The SOFFI Reference Guide - Connecticut Children's Medical Center

DOI: 10.1097/JPN.0b013e31823529da 

J. Perinat Neonat Nurs Volume 25 Number 4, 360–380 Copyright C○ 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 

The SOFFI Reference Guide: Text, 

Algorithms, and Appendices 

A Manualized Method for Quality Bottle-Feedings 

M. Kathleen Philbin, PhD, RN; Erin Sundseth Ross, PhD, CCC-SLP 

ABSTRACT 

The Support of Oral Feeding for Fragile Infants (SOFFI) 

method of bottle-feeding rests on quality evidence along 

with implementation details drawn from clinical experience. 

To be clear, the SOFFI Method is not focused on the 

amount of food taken in but on the conduct of the feeding 

and the development of competent infant feeding behavior 

that, consequently, assures the intake of food necessary 

for growth. The unique contribution of the SOFFI method 

is the systematic organization of scientific findings into clinically 

valid and reliable, easily followed algorithms, and a 

manualized Reference Guide for the assessments, decisions, 

and actions of a quality feeding. 

A quality feeding is recognized by a stable, selfregulated 

infant and a caregiver who sensitively (responsively) 

adjusts to the infant’s physiology and behavior to 

realize an individualized feeding experience in which the infant 

remains comfortable and competent using his nascent 

abilities to ingest a comfortable amount of milk/formula. 

The SOFFI Reference Guide and Algorithms begin with 

Author Affiliations: From the College of New Jersey, Ewing, and 

University of Pennsylvania School of Nursing, Philadelphia (Dr Philbin); 

and School of Medicine, Department of Pediatrics, JFK Partners, 

University of Colorado Denver, and Children’s Nutrition Research 

Centre, University of Queensland, Brisbane, Australia (Dr Ross). 

We thank our colleagues and mentors in the global NIDCAP community 

and the many nurses, occupational therapists, speech-language 

pathologists, researchers, infants, and parents who have helped to 

develop our thinking over the years. Sharon Sables-Baus helped with 

early versions of the algorithms. Manuscript preparation was supported 

by the Children’s Hospital of Philadelphia and The College of New 

Jersey (MKP) and NIH #5 T32 DK 07658-17(ESR). 

Disclosure: The authors have disclosed that they have no significant 

relationships with, or financial interest in, any commercial companies 

pertaining to this article. 

Corresponding Author: M. Kathleen Philbin, PhD, RN, School of 

Nursing, The College of New Jersey, PO Box 7718, Ewing, NJ 08628 

(kathleenphilbin@comcast.net). 

Submitted for publication: August 23, 2011; Accepted for publication: 

August 29, 2011 

prefeeding adjustments of the environment and follow step 

by step through a feeding with observations of specific 

infant behavior, decisions based on that behavior, and specific 

actions to safeguard emerging abilities and the quality 

of the experience. An important aspect the SOFFI Reference 

Guide and Algorithms is the clarity about pausing and 

stopping the feeding on the basis of the infant’s physiology 

and behavior rather than on the basis of the amount 

ingested. The specificity of each observation, decision, and 

action enables nurses at all levels of experience to provide 

quality, highly individualized, holistic feedings. Throughout 

the course of feeding in the NICU, the nurse conveys to 

parents the integrated details (observations, decisions, and 

actions) particular to their infant, thus passing on the means 

for parents to become competent in quality feeding, to enjoy 

feeding time into the future, and to gain in confidence 

as they watch their infants grow. 

Key Words: algorithm, behavior, bottle, manual, feeding, 

guide, nursing care, NICU, preterm infant, quality, SOFFI 

The SOFFI Reference Guide, algorithms, and appendices 

are a manualized clinical resource for 

bottle-feeding preterm, ill, and fragile infants 

with empirical research providing the definition of quality. 

The algorithms guide a clinician through assessments, 

decisions, and consequent actions. At points of 

assessment and action, the algorithms indicate the lettered 

and numbered section of the SOFFI Reference 

Guide that contains relevant information or guidance. 

Each section of the Guide includes a brief statement 

of the topic, the details of the assessment or course 

of action that would result in a good quality feeding 

and details of conditions or actions that would likely 

diminish the quality of the feeding. 

One would not refer to the SOFFI materials or make 

notes during a feeding as this would distract attention 

from the infant and be disruptive. While learning 

360 www.jpnnjournal.com October/December 2011 

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

the method one would study its scientific basis, 1 algorithms, 

reference guide, and appendices away from 

the bedside, practice remembering the details of a specific 

feeding, and subsequently use the SOFFI resources 

for self-evaluation. Practice in remembering the details 

of the feeding has a secondary benefit of sharpening attention 

to infant behavior generally. Nurses can learn in 

pairs by arranging for one to silently observe the other 

during a feeding, identifying the assessments made and 

actions taken, and both reviewing the feeding together 

afterward, away from the bedside. 

The SOFFI method and its scientific basis are fully 

described in Ross and Philbin. 1 A brief summary is provided 

here. 

The primary objective of the SOFFI method is the development 

of an infant’s competence in feeding in the 

context of pleasurable, relaxed, and controlled feeding 

experiences. This results in associating hunger, feeding, 

and food with rewarding/pleasurable experience. 

Feeding competence is generally well developed in a 

term newborn before birth and before requirements of 

ingesting food for growth. Therefore, the adult’s (usually 

parent’s) skill in making feeding enjoyable usually 

involves more or less simple adjustments to an 

infant’s individual characteristics. By contrast, feeding 

competence may be lacking or minimally developed in 

a preterm, ill, or fragile infant when the requirement 

of ingesting food for growth is imposed. In this case, 

considerable skill is required to bring an infant to competence 

in feeding with solid pleasurable associations 

between hunger, feeding, and food. It is not difficult to 

“make” a preterm infant swallow milk/formula from a 

bottle with weight gain as the goal. However, an infant 

whose feedings are driven by this goal is at risk for 

acquiring defensive or problematic feeding behavior, a 

solid association between feeding and discomfort (such 

as struggling to breathe) and, consequently, an aversion 

to food and feeding. 

The SOFFI algorithms, Reference Guide, and appendices 

are successful resources for nurses and others to 

acquire the skills necessary to provide pleasant experiences 

before, during, and after feeding even though 

the infant has immature or atypical feeding abilities. 

To do this the caregiver uses the infant’s behavior to 

guide adjustments that maintain physiologic stability, 

enjoyment of the experience, and the competence of 

emerging abilities. For example, direct supports for a 

bottle-fed infant may include selecting an appropriate 

nipple or eliminating prefeeding activities that cause fatigue. 

Indirect supports may include adjusting light and 

noise levels and actively managing one’s own attention, 

emotional state, and behavior. 2−6 

The following is an example of using the SOFFI feeding 

algorithm (Figure 1) to assess, decide, and act to 

maintain a comfortable, competent feeding experience 

for a beginning feeder. 

