Can Babies Drink and Breathe at the Same Time

Abstract

This prospective written report compared the coordination of sucking, swallowing, and breathing and its relationship to oxygen saturation in infants during breast-feeding and canteen-feeding. Afterward 4 to vi wk of sectional chest-feeding, infants began bottle-feedings of expressed human being milk using one of two systems: a soft-walled bottle and nipple (organization 1, Playtex) or a difficult-walled canteen and nipple (system 2, Avent). Infants' sucking, swallowing, animate, and oxygenation were measured during breast-feeding and canteen-feeding, and coordination of these activities during chest-feeding and bottle-feeding were compared. During chest-feeding, swallowing occurred nonrandomly between breaths and did not interfere with breathing. The aforementioned distribution of swallowing occurred in infants fed with system 1, while swallowing occurred randomly in infants fed with system 2. Swallowing significantly increased during bottle-feeding among infants using system 2, but decreased among infants using arrangement 1. Infants using system ii also had a greater instability in the coordination of sucking, swallowing, and breathing and more perturbation of animate. Oxygen saturation was significantly higher in infants fed with system one compared with organization ii. These results suggest that the overall feeding pattern and oxygenation of system 1 are closer to the physiologic norm than system 2.

Main

Babe feeding is a complex process, requiring the precise coordination of sucking, swallowing, and breathing. The throat is the shared anatomic pathway for both swallowing and breathing; however, these two activities are mutually exclusive. Therefore, the pharynx must exist continually reconfigured and then that an infant can successfully eat and breathe at the same fourth dimension (one–six),simply how infants coordinate these activities is largely unknown. There may also be differences in the overall coordination of these tasks during breast-feeding compared with bottle-feeding, but this has not yet been explicitly determined. Different artificial canteen nipples, the human breast is compliant in response to an baby's suckling activity, and the elasticity of the breast nipple allows it to transform to fit the shape, size, and positioning of the baby's mouth (7). In addition, the magnitude and consistency of the milk flow from a milk bottle are quite dissimilar from that of the breast, and milk bottles may have the possibility of internal pressure, which provides resistance to infant suckling. There may also be singled-out differences among different canteen-feeding systems (e.g. soft- versus difficult-walled bottles, different nipples and venting systems).

One primal deviation between breast-feeding and bottle-feeding is oxygen saturation. Previous studies have consistently demonstrated that breast-fed babies have college oxygen saturation than bottle-fed babies (8–10). A frequently cited explanation for this difference is that canteen-feeding may promote a college charge per unit of swallowing and, in turn, more frequent interruptions of breathing (11). Indeed, studies have shown that there is less ventilatory disruption during breast-feeding compared with canteen-feeding (10,12,thirteen), which may effect in college oxygen saturation. This implies that the coordination of swallowing and breathing is intimately involved in blood oxygenation during feeding, merely relatively few studies have examined the human relationship betwixt oxygen saturation and the coordination of sucking, swallowing, and animate in healthy full-term infants.

The objective of our study was to compare the coordination of sucking, swallowing, and breathing during breast-feeding and bottle-feeding. We also examined the relationship between oxygen saturation and coordination. To allow a detailed analysis of these events, we recorded sucks, swallows, respiratory airflow, and respiratory movements and analyzed the location of swallows to compare coordination. We studied 1) the distribution of swallows relative to sucking and breathing, two) the amount of swallowing, 3) the stability of swallowing, 4) oxygen saturation, and 5) the correlation between oxygen saturation and swallowing variability. Our hypotheses were that during breast-feeding, swallows would be distributed nonrandomly (i.eastward. at specific locations) and that a bottle-feeding organisation that more closely mimics the physiologic norm would promote a similar swallowing pattern. We besides hypothesized that during periods of higher oxygenation, the coordination of sucking, swallowing, and breathing would be more stable (take lower variability) and that during periods of lower oxygenation, the variability of swallowing relative to breathing would be greater.

METHODS

Report participants.

