NOMAS® International

There are many infants in the NICU who are born prematurely and/or remain sick for a lengthy period of time. The medical conditions for these infants often resolve and the infant is able to master oral feeding enough to take sufficient calories and demonstrate adequate weight gain so as to be discharged from hospital to home. Some infants, however, are not able to take enough calories orally and are subsequently placed on feeding tubes; either a nasogastric feeding tube or a gastrostomy tube. 

Often these infants do not present with oral-motor problems but instead have a sensory-based oral feeding aversion. They have learned that bottle feeding was stressful and caused them discomfort and/or pain and so refuse to take the bottle once they are over 3-5 months of age and have developed volitional oral-motor control. In addition, many of these infants have a history of gastroesophageal reflux and the related condition of esophageal dysmotility. When pureed baby food is introduced by spoon, they will turn away, gag, cry, and/ or vomit. Parents do not understand the root of this aversion and are usually unable to coax the infant to successfully transition onto this thicker consistency. Some infants are still refusing strained food when they are 12 months old.

The program that I developed, “The Palmer Protocol for Sensory-Based Weaning” recommends starting at the level where the infant is comfortable. That might be just a “swipe” to the lips of liquid or pureed food or may be 1 cc delivered by finger or dropper, or one spoonful of liquid or pureed. This is offered to the infant while he is seated on the lap or in a high chair, an appropriate mealtime setting, and just prior to the bolus tube feeding. If the infant is fed by continuous drip overnight or for 24 hours the program begins with consolidating the feedings and moving to bolus feeds. Usually infants are fed six times daily and this is important for expansion and contraction of the stomach which serves to develop hunger. These six meals are: breakfast; morning snack; lunch; afternoon snack; dinner; and a bottle before bed.

At the start of the weaning program, it may just be an introduction of oral feeding to the infant. It is recommended that the feeder DOES NOT approach the infant at midline because most likely they will be met with resistance. Instead, it is recommended that the infant be engaged in touching a toy that the feeder is holding or looking at something very interesting while the approach is done laterally. If you allow the infant/toddler to hold the toy it may end up in the mouth which will interfere with oral feeding.

The introduction to oral feeding should be viewed as a part of one meal that is offered, i.e., oral + bolus, and should occur just prior to all bolus feedings. If on a continuous drip, oral feeding should be offered at the times that meals will eventually be scheduled. Once the infant is able to take a measurable amount orally that amount can be subtracted from the bolus feeding that follows. Gradually in this way the amount taken orally will slowly increase while the amount delivered by tube feeding will gradually decrease. Subtraction of the amount taken orally usually begins when the infant is able to take 30 ml/1 ounce by mouth.

              The duration of the tube feeding bolus should be consistent with the amount of time it would usually take the infant/toddler to finish a meal if fed orally. This may be particularly challenging for those infants/toddlers with gastroesophageal reflux because as the stomach expands and fills, the pressure against the lower esophageal sphincter (LES) increases and may cause the infant to be uncomfortable and even to vomit. The slowing of the bolus feeding may take some time and it is suggested that increases be made in 5 cc increments so as to avoid discomfort.

Oral feedings need to proceed slowly as well because the infant/toddler may have esophageal dysmotility in addition to gastroesophageal reflux. These conditions typically result in sensory-based oral feeding aversions so mealtime will need to be a fun time for the infant/toddler and a time that takes the mind off oral feeding. This protocol is not designed for those infants/toddlers who present with abnormal oral-motor patterns, cerebral palsy, or generalized hypotonia. This program is for those infants/toddlers who demonstrate normal oral-motor function but have a sensory aversion, many times secondary to gastrointestinal issues.