At START the physical environment is adjusted to the 

needs of the infant as much as possible (Guide A) and 

the infant has previously shown stability during routine 

care (Guide B). The nurse now determines that the infant 

is physiologically stable lying undisturbed in bed at 

the time of the particular feeding (Guide E) and showing 

readiness by wakening somewhat and mouthing 

the blanket. When he is picked up, however, the respiratory 

rhythm becomes somewhat irregular (Guide 

F). Observing this, the nurse decides to support a return 

to physiologic stability by carefully swaddling the 

infant in a blanket, and holding quietly. Soon after, 

the nurse offers a pacifier for prefeeding nonnutritive 

sucking. The infant accepts the pacifier and, with sucking, 

returns to stable respirations and becomes more 

awake (Guide F). The nurse then offers the bottle with 

a standard nipple (Guide G). The infant feeds with good 

suck-swallow-breathe coordination including regularly 

pausing to breathe between 3 and 5 suck-swallows and 

maintaining physiologic stability (Guide B). The feeding 

continues with evidence of the infant’s physiologic 

stability. The nurse assesses the level of participation 

noting good tone through the face and regular suckswallow-breath 

patterns (Guide H). Assessing efficiency 

(Guide I) she notes that there is no milk around the outside 

of the nipple, no gulping sounds, and the sucks are 

extracting sufficient milk from the bottle. She continues 

the cycle of observations through stability, participation, 

efficiency, and self-pacing. Later, however, the infant 

begins to drip milk around the nipple, has longer 

periods between sucking bursts, appears more sleepy, 

and has less tone throughout the body and face (Guide 

H). She judges that the infant is tired and temporarily 

stops the feeding to rest and reorganize while holding 

him quietly in alignment in a vertical position. (There is 

no back patting/rubbing to force a burp.) (By contrast, 

if there was dripping around the nipple but good facial 

tone and active sucking, the nurse would assess the 

sucking as inefficient [Guide I]. In this case, she would 

stop the feeding to change the nipple to one with a 

slower flow rate, observing whether this corrects the 

spillage [Figure 2 and Appendix 1].) The infant burps 

spontaneously, becomes more drowsy, and resists taking 

the nipple. The nurse then decides to stop the feeding 

(STOP, Guides C and D), holds the infant somewhat 

upright for a few minutes to facilitate a further burp, and 

returns him to bed either wrapped as during the feeding 

or unwrapped, leaving him undisturbed, on top of 

the blanket in which he was held. (Had the infant actively 

accepted the nipple after resting and continued to 

feed, the nurse would follow his lead continuing with 

assessments and decisions around the algorithm.) 

The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 361 


The SOFFI Reference Guides and Algorithms allow 

nurses to sensitively individualize each feeding to the 

infant’s abilities at that moment in time. With practice, 

the details of the Guides become a logical, learned competence 

that frees the caregiver to create a smoothly 

functioning and mutually comfortable feeding experience. 

Parents learn about feeding their baby from the 

nurse who draws on her broader knowledge and experience 

to care for this singular child. The nurse conveys 

to parents the integrated details (observations, decisions, 

and actions) particular to their infant, thus passing 

on the means for parents to become competent in 

quality feeding, to enjoy the feeding interchange, and 

to gain in confidence as they watch their infant grow. 

The theoretical framework and scientific basis of the 

SOFFI method are found in Ross and Philbin. 1 

The SOFFI Reference Guide was developed from 

a variety of sources but particularly from the writings, 

research, and clinical knowledge of Als, Browne, 

Ross, and Philbin. 7−13 More complete descriptions of 

the outward signs of infant stability and behavioral organization 

and of contingent (sensitive) caregiver responses 

are described in the abundant literature on the 

subject. 6−12 Additional evidence supporting the SOFFI 

method and Reference Guide is found in a variety 

of resources. 14−20 Skill training programs that address 

preterm and high risk infant feeding include the Newborn 

Individualized Developmental Care and Assessment 

Program, the Fragile Infant Feeding Institute, the 

Family Infant Relationship Support Training, and Made 

to Order. 5,8,9,21 

Figure 1. Beginning at START, the SOFFI Bottle-Feeding Algorithm 

guides the caregiver through a sequence of assessments, decisions, 

and actions to realize a safe, high-quality infant feeding. Letters in the 

algorithm indicate identically lettered Guides in this article. “STOP” 

indicates ending or pausing a feeding to stabilize the infant. The 

algorithm is more easily followed in color and is available from the 

authors. Reproduced with permission. 



SOFFI bottle feeding algorithm (Figure 1) 

Preparations for feeding (general 

conditions challenging stability) 


conditions supporting stability) 

Guide A: Environment 22 

Guide A-1: Visual environment Provide Avoid 

The eyes of preterm and term infants 

are far more sensitive to light than 

adults and have less protection 

against it. 22 For infants

SOFFI bottole feeding algorithm (Figure 1) 



Guide A: Environment 



Guide A-4: Odorants; the 

environment of scent Provide Avoid 

Infants use scent to identify their 

mother. 32−34 For adults: Use unscented hair products, lotions, soaps, For adults: Avoid perfume, after shave, scented 

Scent is important to after shave, and so on when giving care. Ensure that lotions and hair products. Avoid (as much as 

attachment. Discrimination of 

hospital-provided adult-use soap, lotion, and alcohol possible) using alcohol wipes near or on the infant 

maternal scent can be interrupted by rub are unscented. Completely dry alcohol rub before before or after feeding time. Avoid approaching the 

scents that adults do not perceive as approaching the infant for a feeding. Separate strongly infant with moist alcohol rub on hands. 

strong. 

scented materials (eg, alcohol swab) from feeding time For parents: Avoid failing to provide parents with 

as much as possible as it is aversive. 

information about deleterious effects of their 

For Parents: Explain the rationale for protecting the baby perfumes, after shave lotions, and so forth on the 

from scents other than the mother’s natural 

infant’s ability to recognize the mother. Avoid telling 

(unperfumed) scent. Place mother’s breast pad near a mother to put perfume on something she leave in 

infant’s face and change to fresh pads several times a the infant’s bed as this will likely be aversive and 

day if possible as natural odorants become inactive covers whatever of her natural scent there may be. 

rapidly. 

Guide A-5: Gustatory (taste) 

Taste is closely associated with 

feeding and part of the learned 

response to feeding. Preterm and 

term infants can discriminate among 

similar tastes and show 

preferences. 35 

Provide 

Avoid 

Provide pleasant tastes (ie, mother’s milk or formula) Avoid combining unpleasant tastes with milk and 

with feeding. Place drops of milk/formula on infant’s feeding (eg, putting vitamins in milk/formula); 

lips or fingers (for sucking) during gavage feeding. putting medication directly into a nipple. Avoid 

Separate unpleasant tastes from feeding (eg, give using flavored pacifiers as the “flavor” chemicals 

vitamins between feedings without a milk vehicle and are untested and create a strong taste unrelated to 

by gavage when possible). Separate unpleasant tastes milk. Avoid putting unrinsed (milk, sterile water), 

from tasks involving the mouth; rinse gloved fingers in gloved fingers directly in infant’s mouth. 

sterile water and dip in breast milk/formula before 

putting them in the infant’s mouth. 

