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Readiness Indicators for Oral Feeding in Infants

Claire Miller, PhD, MHA, CCC-SLP, Debbie Dorr, MA, CCC-SLP

January 23, 2017



What are some indicators that would suggest an infant is ready for oral feeding? 


Prior to feeding portion of a feeding assessment with an infant, it is important to consider the infant’s responsiveness, level of alertness and overall behavioral characteristics.  Readiness for oral feeding is not based entirely on gestational age.  First, the infant needs to demonstrate neurobehavioral organization which is the infant’s ability to organize themselves within their own central nervous system maturation and environment.  The caregiver can actually help structure the environment to support the infants’ development. For example, when a caregiver learns to read the infant’s cues and to understand the techniques that support neurobehavioral organization, those interactions are going to support positive interactions and development.  There are several standardized assessments that assess readiness and early feeding skills specific to infants – the Systematic Assessment of the Infant at the Breast, the Preterm Infant Breast-Feeding Scale, The Early Feeding Skills Assessment for Preterm Infants and the NOMAS are a few examples. 

In general, the SLP should be aware of the following readiness indicators:

  • Respiratory rate (breaths per minute) should be 60 or below. You will want to check with your specific medical team to confirm the guidelines in your setting and with each individual case. 
  • Oxygen saturation should be above 92%
  • Minimal fluctuation of heart rate
  • Absence of stress signals which include alterations in breathing, color changes, tremors or startles, placidity (i.e., meaning the baby is very floppy), hypertonicity or stiffness, hyperflexion, gaze aversion or frantic sort of diffuse activity
  • Infant is able to maintain homeostasis, meaning a relatively stable state of equilibrium

The Infant Behavioral States, according to Heidi Als (1995), describe the behavioral organization of the newborn infant.  The states are:

  • State 1  - Deep Sleep, seldom seen in a preterm
  • State 2  - Light Sleep
  • State 3* - Drowsy
  • State 4* - Quiet awake and/or alert
  • State 5* - Actively awake and aroused
  • State 6  - Highly aroused, agitated, upset &/or crying

ÜOral feeding optimal at these states

It is best to do oral feeding in states 3,4 and 5. Otherwise, the baby is will not be alert enough or the baby is so frantic that the he will not be able to organize himself enough to concentrate on the complex work that feeding is for the infant. Ideally, we want to have an oral feeding that occurs in the context of a drowsy or a quiet alert state.

Please refer to the SpeechPathology.com course,  Overview of Clinical Assessment and Instrumental Evaluation of Pediatric Dysphagia, presented in parternship with Cincinnati Children's for more in-depth information about clinical feeding evaluation in the pediatric population and indications for instrumental swallowing assessment.

claire miller

Claire Miller, PhD, MHA, CCC-SLP

Claire Miller is the Program Director of the Aerodigestive and Esophageal Center/Interdisciplinary Feeding Team at Cincinnati Children’s Hospital Medical Center, and holds a clinical position in the Division of Speech-Language Pathology at Cincinnati Children’s. She has a faculty appointment as a Field Service Associate Professor in the Department of Otolaryngology-Head and Neck Surgery at the University of Cincinnati, College of Medicine, and also holds an Assistant Professor - Affiliate appointment in the Department of Communication Sciences and Disorders at the University of Cincinnati.   Her research and clinical interests are in the area of pediatric dysphagia, with a focus on instrumental swallowing assessment and clinical management of infants and children with pediatric dysphagia. 

debbie dorr

Debbie Dorr, MA, CCC-SLP

Debbie Dorr is a member of the Division of Speech-Language Pathology, and participates on the Interdisciplinary Feeding Team, the Videofluoroscopic Swallowing Clinic, Fiberoptic Endoscopic Evaluation of Swallowing (FEES) clinic and also works in the Multidisciplinary Feeding Treatment Clinic. Her area of clinical expertise and focus is evaluation and assessment of infants and children with varied medical diagnoses with accompanying dysphagia. 

Related Courses

20Q: Evaluation and Management of Pediatric Dysphagia
Presented by Claire Kane Miller, PhD, CCC-SLP, BCS-S


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This course provides an overview of pediatric dysphagia, with a specific focus on the role of the speech-language pathologist in the assessment and treatment of infants and children with dysphagia. Clinical protocols for clinical and instrumental assessments are reviewed and options for treatment interventions are summarized.

Thickened Liquids in Clinical Practice: The Plot “Thickens”
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Clinicians who utilize thickened liquids in their clinical practice are aware of their benefits, but what about the risks and contraindications? Advantages and disadvantages of thickened liquids are reviewed in this course with a focus on clinical outcomes, including impacts on medication administration, lung health, and hydration. Product types are evaluated to facilitate appropriate choices for individual clients.

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The importance of using IDSSI to provide standardized language when speaking about texture modification is discussed in this course. Comparisons of IDDSI and the National Dysphagia Diet (NDD), as well as IDDSI standards for pediatric vs. adult patients are presented. Additionally, potential barriers, solutions, and frequently asked questions related to implementation of IDDSI are described.

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Screening of swallow function is a well-regarded tool to identify individuals who are potentially at risk of dysphagia and in need of full swallow assessment, but the options are many and varied. This "back to basics" course teaches participants to make informed, evidence-based choices regarding appropriate screening tools specific to their particular patient populations and settings.

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