Mothers and infants were recruited in hospital on the second mean solar day after birth by enquiry nurses at Beth Israel Deaconess Medical Center in Boston, MA. Each day during the recruitment period, one of 2 research-written report nurses reviewed data from the nascency demography to determine eligibility of potential participants. Eligibility criteria included baby birth weight greater than 2500 g, no medical bug that might influence feeding, and no maternal complications during pregnancy or delivery. All infants who met these criteria were eligible for the study regardless of gender or ethnicity. A second set of eligibility criteria concerned the female parent'south plans for feeding the infant. Only those women who indicated to the research nurse that they planned to breast-feed the infant exclusively for at to the lowest degree 4 to 6 wk after nativity before initiating canteen-feeding (while standing to breast-feed) were eligible. Mothers were excluded if their medical charts indicated any structural or functional characteristics that might impede breast-feeding. The report was described, and mothers were told that study participation involved a laboratory visit at Children'southward Hospital Boston afterwards four wk of sectional breast-feeding. Women who met these criteria and agreed to participate provided written informed consent. Mothers agreed to be contacted past phone approximately 4 wk later on leaving the hospital to adapt a time for the laboratory visit. If a mother decided to discontinue participation at any time earlier the laboratory visit, she and the baby were replaced in the study.

Study process.

The research protocol was canonical past the clinical investigation committees at Beth State of israel Deaconess Medical Centre and Children's Hospital Boston. Infants served as their ain controls for comparison of chest-feeding and bottle-feeding. After four to 6 wk of sectional chest-feeding, mothers introduced an artificial nipple and bottle for supplemental feeding. All bottle-feeding was performed with expressed breast milk. For supplementation, mothers chose either system 1 (a Playtex bottle with a soft-liner that collapses during feeding and a NaturaLatch nipple; Playtex Products, Inc., Westport, CT) or system 2 (an Avent newborn bottle and nipple; Avent Ltd., Bensenville, IL); both bottle systems are commercially available and had equivalent menses rates. Within 2 wk of initiating supplemental bottle-feeding, mothers and infants came to the Infancy Laboratory in the Department of Psychiatry at Children's Hospital Boston for the laboratory visit, which consisted of a xxx-min process during which instrumented recording of three to 4 min of sucking, swallowing, breathing, and oxygen saturation during chest-feeding and canteen-feeding, respectively, were performed; the baby was weighed; and the mother completed a brief oral interview to determine her attitudes about breast-feeding.

For instrumented recordings of the baby's sucking, swallowing, and animate during chest-feeding and bottle-feeding, sensors were attached to the skin of both the mother'due south chest and the infant. The goal was to use the same sensors for breast-feeding and bottle-feeding to get equivalent data. To tape the intraoral sucking force per unit area during chest-feeding, a catheter was secured using medical-grade tape (Transpore Surgical Record; 3M, St. Paul, MN) and then that its open up end was aligned with the tip of the mother's nipple and was taken into the infant's mouth during feeding. To record intraoral pressure during bottle-feeding, the infant was fed with a nipple that was modified slightly from the ones used at home. A catheter identical to the one previously fastened to the female parent'southward chest was embedded within the bottle nipple so that it entered the babe's mouth during feeding. To record swallowing, a miniature wireless microphone (SC4-CT; Shure, Inc., Niles, IL) was secured with tape to the skin below the cricoid and oriented toward the pharynx (fourteen). To record respiratory movements, inductance bands (Inductotrace respiratory monitors; Ambulatory Monitoring, Inc., Ardsley, NY) were secured effectually the infant's breast and abdomen, and an oxygen saturation sensor was as well secured on one foot; the signal from the latter was analyzed by a pulse oximeter (Radical; Masimo Corporation, Irvine, CA). All sensor signals were digitized and simultaneously recorded with information-acquisition software (WinDaq/Pro+; Dataq Instruments, Inc., Akron, OH) on a laptop estimator (Dell Breadth CPi; Dell, Inc., Round Rock, TX). Infants were besides weighed later on feeding using a pediatric scale (Model 4802; Scaletronix, Carol Stream, IL).

Algorithms for locating swallows and calculating relative phase.