Guide A-6: General handling and Provide 

Avoid 

touch 

Announce your presence with quiet touch and voice When approaching an infant for a feeding, avoid 

Preterm infants are very sensitive to before handing. Use gradually changing, smooth, slow touching/handling without warning. When changing 

handling. Abrupt handling is typically movements before, during, and after feeding with a a diaper, wrapping, and so on avoid abrupt, quick 

aversive and can be stressful to the gradual off-on touch pressure. Support the whole body movements of the infant’s body and rapid on and 

point of pain. Handling can be 

continuously during movement or turning. Adapt touch off touch pressure. Avoid supporting some body 

disorganizing to the physiology and and handling to the infant’s movement, facial 

parts but not others (eg, holding only head and 

behavior of preterm or ill infants. expression, behavioral state or physiologic changes. buttocks). Avoid maintaining the adult task agenda 

For infants

SOFFI bottole feeding algorithm (Figure 1) 





Guide A: Environment 

Avoid 

Avoid thinking that the effects of routine tasks 

(physical stress, pain, etc) are separate from or do 

not affect competence in feeding. Avoid a series of 

routine care activities immediately before a feeding 

until the infant maintains all-round self-regulation 

during the tasks with surplus energy and 

organization for the feeding. Avoid adding tasks or 

procedures to an existing bundle/cluster without 

evaluating their cumulative effects on the baby. 

Avoid an uninterrupted series of clearly stressful 

procedures “to get it over with so he can rest” as 

the recovery time may be longer than the time 

between feedings. Avoid completing parent’s care 

activities before they arrive. Avoid leaving parents 

alone while giving care until they have mastered the 

skill of planning with the effect on the infant as the 

primary consideration. 

Provide 

Throughout the day, prioritize essential tasks around 

feedings as much as possible so that essential tasks 

are planned for their effect on the infant’s reserves for 

feeding. Minimally necessary tasks that make high 

demands can be postponed or eliminated if the 

infant’s self-regulation is heavily challenged by higher 

priority tasks or the feeding itself. Consider the entire 

24-hour day when estimating the effects of events 

(including routine tasks) on the energy and 

self-regulation needed for feeding. Spread tasks and 

stressful events across the day (not necessarily in 

“clusters”) and perform them when the infant is 

awake. Novice feeders or those having difficulty 

maintaining self-regulation in many situations may 

tolerate only picking up (without reswaddling or other 

activity) and immediately starting the feeding. Assist 

parents to learn to prioritize tasks by explaining the 

reasoning for your choices and planning. 

Provide 

Organize equipment and the environment before 

touching the infant or opening the incubator (eg, locate 

a comfortable chair and foot stool). Adjust lighting or 

turn the chair to reduce light in the infant’s eyes. Clear 

a flat surface. Lower monitor alarm levels if possible. 

Bring all items to a place within easy reach during the 

feeding. Arrange for someone else to answer calls or 

check monitor alarms. Help parents prepare for a 

feeding, setting up feeding materials as needed so that 

they can eventually become independent with feeding. 

Guide A-8: Planning and control 

A rested infant is more likely than a 

tired infant to maintain physiologic 

stability, motor tone and control, and 

state control for a successful 

feeding. 

Avoid 

Avoid an incomplete setup of materials and the 

environment before starting the feeding. Avoid a 

disjointed, start-stop series of activities after 

touching the infant. Avoid using whatever chair that 

is available even if it is uncomfortable for you or the 

parent. Avoid answering the phone or pager during 

feeding. Redefine a staff tradition that requires 

getting up during a feeding to check on another 

infant. Avoid leaving parents to set up for the 

feeding on their own until they indicate a wish to 

do so. 

Guide A-9: Preparation for a feeding 

Thorough preparation provides the 

caregiver with better concentration, 

less unrelated movement, and the 

infant with a predictable sequence 

of events, facilitating learning. A 

well-fitting chair and foot stool 

support the feeder’s body 

mechanics, concentration, and more 

secure holding. 



Assess infant: indicators of 

instability (adapted from Als) 

Assess infant: indicators of 

stability (adapted from Als6 ) 

Guide B: Assessing stability 

Instability 

HR above or below the resting limits or standards for 

the unit or baby. 

Stability 

Heart rate (HR) stable within 20% above or below the 

average of recent resting HRs and within the 

unit-based standard for limits, or within the individual 

standard for the infant. 

Stability 

Color across face and body is pink or mildly pale. Color 

remains stable. 

Guide B-1: Heart rate 

An indicator of physiologic stability. 

Instability 

Color across face and body is pale, flushed/red, dusky 

(circumoral, orbital, elsewhere across the face), or 

mottled (network of veins apparent). Skin areas 

alternate between pale and dusky. Color has 

changed from pink or mildly pale. 

Instability 

RR outside unit-based or individual limits, irregular 

breath-to-breath intervals, pauses greater than 5 

seconds between breaths, gasping, yawning, 

coughing, hiccoughing, retractions, stridor, nasal 

flaring, increased effort of breathing, puffing/huffing 

motions, expiratory grunt. Blood oxygen levels (ie, 

desaturations) below the lower limit for the particular 

infant. 

Instability 

Diarrhea or constipation, substantial spit up, gagging, 

showing signs of discomfort during or after feeding 

(eg, intervals of squirming, face showing distress), 

not emptying stomach between feedings, feeding 

intolerance. 

Instability 

Very unclear behavioral states (eg, asleep or awake). 

Rapid changes from one state to another (eg, sudden 

onset of fussing, sudden sleep); prolonged fussing or 

crying; difficult to calm or console from crying or 

fussing. When determining readiness to feed, use 

the same definition of state for all infants, including 

those with BPD/CLD. 

Guide B-2: Skin color 

An indicator of autonomic system 

regulation. 

Stability 

RR within 20% above or below the average of recent 

resting RRs or within the unit-based or individual 

standard for limits. Regular breath-to-breath intervals; 

absence of pauses longer than 5 seconds between 

breaths. Blood oxygen levels stable; above the lower 

limit determined for this baby. 

Guide B-3: Respiratory and blood 

oxygen 

A stable respiratory rate (RR) and blood 

oxygen levels are necessary for 

coordinated suck-swallow-breathe. 

Stability 

Uneventful digestion after recent feedings: stomach 

emptying between feedings, soft belly between 

feedings, regular elimination patterns. Small spit up, if 

any. 

Guide B-4: Gastrointestinal 

Retaining and digesting a feeding 

requires a stable gastrointestinal 

system. 

Stability 

Clearly differentiated behavioral states. Gradual changes 

from one state to another. Fussing or crying stops with 

minimal caregiver assistance. For feeding, a 

somewhat drowsy or alert state or arousal to a drowsy 

or alert state with simple handling. For infants with 

bronchopulmonary dysplasia (BPD)/chronic lung 

disease (CLD) successful feeding is possible with a 

skillful caregiver following a highly individualized plan 

even though behavior states are less clear, change 

more rapidly, and require more inclusive or longer 

assistance to calm from crying. 

Stability 

Good tone (neither flaccid nor stiff) as indicated by 

moderate flexion in upper and lower extremities, neck, 

and trunk. Smooth, purposeful movements of 

extremities. Predominant midline position at rest; few 

tremors. 

Guide B-5: Behavioral state, state 

stability 

Infants feed more successfully in 

drowsy or awake behavioral states 

and with behavior state stability. 40,41 

Instability 

Generally flaccid or limp; sagging in face, body, or 

extremities; rigid or tight in face, body or extremities. 

Arching the neck and spine. Attempts to block face 

with hand or arm; turning head away from the 

caregiver when held in feeding position. Flailing or 

jerky movements or multiple tremors. 

