Oral Aversion and Feeding Behaviors

Jenny Murray, BSN, RN / December 2017

Safe and efficient nipple feeding is a complex task, and also one of the most challenging for the preterm or high-risk infant to achieve.¹  Preterm infants have twice the risk of feeding difficulties as full term infants.²

Infants in the NICU can develop oral aversion, which is the reluctance, avoidance, or fear of eating or accepting sensation in or around the mouth.³

Causes of oral aversion can include:

Impact to infant feeding behaviors

Do we really understand how negatively we can impact a baby’s feeding behaviors based on what we do in the NICU?

Yes, we must place OG/NGTs, we must suction at appropriate times, and we must intubate for respiratory stability. But what are some things we can do to offset all the negative stimuli?

If we don’t intervene appropriately, these negative influences can have long-term effects on feeding that could have been minimized by positive oral experiences.¹

As a bedside nurse I always told parents, “Babies are way smarter than you think.”  Who would think that a tiny baby can be capable of learning how to avoid noxious stimuli? Have you ever taken care of a baby that would clamp down, cry, and/or choke to avoid having anything put into their mouth? Have you ever taken care of a baby that when put in the feeding position would immediately begin to cry? We all have.

Do we still try to feed “the rock,” and feel like a champion when we do?

Cue-based feeding

Based on an enormous amount of research, the key to successful feeding is cue-based feeding, not volume-driven feeding. It takes a skilled and observant caregiver to assist an infant with a pleasurable feeding experience that maximizes intake and minimizes stress.¹

When the quality of a feed supersedes the quantity, positive feeding skills develop into a pleasurable feeding experience. As a result, intake is improved.

Preterm babies cannot verbalize what they are feeling, so it leaves caregivers to carefully consider and watch for the behaviors they communicate to understand their thresholds of stress and supporting safe feeding.

Oral aversion: Signs, risks, and interventions

Signs of aversion may include:

  • Refusing to eat even if they appear hungry
  • Starting to eat and then quickly pulling away
  • Poor growth
  • Irritable when placed in a feeding position
  • Autonomic system changes (apnea, tachypnea)
  • Color Changes
  • Visceral signs (gagging, spitting up)
  • Movement/posture (hyperflexed, extended)
  • Muscle tone (flaccid, hypertonic)
  • Attention – the ability to focus on environmental stimuli (faces, sounds, objects)¹

Risks associated with oral aversion include:

  • Poor growth
  • Compromised development
  • Impaired parent/infant bonding
  • Infant and parent distress
  • Parents lacking confidence in their ability to care for and feed their baby

Early supportive interventions to help guide a positive feeding experience should include:

  • Kangaroo care – this helps facilitate readiness for oral feeding, particularly breastfeeding. Feeding maturity is dependent upon neurological maturity.  This can be enhanced with early skin-to-skin care of the ventilated infant and human milk feedings immediately after birth.  These two interventions contribute to the myelination process of the nervous system resulting in neurological maturity.⁴
  • Non-Nutritive Sucking (NNS) – allowing an infant to suck without taking milk (either through an expressed breast, a pacifier, or through finger training). It is very important that NNS is offered with gavage feedings.  This will help the baby to associate the gut filling with sucking, and also help to elicit gastric juices that aid digestion.  Placing a drop of breast milk on the pacifier will produce a positive experience.  NNS also promotes physiologic stability that results in improved oxygenation and a decreased heart rate.¹  Opposed to a traditional belief, pacifiers do not affect breastfeeding in preterm infants.⁵
  • Feeding protocols – this provides clear criteria on the initiation and advancement of safe and positive oral feeding experiences. Picker et al found that the duration of the infant’s hospitalization from the start of oral feedings until discharge was predicted by maturity at the first oral feeding and that positive feeding experiences contributed towards a more rapid transition to oral feeding regardless of the severity of illness.  Cue-based feeding, opposed to volume driven feeding, showed decreased length of stay, increased weight gain, and decreased adverse events.⁶
  • Breastfeed when possible – research indicates that bottle-fed preterm infants experience a significantly higher level of physical stress than breastfed preterm infants.¹ Although most infants in the NICU will require bottles at some point, it is important to remember to allow breastfeeding when possible, and not to steer clear from breastfeeding because the baby may have to “work harder.” Breastfeeding attempts should always precede any bottle feeds.
  • Multidisciplinary team approach – collaboration helps to develop a plan to ensure safe and positive feeding experiences are carried out. This team includes, but is not limited to, neonatologists, SLPs, OTs, and nursing staff.

