not an important predictor of mother-infant interaction. (Zahr, 1991)

b) How does the maternal attitude/demeanor impact infant feeding/growth?

The caregiver-child interaction and the availability of appropriate foods determine whether a typically developing child successfully obtains food. Hungry infants are comforted and consoled when parents provide them with food. This is one of the ways in which caregiver-infant bonds are reinforced.

Premature infants are usually perceived as fragile, and mothers often report feeling insecure about handling them. As a result, mothers may withdraw from their infants and interact unfavorably with them. Furthermore, data indicate that maternal depression and anxiety, which appear to be found at higher rates among women who have delivered preterm infants, are related to decreased maternal encouragement of feeding (Meyer, 1994).

c) What is the potential impact of the caregiver-infant relationship on feeding and growth?

The quality of the relationship can either be a positive or negative experience for both parent and infant. Strengths of one member of the caregiver-infant team can compensate for the difficulty experienced by the other. Thus, the development of an infant may be influenced not only by biological risk factors but also by the ability of the parent to compensate and provide modifications as needed during feeding. (Humphry, 1991)

Not only does the parent's attitude affect the infant's eating, but a child's food aversion may cause parental anxiety resulting in pressure on the child to eat. Poor growth and eating/feeding disorders may contribute to a lack of confidence in caregivers. Studies show that mothers of children with growth deficiencies are less confident about their parenting abilities than mothers of children without growth deficiencies. (Bithoney, 1995)

Failure to thrive and poor feeding have been linked to emotional deprivation in infants. Lack of nurturing results in reduction of food intake; this may be associated with lack of appetite, a common condition in infants with chronic diseases. (Rudolph, 1994)


Quick Checklist for the Health Professional

1. Assess factors that may influence the feeding relationship

2. Observe feeding (Note: an excellent tool for evaluating infant/caregiver interactions during feeding is the NCAST Feeding scale - see references under Barnard, K.)

  • Quality of interactions
  • Facial expressions of caregiver and child
  • Body language in positioning and interactions
  • Use of touch and cuddling
  • Parental responsiveness to infant cues to start, slow down, and stop feeding
  • Parental response to infant distress
  • Negative interactions
  • Alertness of infant

3. Interview parent

  • Feeding history
  • Sources of information about feeding
  • Goals for feeding intake, timing of feeds, feeding skills, infant growth
  • Feelings about feedings

Further assessment of the caregiver-child feeding relationship

The assessment will be more successful if it is individualized. Important components include:

  • Infant temperament and/or the match between parental and infant temperaments: Efforts should be focused on the assessment of maternal perceptions about the infant because maternal rating of infant temperament is a significant variable that correlates with caregiver-infant interaction (Zhar 1991).
  • Parental perception of the infant's problem: The family's assessment should be included in an intervention plan for feeding problems. Additional sources of parenting information should be identified. It follows that recommendations consistent with the social network influencing feeding practices will increase the likelihood of the family's ability to carry out any interventions. (Humphry, 1991)
  • Assessment of psychosocial risk factors: The birth of a low birth weight infant is stressful and challenging for every family. Family function, social support, family adjustment and maternal depression should be considered. (Bithoney, 1995)

Possible Interventions

Family Centered

Family-centered interventions can improve mother-infant feeding interactions. Professionals and families must work together to find solutions because intervention programs, no matter how well intended, do not work unless parents can implement them.

Preparation for Discharge

Preparation for hospital discharge should begin well in advance of discharge. Psychosocial interventions with a family focus during hospitalization have been shown to improve the transition from hospital to home (Meyer, 1994). Written information is helpful, as verbal recommendations may be forgotten in the flurry of activity that occurs at the time of discharge. Books by parents who have had preterm infants are also wonderful sources of practical advice. Rooming in or other trial situations in which parents are given the caregiving responsibility for a set amount of time can enhance the caregiver's sense of competency and reduce anxiety.

General Support for the Family

Feeding interactions are not isolated from other challenges of living with a low birth weight infant. General support for families of preterm infants can improve interactions in general and lead to a better feeding situation. Mothers have identified needs that include knowledge and skills, time, coping strategies, support, professional resources, and material resources (Sterling, 1990).

Specific Interventions

Specific plans for changing caregiver-infant feeding interactions should be thoughtfully considered and be developmentally appropriate for both infant and caregiver. Time commitment and level of impact on other aspects of family life should be taken into account. Enhancing parental sense of control over some aspect of the infant's condition is important. When parents are provided with information about child development and are involved in problem solving, positive developmental outcomes are likely to result. Likewise, intervention programs with an emphasis on improving and supporting caregiver-infant interaction can increase overall quality of the infant-caregiver relationship (Humphry, 1991).

NCAST Feeding Scales

Several studies using the NCAST Feeding Scale (Barnard, 1994) find that teaching parenting skills to parents of low birth weight infants result in consistent, significant improvement in infant development compared to routine follow-up care. The improvements in development were especially striking in VLBW infants. Improving the observational skills of parents, enhancing sensitivity to infant cues, instructing parents about child development, along with providing caregiver-infant enrichment exercises were all components of the parenting interventions. The feeding scale tool may be used with parents to point out areas where things are going well, as well as areas that need work. Many public health nurses and others in the Pacific Northwest have been trained in the use of this tool.

Nutrition Interventions

If the feeding relationship is a difficult one due to limitations imposed by the infant's immaturities or medical condition, nutrition interventions should be considered. These are covered elsewhere on this site and include tube feedings and concentration of formula.

Referral for Further Evaluation and Treatment

The following indicate need for referral:

  • Significant growth problems (see section on growth assessment)
  • Observation of significant negative interactions around feeding
  • Parent states that she or he feels unable to feed child
  • Parent is unable to read infant's cues and persists in overriding infant cues during feeding

Potential sources for referral (See resources for Alaska, Idaho, Oregon, Washington)

  • Public Health Nurse
  • Early Intervention Center/Birth to Three
  • Mental Health Referral
  • Feeding Intervention Team
Feeding Homepage
Gaining and Growing Homepage
More information contact:
Page reviewed: March 24, 2015