To examine the temporal relationship amongst sucking, swallowing, and animate, 10 sequent samples of v- to 10-s periods of breast-feeding and canteen-feeding behavior past each infant were extracted for analysis. These typically exhausted all the sucking behavior recorded, with periods of break in sucking and/or the absenteeism of swallowing excluded. The samples were saved as text files of the individual channels. Algorithms written in MATLAB (The MathWorks, Inc., Natick, MA) were used for Butterworth filtering (Besser Assembly, Mountain View, CA) each recorded channel to calculate the relative phase between sucking and breathing, to calculate the location of swallows with respect to that relative stage, and to count the number of swallows. The results were and then plotted as histograms in which each 360-caste cycle was divided into 20-degree bins, and the number of swallows in each bin was determined. If swallows were attracted to particular phase relations between sucking and breathing, swallows would be distributed nonrandomly.

Round statistics.

A statistical approach, termed circular or directional statistics, was used to decide whether the distribution of swallows was nonrandom (fifteen–17). By recording the observed swallows in a tabular array of their observed frequency across a range of values between zip and 180 degrees, we were able to determine a mean angle weighted by their relative distribution. Circular statistics may be preferable to other nonparametric methods considering the result can be interpreted directionally (i.e. spatially). A standard nonparametric examination would permit us to decline the zilch hypothesis that swallows were uniformly distributed in phase infinite, just would not reveal where swallows were most dumbo. Other statistical tests for parametric comparisons of group information included χ² analyses for frequency of swallows during breast-feeding and bottle-feeding, assay of variance (ANOVA) to analyze amount and stability of swallowing, and categorized correlational analyses of oxygen saturation by group and bottle condition.

RESULTS

Bailiwick demographics.

A total of 70 infants were enrolled in the study. Of these 70 infants, 34 were unable to complete both the abode and laboratory testing portions of the study: 15 mothers were non gear up to discontinue exclusive breast-feeding 6 wk after hospital discharge; mothers of another nine infants switched bottle-feeding systems after their original choice, which made them ineligible to continue on the study, and for 10 infants, we were unable to record sucking at the breast because the infant rejected the tube taped to the nipple when it was presented for feeding. Therefore, after compunction, the written report population comprised the offset 36 good for you newborns who were able to successfully complete both the transition from breast to bottle during a four- to 6-wk menstruation and laboratory testing. There was no difference in dropout rates betwixt the two bottle-feeding groups. Babe characteristics are shown in Table i. All infants were total term. Birth weights and weights at weeks four to vi were like in the two bottle-feeding groups. At that place were no meaning differences between groups with regard to pacifier use.

Tabular array one Baseline characteristics of participants

Full size table

Individual data.

To illustrate the analyses depicting the location of swallows relative to sucking and breathing, we kickoff present data from a single 5-s sample of feeding from an individual infant (Fig. ane). Figure 1A depicts a swallow signal indicating that the infant produced iv successive swallows (the 4 precipitous aamplitude peaks) during this 5-s menses. The swallow signal was then filtered by a MATLAB algorithm, rectified, and then superimposed onto the respiratory (solid line) and sucking (dashed line) signals (Fig. oneB). From this effigy, information technology is axiomatic that swallows occur at the peaks of intraoral sucking pressure (inverted in the figure to be the valley) and that during 2 of the four swallows, in that location is a flattening of respiratory amplitude (come across the middle ii swallows in Figure aneB). The four swallows of shown in Figure 1A were so presented in polar coordinates to indicate their location in a 360-degree round distribution of sucking and breathing (Fig. 1C). As tin exist seen in the figure, the four swallows are not randomly distributed, just rather tended to cluster nigh zero and effectually 180 degrees relative phase. These data thus suggest that swallows are not randomly distributed during feeding, simply rather are likely to occur at detail locations in a space partitioned by ongoing sucking and breathing patterns.

Grouping data.