Guide B-6: Motor (movement and 

tone) 

Good tone stabilizes the body for 

feeding. In face and neck it enables 

efficient suck-swallow-breathe. 9 



Barriers to stabilizing and reorganizing 

(feeding is deferred or stopped) 

Stabilizing and reorganizing after decreased 

self-regulation (feeding is deferred or stopped) 

Instability 

Avoid continuing the activity of the moment (eg, readjusting 

position, feeding). Avoid looking around or talking to 

others. Avoid rocking the infant in a chair, bouncing on 

knees or in arms. Avoid large position changes or 

increased handling (eg, rewrapping). Avoid actively 

burping. 

Stability 

Stop the activity of the moment (eg, feeding, readjusting 

position). Observe the infant closely making small to 

moderate adjustments in body position for increased 

comfort (eg, reduce angle of trunk flexion; tip bottle down 

to stop the flow). Hold the baby still (eg, cease rocking in 

chair, bouncing baby’s body in arms or with own leg 

movement). 

Stability 

To the extent possible, make changes to create an 

environment that is less stimulating (eg, shield eyes from 

light). Cease talking and engaging in other activities 

(Guide A: General Conditions Supporting Stability). 

Guide C: Stabilizing and 

reorganizing feeding is 

deferred or stopped 

Guide C-1: Rest break 

A period of minimal stimulation 

supports the infant’s efforts to 

regain self-regulation and feed 

more successfully afterward. 

Instability 

Avoid maintaining the current level of environmental 

stimulation (eg, brightly lit, noisy, adult conversation, and 

activity near the infant; Guide A: General Conditions 

Supporting Stability). 

Guide C-2: Environmental 

stimulation 

External stimulation adds to 

disorganization/loss of 

self-regulation. It burdens efforts 

at reestablishing self-regulation. 

Instability 

Avoid wrapping tightly, because while the baby may stop 

moving, this may indicate giving up an attempt at 

self-management or self-comforting. Avoid placing an 

infant inside either a tight, confining nest or one so long 

that the feet cannot reach to foot end (ie, no foot brace 

available). Avoid wrapping too loosely to provide 

containment (eg, leaving feet outside the wrap). Avoid 

placing on a flat surface (the bed, the scale) with no 

containment. Avoid leaving an unsettled baby alone. 

Barrier—Instability 

Avoid ignoring infant attempts to escape the bottle (turning 

head away, arching neck and/or back). Avoid trying to 

make the baby feed when fussing, crying, or sleeping. 

Avoid not providing support for motor reorganization if the 

infant is arching or extending neck or back, flailing, 

showing other signs of disorganization. 

Avoid wakening a sleeping infant. 

Avoid leaving infants with BPD (or otherwise unstable) 

essentially on their own to calm from crying (eg, in a 

swing) 

Stability 

Wrap a flailing or crying infant carefully with extremities in 

midline and shoulders and feet supported by a wrapped 

blanket. Hand swaddle (Guide C-7) or surround infant with 

flexible nesting materials allowing room for movement 

with feet braced. Continue hand swaddling until 

self-regulation has returned to baseline. Hand-swaddle 

arms and legs during care or feeding if infant shows 

physiologic or behavioral disorganization. Alter position as 

needed (eg, to side-lying) 1 to locate position of comfort. 

Stability 

Calm from crying or cry face, jerky or flailing movement or 

efforts to escape the bottle (eg, turning head away, 

arching neck or back). Remove bottle. Employ other 

strategies described in Guide C. 

If infant is asleep (as opposed to drowsy), gently hold 

upright with a starighter back for a few minutes as 

necessary to burp, and return to bed without rousing if 

possible. Infants with BPD/CLD often have difficulty 

reorganizing behavioral state from sleep to an awake or 

drowsy state, and difficulty calming from crying and 

arching. Consistent caregivers (who know infant well), 

patience, and skill may be required. 

Guide C-3: Stabilizing body 

position, recovering from 

disorganization 

Disorganized movement, flailing, 

arched posture, and so on 

prevent state organization and 

increase likelihood of physiologic 

disorganization (eg, increased 

HR, RR). 7,9,12 

Guide C-4: Stabilizing behavioral 

state 

A stable drowsy or alert behavioral 

state enables comfortable, 

efficient feeding by permitting 

enlistment of multiple 

self-regulatory mechanisms that 

are not generally available in 

sleep, and is more likely to lead to 

successful bottle-feeding. 16,18,24 



Barriers to stabilizing and reorganizing 

(feeding is deferred or stopped) 

Stabilizing and reorganizing after decreased 

self-regulation (feeding is deferred or stopped) 

Guide C: Stabilizing and reorganizing 

feeding is deferred or stopped 

Instability 

Avoid increasing oxygen concentration or flow as a 

first or only strategy for reestablishing physiologic 

stability without considering the effort exerted by 

the infant. Avoid considering physiologic instability 

as unrelated to state and motor instability. Avoid 

not attending to disorganized behavioral states and 

movement when the infant is physiological instable. 

Guide C-5: Stabilizing physiology 

Improved physiologic stability usually follows 

from regaining behavioral state and motor 

disorganization 

Instability 

Avoid forcing a pacifier into the mouth as a means of 

stopping crying or distress movements. Avoid 

keeping it in place with objects or blankets. Avoid 

putting milk on a pacifier if an infant is upset, crying 

(ie, avoid creating an association between milk and 

discomfort). 

Stability 

Physiologic stability is usually supported by regaining 

motor control (eg, from squirming, flailing, arching) 

improving body position (eg, to increase comfort) 

and regaining state organization (eg, calming from 

fussing or crying to a sleep state or alert state). 

Depending on the infant’s underlying physiology, 

the time required for regaining physiologic stability 

will vary from 1 to 10 or 15 minutes after state and 

motor systems are reorganized. Infants with 

BPD/CLD usually require more time and care than 

other infants due to difficulties with air exchange 

while distressed and consequent oxygen debt as 

well as their typical habits of prolonged crying, 

arched posture, and so on. If increased oxygen 

support is required, decrease it as soon as possible. 

Stability 

If the infant has difficulty settling, offer pacifier by 

brushing it against lips or cheek. Wait for infant to 

show an interest by mouthing or searching for it or 

opening mouth somewhat. Gently insert pacifier 

and withdraw if infant shows resistance with 

tongue, gagging, facial expression, turning head, 

andsoon. 

Guide C-6: Pacifier, nonnutritive sucking 

A pacifier is a strong stimulus to suck. The 

infant usually cannot override it and must 

respond to it. Sucking can distract from 

crying/fussing, to gain state reorganization. 

However, forcing a pacifier into the mouth is 

aversive (even though the infant sucks) and 

contributes to feeding aversion. 

Instability 

Avoid pushing or putting pressure on the infant’s 

extremities, trunk, and so on so that movement is 

restricted. Assiduously avoid using hand swaddling 

for restraint or as a means of forced positioning. 

Avoid swaddling some extremities and not others if 

they are also flailing or in need of support. Avoid 

removing the hands until the infant can maintain 

motor control without it. Avoid quickly removing 

hands as the sudden change in pressure is 

arousing. 

Stability 

See Hand Swaddling, in the following text. If an infant 

is disorganized, crying, or otherwise too aroused to 

feed, hand swaddling either in arms or in bed is 

often effective in assisting the infant to regain 

self-regulation via attaining motor control. 

Although newly born, acutely unstable, and early 

gestation infants who are reactive to touch would 

not be bottle-feeding, it is recognized that hand 

swaddling may be useful to these infants only by 

skilled staff or by parents if limited to light, still head 

and foot touch. 

