Oral Feeding in the NICU: 3 Reasons Why Flow Rate Matters

By Sue Ludwig and Kara Ann Waitzman

You just got your assignment for nightshift in the NICU. One of your patients, baby Smith, is ready to eat. You learn in report that his parents were with him all day and have gone home to have dinner with their other 2 kids. You notice that he has not 1, not 2, but 3 different bottles/nipples at the bedside, all with different flow rates. You check documentation and learn that over the last few days baby Smith has been fed using any one of the 3 nipples depending who was feeding him. There is no documentation that correlates feeding quality and caregiver techniques, so you’re not sure how to predetermine which nipple/bottle solution is the best choice for him.

To which we say, “People. These inconsistencies must stop. Are we still tolerating a practice and culture that provides the infant with a different experience with each new caregiver?”

Flow rate matters. And it’s no longer okay to choose a ‘favorite’ flow rate or nipple/bottle system (when mom not breastfeeding). It’s only okay to assess the infant’s individual needs and respond accordingly and consistently.

Why is it important to make consistent and educated decisions about flow rate?

  1. Picture drinking through a coffee straw versus a fire hose. Would one of those choices lead to gulping, liquid loss, and perhaps choking? Would the fire hose feel safe? Nurturing? How many times would you like to do that per day? What if you had to adjust to either flow rate without warning?

    The first goal of the Infant-Driven Feeding® Model of Practice is safety. Feeding safety can change dramatically based on the equipment we choose for an infant. We must make decisions about flow rate based on comprehensive knowledge of feeding and swallowing while utilizing age-appropriate assessments, language and documentation rather than our own subjective preferences. Safety first.


  2. Feeding is a repetitive experience. Therefore countless neuronal pathways will develop around the activity of feeding. Whether those experiences are wired in a positive or negative way is partly, if not largely, up to the caregiver. (Yes, diagnoses and co-morbidities matter too. In some cases, overwhelmingly so.)

    Therefore, the flow rate the team chooses for baby Smith becomes part of that journey. It’s both that simple and that complex. YOU are someone’s repetitive-experience-provider. And we know that when you are armed with more information about the importance of flow rate, you choose to contribute to positive pathways every day.

    NOTE: Conceptually, the same thing is true for breastfeeding. You wouldn’t ask a mom with incredible milk production to put her infant with chronic lung disease to breast for the first time with no discussion, logical preparation, or consideration for potential flow rate and swallowing safety. You would do your best to make it a safe and positive experience for mom and baby so that they’d both want to do it again.


  3. Consistency of care affects individual experiences, parent satisfaction, length of stay and long-term outcomes. It’s difficult to get 200 caregivers to make the same decision about anything. But what hasn’t worked so far is ignoring the problem or blaming our own team members for switching the nipple 8 times in the last 3 days. The only way we know to change culture and practice is education. We must make decisions about flow rate based on the same information. When we collectively decide to move in the same direction for the same reasons, we change outcomes for the better.

If it feels like advancing oral feeding practice is a challenge, it’s because it is! Oral feeding in the NICU requires specialized education and skilled caregiving. It’s a complex topic. But for today, take this one aspect of flow rate, really assess the infants in your care, and choose to build positive pathways for life. Paycheck or not, that’s why you love your work. And baby Smith needs someone like you today.