Data from each group of infants (fed with arrangement 1 or 2) were so examined and the distribution of swallowing relative to sucking and animate during breast-feeding and canteen-feeding in each grouping was determined. Each 360-caste wheel of sucking and breathing was divided into xx-degree "bins," and the number of swallows in each bin was determined. Separate χ² analyses were conducted on the observed and expected frequencies of swallows during breast-feeding (Fig. iiA) and canteen-feeding (Fig. twoB) in each group. As expected, swallowing was distributed nonrandomly during chest-feeding in both groups (×two = 32.75, df = 8, p < 0.0001 and ×2 = 22.42, df = eight, p < 0.004 for systems 1 and 2, respectively). During bottle-feeding, swallowing was besides distributed nonrandomly among infants using system 1 (×2 = 57.50, df = eight, p < 0.0001). Still, infants using arrangement 2 swallowed at random locations in the circular distribution (×2 = 9.138, df = eight, p = 0.3307). Thus, when infants were switched from chest-feeding to canteen-feeding, only infants using system 1 connected to organize their sucking, animate, and swallowing in a manner similar to their breast-feeding.

Inspection of these results suggest that at that place may exist differences in the overall corporeality of swallowing in infants using the different bottle systems, so a parametric test was conducted on the data from the 2 groups. A group (organization 1, system two) by condition (breast-feeding, canteen-feeding) repeated-measures ANOVA indicated no significant chief effects of group or condition, simply did reveal a significant grouping by status interaction, (F _one,68 = four.567, p = 0.0362). Effigy three depicts the hateful number of swallows during breast- and bottle-feeding in each group. The post hoc analysis indicates that when infants switched from chest-feeding to bottle-feeding, there was a pregnant subtract in swallowing in infants using system 1, but a meaning increment in swallowing in infants using system ii.

The higher up findings too suggest that the organization of swallowing in infants using system 2 may be more variable (i.e. less stable) than in those using organization 1. The mensurate of the SD of relative phase is indicative of the relative stability of coordination (18,19), so we postulated that grouping differences in the SD of relative phase between systems 1 and two may shed light on differences in the variability of swallowing between the two groups. In detail, nosotros hypothesized that system 1 may allow infants to continue swallowing with less perturbation of their breathing compared with organization 2. An ANOVA on the SD of swallowing relative phase past infants in each of the two bottle-feeding groups during breast-feeding and canteen-feeding indicated a principal effect of group (F_1,68 = 4.08, p = 0.047), but no condition main effect or group by condition interaction (Fig. iv). Infants using system two exhibited significantly college SD of swallowing relative phase and, therefore, greater instability in the coordination of sucking, breathing, and swallowing.

Nosotros and so examined the relation between the stability of the coordination of swallowing, sucking, and breathing and claret oxygenation. First, we measured mean (Fig. 5A) and minimum (Fig. vB) per centum of oxygen saturation during chest-feeding and canteen-feeding in infants using the two feeding systems. A group (organisation one, organization two) by condition (breast-feeding, bottle-feeding) ANOVA revealed grouping by condition interactions for both mean percentage of oxygen saturation (F _1,68 = 6.70, p = 0.011) and minimum percentage of oxygen saturation (F _1,68 = four.56, p = 0.036). Post hoc analyses indicated that, in both cases, the significant interaction was due to the reduced oxygenation in infants using system ii during bottle-feeding compared with their own breast-feeding. For infants using system 1, there were no differences in mean or minimum oxygen saturation during breast-feeding and bottle-feeding.

To and then determine whether the finding of lower oxygenation in the group using system 2 was related to the system of their swallowing, we calculated categorized correlation coefficients between hateful percentage of oxygenation and SD of swallowing relative phase separately by grouping and condition (Fig. 6). There were no meaning correlations between oxygenation and SD of swallowing relative stage during breast-feeding or bottle-feeding in infants using organisation 1. However, lower mean percentages of oxygen saturation values were significantly correlated with college SD of swallowing relative phase during canteen-feeding past infants using system 2 (r = −0.4935, p = 0.0374). Infants using system 2 thus had more variable swallowing and a correspondingly lower mean per centum oxygen saturation.

