Overview
Definition:
Oral aversion is a feeding disorder characterized by an infant's unwillingness or refusal to accept oral stimulation, including sucking, chewing, or swallowing
This can manifest as gagging, choking, spitting out food, or complete refusal of the nipple or bottle
In preterm infants, it often develops as a consequence of prolonged or traumatic oral experiences during hospitalization, such as intubation, nasogastric tube feeding, and difficult or painful feeding attempts.
Epidemiology:
The prevalence of oral aversion in preterm infants is not precisely defined but is considered significant, particularly among those with prolonged NICU stays, prematurity, and underlying medical conditions
Factors like gestational age at birth, duration of mechanical ventilation, and the use of non-nutritive sucking (NNS) devices play a role
Infants with conditions like respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), or congenital anomalies are at higher risk.
Clinical Significance:
Oral aversion poses a major challenge to successful transition from tube feeding to oral feeding, impacting growth, development, and parental bonding
It can lead to prolonged hospital stays, increased risk of malnutrition, aspiration, and the need for alternative feeding methods
Early identification and intervention are crucial for optimizing outcomes and preventing long-term feeding difficulties, making this a key area for DNB and NEET SS preparation in pediatrics and neonatology.
Risk Factors
Gestational Age:
Very preterm (<32 weeks) and extremely preterm (<28 weeks) infants are at higher risk due to immature oral motor skills and prolonged need for tube feeding.
Medical Conditions:
Conditions requiring prolonged intubation (e.g., severe RDS, bronchopulmonary dysplasia - BPD), gastrointestinal issues (e.g., NEC, GERD), congenital anomalies (e.g., cleft lip/palate), and neurological impairments.
Feeding Interventions:
Prolonged use of nasogastric (NG) or orogastric (OG) tubes, frequent or painful oral care, intubation/extubation trauma, and lack of structured, positive oral feeding experiences.
Sensory Processing:
Hypo- or hyper-sensitivity to oral stimuli, which can be exacerbated by underlying medical conditions or sensory deprivation in the NICU environment.
Parental Factors:
Parental stress, anxiety, or lack of confidence in feeding can indirectly contribute to feeding difficulties.
Prevention Strategies
Early Oral Stimulation:
Initiate non-nutritive sucking (NNS) with pacifiers or clean fingers as soon as medically stable, even while on tube feeds
This helps establish a positive association with the mouth.
Gradual Transition To Oral Feeding:
Introduce oral feeding attempts early and frequently, even if brief and with minimal intake
Start with expressed breast milk or formula via a specialized nipple or syringe.
Structured Feeding Protocols:
Develop and adhere to evidence-based feeding protocols that emphasize paced bottle feeding or breastfeeding, minimizing distractions, and creating a calm feeding environment
Use specialized nipples that mimic the breast or offer controlled flow.
Minimizing Oral Trauma:
Use oral care routines that are gentle and non-aversive
Minimize the duration and frequency of intubation and NG/OG tube use when possible, transitioning to oral routes as soon as feasible.
Involving Parents:
Educate and empower parents to participate in feeding sessions, providing support and instruction on proper feeding techniques
This fosters confidence and reduces parental anxiety.
Multidisciplinary Approach:
Collaborate with speech-language pathologists (SLPs), occupational therapists (OTs), and lactation consultants to develop individualized feeding plans and address potential sensory or motor issues.
Assessment And Monitoring
Observation During Feeding:
Carefully observe for signs of distress such as gagging, choking, coughing, arching, poor latch, weak suck, or cessation of sucking
Note physiological changes like heart rate or oxygen saturation drops.
Feeding History:
Gather detailed history of previous feeding attempts, tube feeding duration, types of interventions, and infant's responses to oral stimulation.
Oral Motor Assessment:
Assess oral motor skills including suck-swallow-breathe coordination, jaw stability, tongue movement, and lip seal
This can be done by experienced nurses, SLPs, or OTs.
Nutritional Status Monitoring:
Regularly monitor weight gain, intake volumes, and overall nutritional status to ensure adequate growth and identify early signs of failure to thrive.
Management Of Established Aversion
Behavioral Interventions:
Implement sensory-based feeding therapy, focusing on desensitization techniques
This may involve gradual introduction of tactile stimulation around the mouth before attempting feeding.
Positioning And Support:
Use appropriate positioning to support the infant's body and head, facilitating better oral motor control and reducing effort
Sidelying or semi-reclined positions can be beneficial.
Specialized Feeding Equipment:
Utilize specialized nipples (e.g., Haberman Feeder, Preemie Nipple) that provide better control over flow rate and require less active sucking, thus reducing infant fatigue and frustration.
Environmental Modifications:
Create a calm, quiet, and consistent feeding environment
Reduce unnecessary noise and visual stimuli
Feeding should occur when the infant is awake and alert but not overly tired or hungry.
Team Collaboration:
A multidisciplinary team approach involving neonatologists, nurses, SLPs, OTs, dietitians, and psychologists is essential for comprehensive management and addressing underlying issues.
Key Points
Exam Focus:
Understanding the multifactorial etiology of oral aversion in preemies is critical
Focus on early prevention strategies like NNS and structured feeding
Recognition of signs and prompt intervention using a multidisciplinary approach are exam priorities.
Clinical Pearls:
Start NNS early, even with NG tubes in place
Positive oral experiences are key
Parental education and involvement build confidence and compliance
Always rule out underlying medical causes for feeding refusal
Delicate balance between providing adequate nutrition and avoiding further oral aversion.
Common Mistakes:
Delaying oral feeding attempts, forcing feeds, inconsistent feeding practices, neglecting parental support, and failing to involve a multidisciplinary team
Over-reliance on tube feeding without proactive oral stimulation can lead to persistent issues.