Aspiration occurs when food, liquid, or saliva accidentally enters the airway and lungs instead of passing down the esophagus toward the stomach. This misdirection of material happens when the protective swallowing mechanisms are not fully coordinated, which is common in infants. Consequences can range from immediate choking to serious long-term respiratory issues like aspiration pneumonia. Understanding how to manage feeding practices and the baby’s environment provides parents with methods to significantly reduce this risk during feeding, sleep, and in the event of an acute airway obstruction.
Prevention Techniques During Feeding
Proper positioning during feeding is the most direct way to support an infant’s swallowing mechanics and prevent aspiration. The baby should be held in an upright or semi-upright posture, with the head elevated to at least a 30 to 45-degree angle. This use of gravity helps direct milk or formula down the esophagus and away from the trachea, supporting the natural swallow-breathe coordination. Feeding a baby while they are lying flat should be avoided as it increases the risk of liquid entering the airway.
The rate at which the liquid flows is equally important, particularly for bottle-fed infants. Using a slow-flow nipple, often labeled as “newborn” or “preemie,” allows the baby to maintain a coordinated suck-swallow-breathe pattern, ideally a 1:1:1 rhythm. If the flow rate is too fast, the infant may struggle with gulping, excessive milk leakage from the mouth, or frequent coughing, all signs that the liquid is overwhelming their ability to swallow safely. Conversely, a flow that is too slow can cause frustration and fatigue.
Paced bottle feeding is a technique designed to give the baby control over the flow, mimicking the intermittent pauses that occur during breastfeeding. This involves holding the bottle horizontally or parallel to the floor, tilting it only enough to keep the nipple partially filled, forcing the baby to actively suck. The feeder should encourage frequent breaks by lowering the bottle to temporarily stop the flow after about 20 to 30 seconds, or after three to five continuous swallows. This external pacing prevents the baby from being flooded with liquid and ensures they are awake and alert enough to manage the feed effectively.
Strategies for Managing Reflux and Sleep
Gastroesophageal reflux (GER) is common in infants due to an immature lower esophageal sphincter, and the resulting spit-up can increase the risk of aspiration. Managing reflux often begins with non-medical interventions, such as adjusting the frequency and volume of feeds. Offering smaller, more frequent meals reduces the total volume in the stomach, decreasing the likelihood of stomach contents washing back up into the esophagus.
Thorough burping mid-feed and immediately after the feed is an important step to release trapped air, which can otherwise contribute to spitting up. After feeding, the baby must be kept in an upright position for at least 30 minutes, and ideally up to 90 minutes, to allow gravity to assist in keeping the stomach contents down. A burping position involves holding the baby upright over the shoulder with their legs extended, which is generally more effective than a seated position.
When it is time for sleep, the safest practice is to place the baby on their back, or supine position, on a firm, flat, and non-inclined surface. The recommendation to place an infant on their back stands even if the baby has reflux, as healthy infants have a protective gag and swallow reflex that prevents aspiration. Placing a baby on their back does not increase the risk of choking, and using inclined sleepers, wedges, or pillows is discouraged. These positioning devices are unsafe and have not been shown to reduce reflux, but they do increase the risk of Sudden Unexpected Infant Death (SUID).
Identifying Symptoms of Aspiration
Recognizing the signs of aspiration is important because symptoms can be immediate or develop over time. Acute signs of aspiration during a feed include sudden, forceful coughing, gagging, or choking. The baby may display difficulty coordinating sucking and swallowing, such as gulping or stopping breathing for short periods while eating.
If the aspiration is chronic or silent, the symptoms may be more subtle and persist after the feed is over. Parents might notice a wet or gurgly sound in the baby’s voice or breathing, sometimes described as a “wet” cry. Recurrent respiratory issues, such as frequent bouts of pneumonia, chronic wheezing, or a low-grade fever following feeds, can indicate that small amounts of material are entering the lungs over time.
Other chronic signs include labored or rapid breathing, as the lungs struggle to process the aspirated material. Any noticeable sign of distress, such as a change in skin color or a weak suck during feeding, should be noted. If any of these chronic symptoms are observed, a medical evaluation from a pediatrician is necessary to determine the underlying cause and develop a management plan.
Immediate Action Steps
If an infant begins to choke and is unable to cough, cry, or breathe effectively, immediate and forceful action is required. The first step is to call for emergency medical services (911 or local equivalent) or instruct someone else to do so immediately. The caregiver should then begin a cycle of back blows and chest thrusts.
To deliver back blows, hold the baby face-down along your forearm, supporting the head and neck, ensuring the head is lower than the chest. Use the heel of your free hand to deliver up to five sharp blows between the shoulder blades. If the obstruction is not cleared, flip the baby onto their back, still supporting the head and keeping it lower than the chest.
Use two fingers placed in the center of the chest, just below the nipple line, to deliver up to five quick chest thrusts, compressing the chest about 1.5 inches deep. Continue alternating five back blows and five chest thrusts until the object is dislodged or the baby becomes unresponsive. Abdominal thrusts, commonly known as the Heimlich maneuver, should never be performed on an infant due to the risk of internal injury.