Word

This study examined the coordination of sucking, swallowing, and breathing during breast-feeding and compared it to coordination during canteen-feeding among infants using two different feeding systems. Our hypotheses were that during chest-feeding, swallows would exist distributed nonrandomly (i.e. at particular locations) and that a canteen-feeding system that more closely mimics the physiologic norm would promote a like swallowing pattern. We also compared oxygenation during both breast-feeding and canteen-feeding and hypothesized that during periods of higher oxygenation, the coordination of sucking, swallowing, and breathing would be more stable (take lower variability), and a bottle-feeding organisation that more than closely mimics the physiologic norm of chest-feeding would more probable promote a coordination pattern with lower variability.

The study findings presented here demonstrate that during breast-feeding swallowing is segregated from breathing. These data propose that sucking and breathing patterns create "windows of opportunity" for swallows and that the primal nervous system may expect for opportunities inside ongoing sucking and breathing patterns in which to fit swallows, making it possible for an infant to continue feeding without interruption. Thus, infants are able to maintain a relatively constant milk flow and continue breathing by inserting swallows into detail regions of the extant sucking and breathing relationship. The results are consistent with and extend the findings of earlier studies (3,four,xx).

The results of this study also indicate that there were significant differences in coordination patterns in infants using different bottle-feeding systems. Organization one (Playtex) promoted a design of coordination between sucking, swallowing, and breathing that was more like to the physiologic norm than was system 2 (Avent). Infants using system 1 distributed their swallows nonrandomly in time and so that they were less likely to occur at the location of respiratory inspirations. By contrast, infants fed with organisation ii distributed their swallowing more randomly, even when they segregated swallowing from breathing while they were breast-feeding. Furthermore, there were too statistically significant differences betwixt the two systems in the amount of swallowing and in the stability of coordination of sucking, swallowing, and animate. One possible consequence of this increased swallowing is that infants who swallow more than frequently accumulate air in the breadbasket, which may crusade postfeeding gastric upset. A relevant finding in this regard is reported in one of the few studies that have measured oxygen saturation during and after breast-feeding and bottle-feeding (21). The authors reported significantly lower oxygenation following bottle-feeding than during the actual feeding period and attribute this to burping and gastric distress later the feeding. A follow-up report that examines swallowing during feeding with pulse oximetry measures during and subsequently feeding may aid to clarify the postfeeding distress experienced by some bottle-fed infants.

Additionally, the reduced oxygenation (decreased oxygen saturation) that we observed during bottle-feeding compared with breast-feeding is consistent with previous studies (eight–10). Previous research suggests that alterations in blood oxygen levels are due to decreased ventilation (xx,22), which may be due to airway closure associated with swallowing and decreased ventilatory effort (twenty). Therefore, the higher oxygen levels that have been consistently observed during breast-feeding may be due to more coordinated sucking, swallowing, and animate compared with canteen-feeding. This hypothesis is supported by our coordination analyses, which show the well-organized pattern of swallowing relative to sucking and breathing during chest-feeding. The coordination analyses too suggest that i reason why infants using system one exhibited similar oxygenation during both chest-feeding and bottle-feeding was that their swallowing was amend organized.

The fact that oxygen saturation is higher during chest-feeding than bottle-feeding suggests something about the overall mechanics of the feeding process. There may be a mechanistic basis for the advantages of breast-feeding over bottle-feeding as a event of differences in natural language posture and less disruption of animate. Past extension, there may be differences amidst bottle-feeding systems, some of which may promote more natural postures and breathing patterns than others. If a system can be designed that promotes less swallowing, babies tin can feed more like the natural physiologic norm of breast-feeding.

What may accept contributed to the variable location and instability of swallowing during feeding in the grouping using organization 2? During breast-feeding, the tongue is grooved around the nipple and remains under the nipple throughout feeding (2,seven). The muscular action of the tongue produces peristalsis, and then that the timing of swallowing is a continuous event in a sequence of standing waves (2). The position of the tongue during bottle-feeding in the ii groups may have been dissimilar, only nosotros do not know this with certainty. If the tongue is more "piston-like" in infants using system two and the job of finding the windows of opportunity for swallowing is more than hard, swallowing may occur at a moment in the respiratory bicycle that destabilizes breathing, and, therefore, may promote oxygen desaturation. Ultrasound or other imaging studies in conjunction with our relative phase and oxygenation measures may help clarify this hypothesis.