Guide C-7: Hand swaddling 

Hand swaddling is effective across all ages of 

neonate and nearly all acuity levels. 



Hand Swaddling Purpose and Method 

The purpose and method of hand swaddling appear to be often misunderstood as a way to reinstate an infant’s control by stopping his movement 

and securing his body in a position chosen by the caregiver. Unfortunately, this is not hand swaddling but, rather, restraint. As hand swaddling is a 

particularly useful means of supporting an infant who is too distressed to feed, the method is described here in some detail. 

The purpose of hand swaddling is to assist the infant to gain control of movement, NOT to prevent movement. With this goal in place, hand 

swaddling has several distinct uses. 

First, hand swaddling is a gentle assist in controlling or directing flailing movement of arms and legs. For an infant in a very disorganized 

(uncontrolled), crying/flailing state (Brazelton/Als behavioral states 5 or 6) hand swaddling is done by gently cupping hands over the space 

bounded by arm and leg extensions and gradually reducing that boundary in the direction of the flexions. Initially, the hands provide a firm but 

resilient, “wall” that lightly limits extension without directing the movement. With that as a first external limit the infant gains increased control of 

flexion, eventually using the hand-wall to direct flexion by more purposefully pushing against it. Extensions may come under control afterward. 

With increased control and smaller extensions, the hand-wall boundary becomes smaller allowing the infant to reach it without having to turn to 

greater extension. One can feel the return of control as the touch of a foot or arm becomes less like a random “kick” or “swat” and more like a 

directed “push off.” Despite appearances, even very small infants will direct these push offs to move their body into a self-defined position of 

comfort. With the return of motor control, physiologic and behavior state control is more attainable. It is important to maintain a light hands-on 

conclusion to the swaddling until the infant can hold onto behavioral stability without it. To test this, remove the hands slowly and observe the 

infant for a full minute. A tired infant may fall asleep (behavioral states 2 or 1) if the hand swaddling is skillful and the infant otherwise 

comfortable. After removing the hands, a freely moving, light loose cloth may be sufficient as a touch, kinesthetic reminder of the movement 

boundaries and help sustain control. 

Hand swaddling is also used to direct the ineffective movement of a more organized (self-controlled) infant. An example would be gently directing 

jerky top arm extensions of a side-lying infant toward midline. In this case, the adult’s other hand might be lightly placed on the infant’s head or 

trunk. It also takes the form of a surrounding light touch to assist with relaxation or provide the comfort needed for asleep. This may be as limited 

as hands on head and foot or, surprising to some, only on the ball of a foot. Parents may be particularly effective in this touch relaxation as they 

are focused on the infant’s comfort and generally have time to stay “hands on” as long as the infant needs it. 

In all uses of hand swaddling, it is important that the hands DO NOT PUSH on legs or arms, but rather gently follow the infant’s lead in the speed 

and direction of the closing boundary. Pushing is counterproductive because it adds a further stressor, elicits a natural counterpush or more 

vigorous extension, and overrides the infant’s efforts to attain the flexed position of comfort. Pushing extremities into contact with the trunk may 

result in the appearance of a calm infant, but if the hands are removed the infant’s uncontrolled movements generally pop back. Although not 

intended as such, pushing the infant into a too-confining blanket or “nest” only conceals resistance and is, actually, undocumented physical 

restraint of a patient. 



Avoid unpleasant experience associated 

with feeding by gavage 

Gavage feeding: if infant is too 

unstable to feed by bottle 

Guide D: Gavage 35,36 

Avoid 

Avoid inserting tube rapidly or while infant protests or gags. 

Guide D-1: Inserting tube Provide 

Dip gavage tube into milk prior to inserting into baby’s 

mouth. Insert gavage tube slowly, allowing infant to suck 

Avoid 

Avoid missed opportunities to make the gavage experience 

less stressful. Avoid excluding parents from participating 

in gavage placement possibly by hand swaddling. Avoid 

wearing gloves that have not been rinsed in sterile water 

or milk/formula. 

Avoid 

Avoid feeding by gravity as the rate tends to be fast causing 

the stomach to hurt from expanding too quickly. In 

addition to discomfort, rapid stomach stretching is an 

aversive experience associated with feeding. 

Avoid 

Avoid gavage feeding when the infant is in bed with little or 

no support (eg, side-lying without secure back support; a 

blanket or commercial “boundary” that is too long or 

wide to provide stabilizing boundaries or so tight fitting 

that it limits movement). Avoid advising parents to keep 

away/not touch their infant during gavage. Avoid leaving 

an infant alone during a gavage feeding as this prevents 

knowing if the infant becomes uncomfortable; and 

because it is not safe. 

See Guide A: 

General Conditions Interfering with Stability 

Indicators of not being ready 

to feed, while undisturbed 

Not ready to feed 

Very little or no facial movement; very little or no movement 

of extremities or trunk; shallow, irregular breathing 

the tube down. 

Provide 

Provide tasting and smelling milk/formula by putting a drop 

of milk on a pacifier or the baby’s fingers to suck. Parents 

can use their own, ungloved finger with a drop of milk. 

Rinse gloves in sterile water then dip fingers in 

milk/formula, shaking off the excess. 

Provide 

Use a feeding pump over 20 to 30 minutes so that the 

stomach expands slowly. A rapid infusion rate of a 

feeding is associated with increased behavioral signs of 

discomfort. 

Provide 

Hold the infant during gavage feedings, as tolerated. If 

holding is not tolerated use light hand swaddling during 

the feeding. See item C-7. If blanket swaddling is needed 

see item G-2 for method. 

Guide D-2: Positive 

experience of taste and 

smell 

Guide D-3: Time allowed for 

gavage feeding 

Guide D-4: Bodily comfort 

and secure support 


Infant is asleep. Avoid vigorously stimulating a sleeping 

infant to awaken for feeding. Avoid starting to feed an 

infant that is sleeping (rather than drowsy). Avoid waiting 

until the exactly scheduled feeding time if the infant is 

clearly hungry before then. Avoid feeding a crying infant. 

Guide D-5: Nonstimulating See Guide A: 

environment 

General Conditions Supporting Stability 

Guide E: Readiness to feed, 

Indicators of readiness to feed, 

while undisturbed 

while undisturbed 

Guide E-1: Movement Ready to feed 

General stirring (movement of extremities and head); 

moving hands onto face or mouth; moving the face 

against bed linens or hands; mouthing or sucking 

movements. 

Guide E-2: Behavioral state Ready to feed 

Crying from hunger indicates Light sleep, drowsy, or awake. Mild fussing from hunger 

readiness to feed but 

that is calmed with holding and preparations to feed. 

increases the difficulty of Begin feeding before an infant is crying from hunger. 

feeding with necessary However, if more subtle feeding cues are missed, calm a 

self-regulation, raises heart crying baby before starting to feed (eg, with holding, 

and RRs, and wastes 

movement/gentle vestibular stimulation, pacifier) Stabilize 

energy. It is nearly always infant as needed (Guide C: Stabilizing/Reinstating 

preceded by signs of 

Stability/Calming). 

hunger. 



Indicators of being unprepared to feed when 

held in arms with nonnutritive sucking 

Indicators of readiness to feed when 

held in arms with nonnutritive sucking 

Guide F: Readiness: 

held in arms 


Avoid activity that arouses an infant suddenly (eg, abrupt 

touching, handling) or that elicits a startle. 

