Very preterm (VP) infants have an immature feeding system that often cannot function well

enough on its own to sustain the infant. This is due to a dynamic system that has to coordinate together
to achieve the efficient suck-swallow-breath pattern that infants need to complete an efficient and
stable feeding. Park, Thoyre, Knafl, Hodges, & Nix (2014) share that, Impaired lung function, combined
with oral-motor and neurologic immaturity, significantly interferes with VPs abilities to eat, which
contributes to frequent feeding difficulties. Typical, full-term infants can regulate and compensate for
minor disruptions in the feeding process, such as increasing their heart rate (HR) to achieve appropriate
oxygen saturation if their breathing is altered. VP infants, on the other hand, often struggle to use these
compensatory strategies when feeding. If their breathing is compromised, their HR often slows down to
dangerous levels. Therefore, it is important that professionals working with this population know some
strategies to help increase their physiological stability and feeding performance. One of these strategies
used centers around the positioning of the infant during feedings.
There are two popular positions used during feedings in the NICU. The first is the semielevated
supine position and the second is the semielevated side-lying position. A pilot study was completed on
the efficacy of the semielevated side-lying positioning during bottle feedings of very preterm infants in
2012. They sought out to compare the differences in the physiological stability and feeding performance
in VP infants when fed in the ESU and ESL positions. The measurements they used to determine
physiological stability included: heart rate, oxygen saturation, and respiratory characteristics. They
measured feeding performance in terms of percent intake, proficiency, efficiency, and the duration of
feeding. The conclusion of their study claimed that, When fed in the ESL position, VP infants had less
variation in HR and less severe and fewer decreases in HR. Additionally, they had higher breathing
frequency that was closer to their prefeeding state, and shorter and more regular intervals between
breaths (Park et al., 2014).
Although there was no significant difference in feeding performance, the HR and breathing
frequency seined to beneficially favor the ESL position. The study gave some possible explanations for
these findings. The ESU position allows a greater gravitational force, that when combined with a more
upright angle of the bottle, causes a faster flow of milk. Consequently, infants have a harder time
controlling the bolus of fast flowing milk and have less opportunity to breath in between sucks. Many
professionals in the NICU use this method, however, because it allows them a full frontal view of the
infant in order to read facial cues from the infant. Conversely, the ESL position is more natural and
assumes the position an infant takes when breast feeding. This side-lying aspect decreases the impact of
gravity and the less severe angle of the bottle gives the infant more time to control the bolus of milk and
take more evenly paced breaths. When breathing is more regulated, the HR is more on target and the
body obtains sufficient oxygen saturation.
VP infants are at risk for feeding difficulties. Achieving safety, efficacy, and success in oral
feeding can reduce long term consequences such as aversions to feeding or eating, (Lau et al., 2013).
There are many different strategies to help sustain these infants until full oral feeding can be
independently obtained. ESU and ESL positioning during feedings are some of the most popular used
interventions in the NICU while bottle feeding. While there is still much research that needs to be done
on these two strategies, there has been some evidence that the ESL positon can help with physiological
stability in infants.