Specific Recommendations for Weaning from Feeding Tube onto Oral Feeding:

1. Discontinue all continuous drip feedings by night
2. Discontinue all continuous drip feedings by day
3. Transition infant/toddler onto mealtime schedule during the day: 3 meals and 2 snacks
4. Transition from predigested formula onto standard stock formula
5. Introduce all oral activities and feeding as part of the total mealtime, just prior to tube feeding
6. Approach the “oral sensorium” from the buccal cavity; avoid the tongue
7. Practice maintenance of bilabial closure with nasal breathing if age appropriate
8. Establish a baseline for oral feeding: type of food, amount, placement, utensil, texture, etc.
9. Be sure that the infant/toddler is receiving sufficient calories to grow and that weight is adequate to begin this program
10. Select only one variable to modify at mealtime
11. Slow tube feeding to approximately 30 minutes per feeding (variable depending upon amount)
12. Be sure that all changes are subtle and gradual
13. Once oral intake reaches 30 cc (one ounce) and is equal to 30 calories begin to subtract from tube feeding
14. Once infant/toddler is taking 30 cc more than once a day begin the 60 hour wean
15. SUCCESSFUL WEANING IS DEPENDENT UPON PROPER SELECTION OF CANDIDATE

Palmer Protocol for Sensory-Based Weaning From Tube to Oral Feeding

	Phase 1: Transition	Phase II: Tolerance	Phase III: Wean	Phase IV: Oral Feeding	Phase V: Discharge
Feeder	Primary Caregiver	Primary Caregiver	Primary Caregiver	Primary Caregiver	Primary Caregiver
Position	Transition from reclining to feeder’s lap or seat	Feeder’s lap or seat	Feeder’s lap or seat	Feeder’s lap or seat	Feeder’s lap or seat
Food Presentation	Transition from drip to 4-6 bolus feedings. Eliminate drip/nighttime feeds	Child is now on bolus feeds, begin oral feeding with baseline utensil, placement, texture as indicated on baseline sheet	Continue with utensil, placement, texture as indicated in most recent baseline sheet	Continue with utensil, placement, texture as indicated in most recent baseline sheet. Increase variety of food/liquid accepted	Infant/toddler accepts a variety of foods/liquid delivered by appropriate utensil
Social Interaction	Use of positive social interaction to make mealtime more pleasant	Distract when necessary with auditory, visual, and tactile stimuli paired with food presentation	Visual regard for feeder and positive anticipation of food. Distraction and verbal praise may be used	Visual regard for feeder and positive anticipation of food. Distraction and verbal praise may be used	Visual regard for feeder and positive anticipation of food. Distraction and verbal praise may be used
Complimentary Feeding	Mealtime exercises 3x/daily while transitioning to bolus feeds	100% normal caloric requirement until oral intake is equal to 30 cal/oz. in 30 cc 3x daily, then subtract 30cc from each bolus feed given by tube	100% normal caloric requirement minus 30 until 60 cc is taken orally 3 x daily. Begin the first 60 hour wean	Resume supplemental tube feeding for two weeks. Begin second 60 hour wean	Infant/toddler takes between 50-100% of total caloric requirement orally
Duration	Bolus approximates an oral feeding, which is 15-45 minutes, whatever is developmentally correct	15-45 minutes, whatever is developmentally correct	15-45 minutes, whatever is developmentally correct	15-45 minutes, whatever is developmentally correct	15-45 minutes, whatever is developmentally correct
Data Collection	Complete drip to bolus sheet	Baseline data sheet completed	Baseline data sheet completed	Baseline data sheet completed	Baseline data sheet completed
Criteria to move to next phase	Tolerates bolus feeds of an amount that is appropriate. Infant/toddler does not gag, choke, retch, or vomit	Tolerates presentation of food/liquid to mouth. Infant/toddler does not gag, choke, retch, or vomit	Accepts presentation of food/liquid to mouth, indicated by visual response, mouth opening, and/or cooperation	Accepts at least 50% of normal caloric requirements by mouth without distress or discomfort. Swallow 100% of total amount fed	Accepts 75-100% of total caloric requirement orally. Swallows 100% of total amount fed

Marjorie Meyer Palmer MA, NLP, CCC-SLP, Neonatal / Pediatric Feeding Specialist, Speech-Language Pathologist, Founder / Director NOMAS^® International