Ready to feed 

Whether drowsy or awake, approach the infant by first 

providing an “acoustic distance alerting” of a few 

moments of quiet speech directed to the baby. This is 

followed by the “proximal alerting” of a light hand 

swaddle or light touch on head and body while speech is 

continued. These “alerts” use natural biological functions 

to ready all systems for an event. 

Ready to feed 

Wrap infant securely (not tightly) with extremities flexed in 

midline, shoulders and back of head supported inside the 

blanket, and hands near face/mouth as infant’s own 

movement indicates. Hold infant in arms. 

Guide F-1: 

Approaching the 

infant 


Avoid omitting this assessment. The infant is not ready to feed if 

he remains asleep or becomes unstable or does not take the 

pacifier voluntarily or if sucking is weak and intermittent. Avoid 

pushing the pacifier in the infant’s mouth or inserting it when 

mouth is open (as in a yawn) but infant is not showing interest 

in it. Avoid picking up a sleeping baby and stimulating to an 

awake state to start a feeding. Avoid advising parents to initiate 

a feeding by these methods. 


Avoid forcing pacifier into the infant’s mouth. Avoid considering 

the infant ready to feed even if the pacifier is not accepted 

voluntarily. 

Guide F-2: Holding in 

arms 

Ready to feed 

Offer pacifier by brushing it against lips or cheek (to elicit 

rooting). Wait for infant to show interest (turn toward, 

mouthing movement, opening mouth) or accept the 

pacifier. 

Ready to feed 

The infant is ready to feed if he attains or maintains a 

drowsy or awake behavioral state and maintains 

physiologic stability and shows spontaneous interest in 

the pacifier, and if sucks vigorously in a series of sucking 

bursts and pauses. 

Guide F-3: Offer 

pacifier and 

observe28,29 Not ready to feed 

The infant is not ready to feed if he remains asleep or becomes 

unstable or does not take the pacifier voluntarily or if sucking is 

weak and intermittent. Avoid pushing the pacifier in the infant’s 

mouth or inserting it when mouth is open (as in a yawn) but 

infant is not showing interest in it. 

Guide F-4: Assess 

ability and 

readiness 



Ill advised preparations and actions 

for a bottle-feeding 

See Guide A: 


Avoid 

Avoid swaddling each infant in the same way. 

Avoid wrapping the baby loosely (or not at all) so 

that shoulders and head are not supported or the 

feet hang out. 

Avoid forcing the infant’s hands away from the 

mouth by wrapping them tightly inside the 

blanket with arms extended at the side. This 

restraint is uncomfortable, works against 

forward flexion of the shoulders, and wastes the 

infant’s energy fighting against it. 

Restraining hands away from the face interferes 

with the development of face-hand coordination 

which later evolves to eye-hand coordination. 

Resting the infant’s neck on your arm causes 

neck extension (and possibly shoulder/scapular 

extension) and increases potential for choking/ 

coughing and defensive, disorganized oromotor 

behavior. Avoid grasping the infant’s neck or 

base of skull to maintain head position (the 

Spock grip). This eliminates infant’s ability to turn 

away/escape the bottle. 

Avoid 

Avoid using whatever chair is available, including 

using an armless chair or one with arm supports 

lower than the functional height of the elbow. 

Avoid minimizing the effect of your comfort on 

the success of the feeding. Avoid a chair that 

causes you to slouch. 

Preparation and actions for a 

Guide G: Feeding by bottle 

successful bottle-feeding 

Guide G-1: General preparation See Guide A: 


Guide G-2: Stable body position Provide 

Head and neck position are closely If self-support as described here is not possible, a 

involved in suck-swallow-breathe 

swaddling blanket is used to provide it externally. It is 

coordination. Quality feeding 

folded around the infant to support the shoulders and 

requires stable, forward flexion of head (at the occiput) as described here. Arms are 

shoulders and extremities and stable automatically positioned slightly forward (by the 

control of neck and head with face at forward-flexed shoulder) so that the hands are free to 

the midline. Without this, the infant locate their position of comfort near or on the face. 

wastes energy attempting to 

Feet are stabilized with snug containment in the 

achieve balance and stability. There blanket by pulling the “foot” corner up across the body 

is also increased possibility of 

first and securing it with the right and left corners. In 

choking, and incompetent feeding. addition, a pillow may be used to support the infant’s 

entire body comfortably and to maintain the comfort 

and relaxation of the person providing the feeding. 

Reduce or withdraw supports over days as the infant 

achieves self-supporting abilities. During feeding 

support head and shoulders (not neck) on your arm. 

Provide 

Seating with comfortable back and arm support that 

allows sitting with erect posture. A footstool may help 

by stabilizing legs and trunk. Lighting should enable 

seeing detail without being so bright that infant cannot 

open eyes or squints. A shading device for the infant’s 

face may be necessary if bright light is required. The 

NICU needs several differently sized types of chairs to 

accommodate all staff. 

Guide G-3: Comfort of the person 

providing the feeding 

The adult must be comfortable with 

good posture. The arm must be 

supported so that the spine is not 

bending to the side to reach the 

chair arm. A comfortable, relaxed 

person is better able to focus on the 

infant and avoid compensatory 

postures that interfere with holding 

the baby to best advantage. 



Ill advised preparations and actions 

for a bottle-feeding 

Preparation and actions for a 

successful bottle-feeding 

Guide G: Feeding by bottle 

Avoid 

Avoid holding the infant’s head in a fixed position 

usually at the back of the neck/occipital area (the 

Spock grip) in order that he cannot turn away from 

the bottle. This interferes with the infant developing 

control of head and neck. This is often used as a 

means of preventing the infant from escaping or 

avoiding the nipple-–aversive experiences 

associated with feeding. 

Avoid 

Avoid pushing the nipple into the infant’s mouth as 

the oral-motor system is not prepared for managing 

a bolus and the infant is more likely to employ 

uncoordinated feeding movements to handle it and 

to choke. Avoid inserting the nipple when the infant 

is yawning or otherwise is not expecting a nipple. 

Provide 

Hold infant in arms if possible or near the body while 

supporting the head. Hold the infant’s head if 

necessary so that he can easily turn away and the head 

and neck remain under the baby’s control. Hold infant 

in a semi-upright position or possibly in side-lying; 

maintain head at least 45◦ to 60◦ but not more than 90◦ above the hips. Hold so that your own hand or a finger 

on the infant’s back to help count breaths if necessary. 

Guide G-4: Holding for a 

feeding 

Guide G-5: Inserting nipple Provide 

Brush the nipple across the infant’s lips or cheeks to 

elicit a rooting reflex. With a young preterm infant the 

rooting response may consist of a brief parting of the 

lips. A quick response is needed to insert the nipple 

during the rooting reflex when the oral-motor system 

is expecting it. 

Guide G-6: Assess stability See Guide B: Assess Stability See Guide B: Assess Stability 

Guide H: Participation Indicators of active participation in the feeding Indicators that the infant is not participating in the 

feeding 

Guide H-1: Stable 

Participating 

Not participating 

physiology 

All signs of stable physiology are present. See Guide B: One or more signs of stable physiology are absent. 

Indicators of Stability: Physiologic Stability. 

See Guide B: Indicators of Stability: Physiologic 

Stability. 

