I’ve decided to update a post I originally wrote in September 2010. Since then I’ve seen more than 200 children with DS for feeding evaluations. Aside from some wrinkles and a few extra-pounds, I’ve gained great experience – especially from our occupational therapist/feeding specialist Krystin Turner.
When assessing feeding in infants with Down syndrome I first listen to the family and ask:
- How long does it take for your child to take a bottle
- Which bottle/nipple are you using
- Does your child leak formula/breast milk when they drink?
- Do they race to take the first few ounces and then get tired?
- Does your baby take many sips in a row and then stop to catch her breath?
- Does your baby respond to feeding better at a certain time of day, in a particular position, etc?
- Are they interested in feeding? Are they active – moving during feeding (arching, wiggling, splaying fingers)?
These questions give me important clues about the quality of feeding and potential factors contributing to difficulties. I also get “hands-on” and look at:
- Structures of the face and mouth (like the palate)
- Reflexes including rooting and gagging
- Suck: Swallow: Breathe coordination when taking a bottle (the rhythm and pace of bottle drinking)
- Coordination and position of the jaw, lips, and tongue while feeding
One of the more common questions I get is regarding nipple choice. Is there one type of nipple that is the best for children with DS? In short – No. However, there are a few I don’t love. (I’ll get to that later)
When examining the child I look for a good latch on the nipple, lips that are well sealed, and minimal to no liquid loss when eating.
How do I know if the nipple is the problem with my baby’s poor feeding skills?
It’s important to work with a feeding specialist to determine the exact cause if your child isn’t eating well from a bottle. I used to be quick to change the nipple used, but now I alter positions and use other modifications to assist with bottle drinking. If your baby takes a long time to take a bottle (30+ minutes), isn’t gaining weight well compared to their own growth curve (regular growth charts), or has other signs of difficulty – coughing, gagging, arching, etc, talk to your pediatrician about a referral to see a feeding therapist. Depending on your area this could be an occupational therapist or a speech pathologist.
**Been there moment** I nursed my oldest son for 10 weeks before trying to transition him breast-to-bottle. I had 2 weeks before my return to work. I had registered for the finest bottles speech pathologists could recommend (at that time, he’s almost 9 years old now). The system was sterilized and ready to go…
… And I failed miserably. Failing to help Louis make this transition felt like failure as a mother.
I kept trying for those 2 weeks (insert many postpartum tears). He would take forever to use a stage 1 nipple and with a stage two milk would pour out like a faucet. It wasn’t until I tried my sixth nipple that he finally took the bottle with success. I didn’t know anything about bottle feeding at that time. To be honest, I had wonderful friends (Thanks Cory!) with children slightly older than mine who loaned me sterilized nipples and bottles to try out.
When evaluating a baby with Down syndrome I look to see if a baby is losing milk out of the lips, the frequency of loss, and when it’s occurring (at each suck, when swallowing, or when breathing). I try some simple modifications like using a side-lying hold, swaddling, pulling the cheeks forward before experimenting with a different nipple. The shape of the child’s palate, position of the tongue, and coordination of the lips all affect success. You can’t tell is there will be a problem just by looking at the structures – you must have a trained eye watch the whole feeding process.
So with all the choices out there, what type of nipple should I use?
First of all, if your child is not having any problems with the bottle they are already on, don’t change. In my experience with children with Down syndrome have good results using nipples that are narrow and long. We use a hospital grade nipple by Similac in our clinic. The closest thing in shape is Dr Brown’s silicone nipple. You don’t need the whole Dr. Brown’s system (with all of its many) parts. Just the nipple and standard bottle will work. I actually used this nipple with my youngest son on a glass bottle. If not Dr. Brown’s Natural Flow Nipple then latex nipples like Evenflo Classic Latex Nipple or NUK First Essentials Latex Nipple are close to this shape.
The more narrow base of these nipples allows for slightly more stability in the jaw. If the jaw is stable, this will help coordinate movement in the tongue and lips. Think about how a baby opens it mouth for a wide base versus a narrow one. Now think about you – Is it easier for you to eat a sub-sandwich or a plain old, two-slice ham and cheese?
Which flow is best?
Provided your baby does not have a heart or lung condition that causes fatigue, choose a slow flow nipple initially. Faster is not better and you don’t necessarily need to advance your child to the next flow level as they age. Your child should take between 15 and 25 for a full feeding. This essential to proper digestion. If he leaks formula or breast milk from one or both sides of the mouth, then try pulling his cheeks forward for support (see picture example). Your SLP or OT may also have some ideas about positions used to improve bottle drinking. Taking more than 30 minutes to eat can cause the child to burn calories. Talk to your pediatrician if your child consistently takes longer than a half-an-hour to take a bottle.
What are more serious problems that can occur during bottle feeding?
There are several things feeding therapist look for when working with an infant with Down syndrome. If your child experiences the following symptoms please contact your pediatrician feeding:
- Regularly coughing and sneezing, watery eyes, and/or runny nose during feeding but not necessarily other times
- A “wet” sounding voice, like her voice needs to be cleared
- No or little weight gain despite regular feedings as measured on the WHO growth chart
- Rapid fatigue
- Racing with many lengthy pauses to breathe (this may include breathing where the ribs appear to pull in strongly)
- Respiratory infections including pneumonia
- Frequent vomiting
I’ve heard I should use a slower nipple to make feeding an exercise for my baby. This will help his speech development.
Bottle feeding should not be used to “exercise” your baby. It’s true, the muscles used to suck from a nipple are the same as the ones for speech. However, they are controlled by different parts of the brain for the feeding process. You aren’t going to cross-train the muscles. A child can be a poor feeder and an excellent speaker. Speech is highly complex. That’s why it takes your baby longer to gain speech skills. That, and they wouldn’t survive without eating!
The most important thing, especially during the first few months, is growth. As a clinic we see more children with failure to gain weight than children who are obese. Breast milk and formula is rich in good fats and proteins, essential nutrients for brain development. No matter what way your child is feeding (tubes included!) you are helping them develop. Growth happens in body and mind.
Use feeding as a time to bond and develop a relationship with your little one. Feeding is the first communication experience baby’s encounter. Just after delivery their bodies sense us. Soon their eyes search for us. One day you will get a milky-smile looking up at you. Savor those moments. Smile and cuddle your precious baby. They will grow and thrive with your love.