As breastfeeding experts, we must be able to evaluate a feed and recognize warning signs that alert a professional to its lack of safety and efficacy.

Feeding at the breast is physiological for newborns and, as has been pointed out, the patterns of an infant born at term with adequate weight should be mature, effective, and safe (Rendón-Macías et al., 2012; Shandley et al., 2021). Despite this, there are situations in which infants will present disturbances in the feeding process (Rendón-Macías et al, 2012; Shandley et al., 2021), which may cause early discontinuation of breastfeeding (Bairros et al., 2019).

Assessment of a feed

Before the feed, the practitioner should check the newborn’s oral structures at rest and during the feed, evaluate the pattern of nutritive and non-nutritive sucking during the feed, but also and especially situations that happen during the feed that show that the sucking is not effective or safe. These situations are of various kinds and can happen in different phases of feed, offering clues to the professional to understand the disturbances of the process and, therefore, lead to possible subsequent interventions, if necessary.

Assessment of the suction

In the presence of altered or compensated sucking, we usually hear tongue clicks, see difficulties in maintaining a lip seal (which generates milk leakage), the appearance of perioral cyanosis during sucking, and so on.

Assessment of swallowing

Regarding the swallowing process, the following can happen: coughing after swallowing, gagging or conspicuous laryngeal stridor, and so on. Also, the infant’s behavior during the feed must be taken into account: excessive pausing, excessive crying, facial grimacing, staring, and so on.

Dysfunction correlations

If any of these situations appear during the feed that correlates with maternal pain or difficulties in weight gain, then a referral to a speech therapist and a physiotherapist will be necessary.

Below, you can find a table as a reminder to determine all the signs that should make you think about the lack of safety and efficacy of the process:

Suction	Difficulties to initiate sucking (Rendón-Macías and Serrano, 2011). Deficient lip seal with loss of milk through the mouth corners (Rendón-Macías and Serrano, 2011). Dysfunctional suction (Rendón-Macías and Serrano, 2011). Softness and irregularity of nutritive suction (Shandley, et al., 2021). Increased muscle work in lip orbicularis oris muscle, masseter, and buccinators (Mahurin-Smith Watson, 2019). Tongue clicking (Mahurin-Smith Watson, 2019). Appearance of cyanosis during sucking (Mahurin-Smith Waston, 2019; Rendón-Macías and Serrano, 2011).
Swallowing	Appears choking (Rendón-Macías and Serrano, 2011). Appearance of cough reflex (Rendón-Macías and Serrano, 2011). Nasal reflux (Rendón-Macías and Serrano, 2011). Laryngeal stridor (Rendón-Macías and Serrano, 2011).
Breathing pattern	Shallow or labored breathing (Geddes and Sakalidis, 2016). Apneas (Rendón-Macías and Serrano, 2011; Shandley, et al., 2021).
Infant behavior	Excessive pauses (Rendón-Macías and Serrano, 2011). Sucking refusal (Rendón-Macías and Serrano, 2011). Abnormal behavior (Rendón-Macías and Serrano, 2011). Excessive crying, facial grimacing and staring (Vijay, 2023). Hyperextension of the extremities, arching of the head and increased body rigidity (Vijay, 2023).

References

Bairros, F. [Franciani], Fernandes, P. [Pereira], Gurgel, G. [Gonçalves], Fujinaga, I. [Ide], & Almeida, S. T. de. [Sheila Tamanini]. (2019). Breastfeeding assessment protocols and Speech Therapy: an integrative literature review. Revista CEFAC, 21(5). https://doi.org/10.1590/1982-0216/201921514018 

Geddes, D. [Dona] & Sakalidis, V. [Vanessa]. (2016). Breastfeeding: how do they do it? Infant sucking, swallowing, and breathing. Infant Journal, Volume 11 Issue 5. pp.146-150. https://www.semanticscholar.org/paper/754514617cc7a8b3e3e092212728193cdf53b584

Mahurin-Smith, J. [Jaime] & Genna, C. [Catherine] (2019). Assessing the breastfeeding dyad: A guide for speech-language pathologists. Perspectives of the ASHA Special Interest Groups, 4(3), pp.502–506. https://doi.org/10.1044/2019_pers-sig13-2018-0018

Rendón-Macías, M.E. [Mario Enrique] y Serrano, J.G. [Guillermo Jacobo]. (2011). Fisiología de la succión nutricia en recién nacidos y lactantes. Boletín médico del Hospital Infantil de México, 68(4), pp. 319-327. http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S1665-11462011000400011&lng=es&tlng=es

Rendón-Macías, M.E. [Mario Enrique], Domínguez-Jiménez, H. [Héctor] y Aguilar-Álvarez, Y. [Yolanda]. (2012). Condición de la succión evaluada a las 48 horas de vida en neonatos con peso adecuado o peso bajo al nacer y su relación con el crecimiento ponderal a los 28 días de vida. Boletín médico del Hospital Infantil de México, 69(5), pp. 367-375. http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S1665-11462012000500007&lng=es&tlng=es

Shandley, S. [Sabrina], Capilouto, G. [Gilson], Tamilia, E. [Eleonora], Riley, D. [David], Johnson, Y. [Yvette] y Papadelis, C. [Christos]. (2021). La succión nutritiva anormal como indicador de lesión cerebral neonatal. Fronteras en pediatría, volumen 8, 599633. https://doi.org/10.3389/fped.2020.599633