Dear community

Who decides when a preterm infant is ready to feed by mouth, and how do we diagnose dysphagia?

Three recent papers prompted this question. Reynolds et al. (J Perinatol 2026) describe a level IV NICU where every VP/VLBW infant has a structured clinical feeding evaluation by a certified neonatal therapist (SLP or OT) once unit-based criteria for oral feeding are met. Mothers are offered 1–2 weeks of protected breastfeeding first. Infants who still struggle around 38 weeks PMA, despite positioning, pacing and slow-flow nipples, go on to FEES. Dysphagia was defined as laryngeal penetration with or without aspiration, and it was confirmed in 25% of the cohort. Of these infants, 95% went home on thickened feeds.

Tan (J Hum Lact 2025) and Graham (Ann Otol Rhinol Laryngol 2023) make a related point. VFSS cannot assess the breastfeeding swallow, so FEES at the breast, run by an SLP together with a lactation consultant, is the only instrumental option if direct breastfeeding is the goal.

Some caveats apply. Only symptomatic infants were scoped, penetration alone counted as dysphagia, and no protocol for clinical or instrumental assessment has been validated. This model also depends on dedicated feeding therapists and endoscopy, which many NICUs don't have.

So I'd love to hear how this works in your units:

• Who decides when oral feeding starts: neonatologists, nurses using cue-based scales (which ones?), SLPs/OTs, or a team?

• Does breastfeeding come before the bottle?

• What triggers an instrumental study, and do you have access to FEES or VFSS?

• What threshold do you use to diagnose dysphagia, and how often do you thicken feeds?

Journal of Perinatology (2026) 46:1276–1282; https://doi.org/10.1038/s41372-026-02701-1

J Hum Lact 2025 Aug;41(3):379-381.https://pubmed.ncbi.nlm.nih.gov/40526011/

Ann Otol Rhinol Laryngol 2023 Oct;132(10):1194-1199.https://pubmed.ncbi.nlm.nih.gov/36503275/

Thank you (and if you are going to CEPAS, I'd love to have a chat about it in person ;-)

Very interesting papers, thank you for sharing. We sometimes use thicken up, but I have not read much about it's use. We do not follow a strict timeline for breastfeeding; instead, our nursing staff bases the process on the individual infant's readiness. While we begin early oral stimulation using the mother's milk, actual breastfeeding is initiated when the child is ready, typically between weeks 31 and 33. Thanks to a robust social security system, parents can remain at the bedside 24/7 from 28 weeks onward. This allows us to practice skin-to-skin care aiming at eight hours a day if feasable, making the transition to the breast a very natural, minor step.

If an infant struggles with swallowing, we consult a speech and language therapist for an assessment. We do frequently manage aspiration and reflux, but these issues are generally related to positioning, bowel care, or overall immaturity rather than the act of breastfeeding itself. If there is a prolonged problem with establishing feeding somebody will usually say, it's time for radiology. But it will usually be after we have tried milk protein-free fortifiers, esomeprazol or thickening.