A positive impact on feeding

The impact you have on babies and families every day is nothing short of amazing.

Feeding seems so minute compared to the daily tasks of maintaining airways, managing the multitude of medications that work to keep a baby alive, caring for the critically ill post-op surgery baby, and so much more. It’s hard to think beyond your shift at times.

If you go home after 12 hours and have watched your patient go from high to low ventilator settings and have been able to tell a parent that they can touch their baby today because they are stable enough, you leave feeling successful. That’s so incredibly true! Think about the NICU reunions we have, though. I know we want to impact the lifelong success of a patient and their family.

Feeding is big! Outpatient feeding clinics are huge. It’s not “just feeding”; it’s changing the life of a child and an entire caregiver circle.

Long term outcomes

Think about the long-term effect feeding has on a patient and the impact we, as nurses, can make. Positive feeding experiences are so important to a baby’s life and long-term outcome.

Educating ourselves and understanding the research behind oral aversion (including causes, signs and symptoms, risks, and supportive interventions) help us establish a change in thought process, which in turn, can change our practice.

Like myself, I know we all get caught up in the moment of our shift, but what we do each hour can have lifelong impacts on our patients and their families.

Remember that once the child heals from surgery, once they are extubated, once the multitude of medications are discontinued, nutrition remains key to health. You can have a positive impact on feeding experiences beginning from day one.

And that’s a lifelong gift.



  1. Lubbe, W. Clinicians guide for cue-based transition to oral feeding in preterm infants:  An easy-to-use clinical guide.  Journal of Evaluation in Clinical Practice, 2017;00:1-9.  https://doi.org/10.1111/jep.12721
  2. Jadcheria, S.R., Peng, J., Moore, R., Saavedra, J., Shepherd, E., Fernandez, S., Erdman, S.H., & DiLorenzo, C. Impact of Personalized Feeding Program in 100 NICU Infants:  Pathophysiology-based Approach for Better Outcomes.  Journal of Pediatric Gastroenterology Nutrition, 2012;54(1):62-70.
  3. Bird, C. “Oral Aversion in Infants:  Special Risks for Premature Babies”.  Very Well, https://www.verywell.com/oral-aversion-in-the-premature-baby-2748511?.  Accessed 2 November 2017.
  4. Dodrill, P., McMahon, S., Ward, E., Weir, K. Donovan, T., Riddle, B. Long-term oral sensitivity and feeding skills of low-risk pre-term infants.  Early Human Development.  2004;76(1):23-37.
  5. Collins, CT., Ryan, P., Crowhter, CA., McPhee, AJ., Patterson, S., Hiller, JE. Effects of bottles, cups and dummies on breast feeding in preterm infants:  a randomized controlled trial.    2004;329(7459):193-198.
  6. Pickler, R., Best, A., Crosson, D. The effect of feeding experience on clinical outcomes in preterm infants.  Journal of Perinatology.  2009;29(2):124-129.

About the Author

Jenny Murray

Jenny Murray, BSN, RN, began her career 18 years ago as a neonatal nurse in neonatal intensive care. She has since served in a variety of nursing leadership roles within the NICU. Her experience in those roles has driven her love for education and research, especially educating and supporting clinicians in the advancing, innovative world of neonatology. Jenny currently works as a Clinical NICU Specialist for Medela LLC.

2 thoughts on “Oral Aversion and Feeding Behaviors

  1. Loved this article! Thank you for the reminder that what NICU nurses do everyday, and how we do it, affects our tiny patients’ long term outcomes.

    P.S. I think I met you earlier this year in south Texas.

  2. As an IBCLC, I see the effect of scheduled/volume feedings as not only the problem of infant aversion, which is HUGE, but also parental role acquisition. My role is to work with parents on transitioning home to breastfeeding on cue. Parents do not trust themselves or their infants to take the leap of faith required to observe and offer feedings when the infant is receptive and when to discontinue when the infant is satiated. Those who have been d/c from a cue-based feeding hospital v a volume hospital (I see patients 50/50 from either hospital in my region) have very different ways of interacting with their infants.

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