Guide H-2: Behavioral 

Participating 

Not participating 

state 

Infant is drowsy or awake. See Guide B: Indicators of Infant is fussing, crying, or clearly sleeping. Avoid 

Stability: Behavioral State 

arousing an infant from a deep sleep during a 

feeding to make the infant continue sucking. See 

Guide B: Indicators of Stability: Behavioral State 

Guide H-3: Movement 

Participating 

Not Participating 

and tone 

Infant has good tone in extremities, trunk, neck, and 

Infant has low tone in extremities and trunk (ie, limp, 

face. Infant maintains a seal around the nipple 

hanging, flaccid). Infant has low tone in neck and 

(assuming that correct nipple has been determined). 

face (ie, head flops to side or back if not supported, 

lower face appears to sag, mouth is slack, and the 

tongue does not maintain a seal around the nipple). 

Guide H-4: Spontaneous 

Participating 

Not Participating 

sucking 

Infant sucks spontaneously with pauses after short 

Infant stops sucking and restarts only with stimulation 

sucking bursts and restarts sucking independently. 

inside the mouth. Infant remains asleep through 

Infant restarts sucking spontaneously after a burp. See and after a burp. Infant remains asleep despite 

Guide H: Efficiency. 

efforts to arouse by stimulating (eg, unwrapping 

changing position) 



Figure 2. Beginning at “Start, the SOFFI Efficiency; Flow Rate and Nipple Unit algorithm 

guides the caregiver through assessments, decisions, and actions to determine the nipple 

unit most compatible with the oromotor strength and coordination of an individual infant. 

The goal of the algorithm, as with all aspects of the SOFFI Method, is a comfortable, quality 

bottle-feeding. This algorithm is accompanied by a narrative in Appendix 1. The algorithm is 

more easily followed in color and is available from the authors. Reproduced with permission. 



Guide I: Efficiency 

(see Figure 2) Indicators of efficiency (see Appendix 1) Indicators of inefficiency (see Appendix 1) 

Having difficulty 

Flow may be too fast if an infant uses integrated 

compression/suction with the pacifier but only 

compression with the bottle nipple. Flow may be too fast 

if more than 3 to 5 sucks occur with no pause to breathe. 

Flow may be too fast if milk/formula drools or dribbles 

around the nipple. 38,39 

Having success 

Infant maintains integrated compression and suction 

throughout the feeding. Infant maintains a pattern 

of 3 to 5 suck-swallows followed by a breath (can be 

a short catch breath) with an occasional long pause 

(for catch up breathing or rest). The longer pause is 

followed by a self-initiated return to sucking in a 

pattern of a short series of suck-swallow bursts and 

brief pauses for breathing. Minimal or no 

milk/formula is seen around the edge of the nipple. 

Guide I-1: Suckswallow-breathe 

pattern with fluid in 

bottle 


A slower flow nipple (and extra support) may be needed if 

the infant begins a feeding with stability (physiology, 

state, and motor) but loses it (Guide B: Indicators of 

Stability: Physiologic Stability), or cannot maintain 

suck-swallow and breathe. 62,63 See Guide C: Stabilizing. 


Flow may be too fast if the infant stops feeding or falls 

asleep before achieving an appropriate intake. 


Infant maintains drowsy or awake state through the 

feeding with active participation. See Guide G: 

Participation. 

Guide I-2: Maintaining 

energy 


Infant ingests an appropriate amount of milk/formula, 

finishing in a drowsy or sleeping state with good 

tone and stable physiology. 


Guide I-3: Amount of 

intake 


Guide J (see Figure 1 

and Appendix 2) 

Figure 3. The SOFFI Method Pacing Technique. The pacing technique leads the 

caregiver through a series of assessments, decisions, and actions to facilitate 

the infant’s coordination of suck-swallow-breathe. A graduated series of levels 

leads the caregiver to the pacing method most suitable for an individual infant. The 

algorithm is accompanied by a narrative of the method in Appendix 2. The algorithm 

is more easily followed in color and is available from the authors. Reproduced with 

permission. 

Provide 

Preterm infants learning to feed use a 

pattern of successive suck bursts and 

pauses. Observe and count breaths as the 

infant sucks. Mature sucking integrates 

breathing within the sucking burst. After 3 

to 5 sucks with no breath, use techniques 

in Appendix 2. Observe for subtle signs of 

needing a rest break (eg, dropping from 

alert to drowsy, loss of tone). Allow infant 

to determine the length of the rest—which 

can seem to be long to the caregiver (eg, 

1-2 min). 

Avoid 

Avoid removing the nipple only if the baby 

coughs or chokes. Avoid restarting sucking 

when the baby pauses by moving the 

nipple in his mouth. Avoid continuing to 

make infant suck if the pace becomes very 

slow or the baby falls asleep or gets floppy 

before taking the expected amount. 

Avoid arousing the baby intentionally (eg, 

removing the swaddling blanket, 

vigorously burping,” talking loudly, 

changing baby’s position several times in 

quick succession). Avoid continuing to 

feed if vital signs are not within 

established parameters. 



Avoid 

Avoid separating parents and infants by telling parents that 

their baby is too tired to be with them. This conveys that 

they are not important to the infant’s welfare or 

competent enough to perform the most minimal of 

functions. Avoid evading parents by completing care that 

they could do before they arrive. Avoid social or 

unnecessary professional talk in the parent’s space as 

this conveys that they do not belong and are not worth 

the consideration of doing business elsewhere. Avoid 

withdrawing from parent’s with problematic interaction 

behaviors. 

Provide 

Assist parents in gaining competence with early inclusion 

of their participation in care, even if this is a very 

simple action such as adjusting an eye covering for 

light therapy, or containing a hand while the infant is 

repositioned. Look for and set up opportunities for 

parents to work with you at their skill level. Gradually 

increase their participation so that they are competent 

in their care and confident in themselves when the 

infant is ready to bottle feed. For parent’s with 

problematic interaction behaviors, seek assistance 

from available resources and cooperate in developing a 

staff-wide approach to working with them collegially. 

Provide 

Approach the parents’ achievement in feeding in a 

step-by-step manner. Stay at the parents’ side as they 

learn caregiving tasks and feeding until they are 

thoroughly at ease. Help parents achieve rewarding 

social interaction by pointing out preterm-specific alert 

behavior. Explain the need for a great deal of 

sleep-–why he is so often asleep when they arrive. 

Point out fatigue behaviors (eg, fussing, squirming, 

turning head away, sleeping) and assist them in 

rewarding interaction (eg, quieting their own voices, 

containing their own excitement, handling slowly and 

smoothly; providing rest periods. Help parents set 

limits with their relatives and friends. 

Guide K: Care by parents4,11,12 Guide K-1: Inclusive 

interactions with parents 

Among NICU professionals, 

bedside nurses are in the best 

position to include parents as 

competent colleagues in all 

aspects of their infant’s care. 

This collaboration sets the 

conditions for parents seeing 

themselves as competent in 

feeding and confidence in their 

abilities as parents. 

Avoid 

Avoid leaving parents alone doing care or feeding their 

infant if they are not fully skillful and confident. 

Avoid asking parents if it is OK for you to leave, as the 

expected answer is “yes.” 

Guide K-2: Parents’ experience 

with bottle-feeding 

It is important for parents to be 

competent in their abilities and 

confident in their judgments 

as the infant begins to feed. 