A potential limitation of this study is that all bottle-feeding measurements were performed after breast-feeding. Since breast-feeding was "early" in the feeding cycle and bottle-feeding was "later," some of the differences in sucking patterns may exist due to the relative timing during the feeding bicycle. A cross-over report design (in which bottle-feeding measurements were also performed before breast-feeding) may thus have been beneficial in confirming these results. Nonetheless, the way the study was performed mimics the real-life feeding patterns of infants (i.e. breast-feeding kickoff, followed by a switch to a bottle) and therefore has external validity.

Guidelines from the American Academy of Pediatrics promote exclusive chest-feeding for the first 6 mo, with continuation for at least the first year (23). Although breast-feeding is clearly all-time for infants, it may not always be possible. To the extent that an bogus nipple and milk container let the hungry infant to suck vigorously without unduly competing with breathing, the experience of bottle-feeding may exist more like to breast-feeding. By designing artificial nipples and reservoirs that are compatible with the intrinsic dynamics of babe beliefs, it may be possible to make oral feeding by canteen more like to the physiologic norm of breast-feeding. The bogus nipple used in system 1 in this study explicitly models the elasticity, shape, and texture of the man nipple, and the collapsible milk reservoir supports a constant milk menses that does not increase hydrostatic pressure as the remaining volume decreases. The nipple provides 1) a tip that extends elastically so that tongue peristalsis can more than effectively draw milk into the posterior pharyngeal region to accumulate gradually before swallowing, 2) a shape that provides a rounded profile like to the region betwixt the nipple and areola of the breast, and 3) a textured region of the nipple contacted by the infant'south lips that provides a skid-free surface to promote latching on with an effective seal between lips and the silicone material. The mechanical properties of the artificial nipple, similar the chest, provide an elastic response in which the nipple extends and withdraws in a piston-like manner, storing and releasing potential energy. Breast-feeding infants who have mastered a suck-swallow response that capitalizes on this stored potential energy may be able to boring their respiratory charge per unit so that their swallowing fits the respiratory rhythm without prolonged interruptions.

In conclusion, the results of this study have several applied implications for evaluating problems of swell concern to women who breast-feed but who may elect to supplement breast-feeding with breast milk fed by canteen and bogus nipple. These women face the hard choice of which bottle and bogus nipple to apply, and many practise so in the context of confusing and conflicting professional and family advice. At that place has too been business organization in the clinical literature regarding the potential for nipple confusion if artificial nipples are used. The methodology of the present study suggests a research strategy that may be used to compare the overall dynamics of breast-feeding and canteen-feeding under a range of parametric manipulations. It may thus be possible to use principles derived from the study of coordination dynamics to go on to improve means to supplement breast-feeding when women and their families choose to exercise and then.

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Author information

Affiliations

Children's Infirmary Boston, Boston, 02215, Massachusetts

Eugene C Goldfield & Stacey Margetts
Harvard Medical School, Boston, 02215, Massachusetts

Eugene C Goldfield & Kimberly 1000 Lee
Centre for the Ecological Study of Perception and Action, Academy of Connecticut, Storrs, 06269, Connecticut

Michael J Richardson
Beth Israel Deaconess Medical Center, Boston, 02215, Massachusetts

Kimberly One thousand Lee

Corresponding author

Correspondence to Eugene C Goldfield.

Additional information

This report was supported by a grant from Playtex Products, Inc. (Westport, CT), which also provided both types of infant bottles and nipples for the inquiry. Supported by NIH grant 2R44HD047128 to the first author and by the Children's Hospital Boston Mental Retardation and Developmental Disabilities Research Eye, #P01 HD18655.

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Goldfield, East., Richardson, Thou., Lee, K. et al. Coordination of Sucking, Swallowing, and Breathing and Oxygen Saturation During Early on Babe Breast-feeding and Bottle-feeding. Pediatr Res 60, 450–455 (2006). https://doi.org/10.1203/01.pdr.0000238378.24238.9d

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Received: 06 Jan 2006
Accepted: 22 May 2006
Issue Appointment: 01 October 2006
DOI : https://doi.org/10.1203/01.pdr.0000238378.24238.9d