This begins long before 

feeding through doing other 

kinds of care. Confident 

parents have infants that are 

less likely to develop feeding 

problems during the first year 

and more likely to make 

feeding a mutually rewarding 

event. 12,13,18 

Avoid 

Avoid ignoring that all parents in the area are learning by 

observing you as you feed other infants. Avoid 

unintended expressions of social power (eg, calling the 

infant “my baby,” referring to the infant him by 

staff-invented nicknames). Avoid interrupting parents’ 

concentration while feeding. Avoid taking over a feeding 

when the parent is having difficulty. Avoid expressions 

meant to be cute (“He’s just being a bad boy, today.”) but 

conveying no information and possibly insulting the 

parent. Avoid directing attention to yourself as the 

teacher rather than directing attention to the infant as the 

source of information. 

Provide 

Provide a good example for all parents (eg, those 

perhaps observing at a distance) of feeding infants 

sensitively and knowledgably. Incorporate parents’ 

ideas about feeding to the extent possible; Stay seated 

beside a parent during early feedings focusing only on 

the feeding. Narrate (identify and describe) briefly and 

quietly in real time how a particular skill/behavior of the 

mother is helping the infant. 18 As each feeding 

concludes, describe at least one good feature of the 

parent’s efforts, however small and of the infant’s 

competence. Adjust the infant’s schedule to suit the 

parents’ schedules. Work with hospital and community 

supports (ie, social workers, Part C personnel) to find 

resources for families to get to the hospital for feeding. 

Guide K-3: The bedside nurse 

sets the standard 

Nurses have high status in giving 

hands-on care. Parents 

observe nurses closely in 

learning how to do something 

“right.” The nurse’s 

behaviors, conversation, and 

deportment set the standard 

for the “right” way, whether 

or not the nurse intends it. 



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Nurs Rev. 2002;2:174–186. 

38. McGrath JM, Braescu AV. State of the science: feeding 

readiness in the preterm infant. J Perinat Neonatal Nurs. 

2004;18:353–368; quiz 69–70. 

39. Dsilna A, Christensson K, Gustafsson AS, Lagercrantz H, Alfredsson 

L. Behavioral stress is affected by the mode of 

tube feeding in very low birth weight infants. Clin J Pain. 

2008;24:447–455. 

40. Mosca N. Holding Premature Infants During Gavage Feeding: 

Effect on Apnea, Bradycardia, Oxygenation, Gastric Residual, 

Gastrin, and Behavioral State. Cleveland, OH: Case 

Western Reserve University; 1995. 

41. White-Traut RC, Berbaum ML, Lessen B, McFarlin B, Cardenas 

L. Feeding readiness in preterm infants: the relationship 

between preterm behavioral state and feeding readiness 

behaviors and efficiency during transition from gavage 

to oral feeding. MCN Am J Matern Child Nurs. 2005; 

30:52–59. 

42. Eishima K. The analysis of sucking behaviour in newborn 

infants. Early Hum Dev. 1991;27:163–73. 

43. Chang YJ, Lin CP, Lin YJ, Lin CH. Effects of single-hole and 

cross-cut nipple units on feeding efficiency and physiological 

parameters in premature infants. JNursRes. 2007;15:215–223. 



Appendix 1 

SOFFI Method of Determining Nipple Flow Rates 

The goals of selecting an appropriate nipple unit are to: 

• Increase the infant’s physiologic stability 

• Increase the infant’s overall stability (ie, behavioral, motor, oromotor) 

• Decrease the infant’s drooling and increase efficiency 

• Increase the volume ingested 

The flow rate of a nipple unit is determined by its size, shape, and the material from which it is made. Some 

nipples are labeled “slow, fast, preemie.” In general, nipples labeled “preemie” flow more quickly than those 

labeled “slow flow.” The goal is to increase the flow rate enough to achieve the needed volume transfer while 

slowing the flow rate to facilitate comfortable suck/swallow/breathe coordination and physiologic, motor and 

state stability. 37,41 As every NICU uses different nipples, and there are no published data to accurately indicate flow 

rates for the nipples available, NICUs must determine through clinical experience a progression from slower flow 

rate to faster flow rates. However, a guide to make these decisions is included below. These considerations are 

in addition to the number and size of the hole in the nipple, with the larger the size or the greater the number of 

holes resulting in faster flow. 38 

Size 

Orthodontic nipples tend to be larger than straight nipples. The greater surface area of an orthodontic nipple 

may facilitate latching for some infants. Straight nipples can have longer or shorter nipple length. The optimal 

size should allow using the entire oral cavity without compromising breathing. A small size nipple will deliver 

the fluid more forward on the tongue. For infants with a small mandible (ie, lower jaw), this allows the oromotor 

mechanisms to more easily manage the bolus for swallowing. With better control, the infant will usually be more 

stable because there is less chance of choking and greater ease maintaining a sucking burst-pause pattern. 

Shape 

Nipples come in various shapes, ranging from a variety of straight nipples, to orthodontic or flatter nipples. Straight 

nipples require greater lateral tongue elevation than orthodontic nipples. That is, the tongue has to sustain more 

of a curl around a straight nipple. An orthodontic nipple may increase the flow rate for an infant with lower tone 

in the tongue (ie, a flatter tongue). 

Material 

Nipples typically come in 1 of 2 materials-–Latex-free (ie, plastic) and silicone. Usually the more pliable (ie, 

bendable or soft) a nipples is, the faster its flow rate. More pliable nipples allow the infant to compress the nipple 

more easily than firmer nipples, thus increasing the flow rate. Latex free nipples have a wider variety of pliability 

than silicone, but in general latex free nipples are more pliable than silicone nipples. 

Straight Nipples Orthodontic Nipples 

|| 

|| 

|| 

|| 

|| 

|| 

⇓ 

FASTER FLOW RATE FASTER FLOW RATE 

Two hole || Large hole, soft sided Latex-Free plastic 

One hole, soft sided Latex-free plastic || 

|| Standard hole, soft sided Latex-free plastic 

One hole, firm sided Latex-free plastic || Standard hole, firm sided Latex-free plastic 

|| 

One hole, firm sided silicone || Standard hole, silicone 

SLOWER FLOW RATE ⇓ SLOWER FLOW RATE 



Appendix 2 

SOFFI Method Pacing Technique 

Pacing is a method of providing external control of the infant’s suck-swallow-breathe pattern. The goals of pacing 

are to 

• Increase the infant’s physiologic stability 

• Prevent the formation of maladaptive, oromotor patterns 

• Increase the infant’s comfort of feeding 

• Assure an appropriate intake volume 

Premature and ill newborns may lose stability when they begin feeding because their suck reflex is strong enough 

to bring an amount of fluid into the mouth that is too large to be shaped into a bolus and too fast-moving to be 

controlled. The infant manages the large bolus with a reflexive swallow to protect the airway. This sequence repeats 

itself and overrides respiratory control causing the infant to be unable to breathe while repeatedly swallowing 

large, fast-moving boluses. Feeding apnea is defined as a period of 5 to 7 consecutive sucks without breathing. 

It causes physiologic instability, lowers the motor tone important for feeding, and is an unpleasant experience. 

Infants with feeding apnea may benefit from pacing because it restores their ability to breathe while feeding. 

Pacing technique is designed to improve the infant’s skill level by interrupting the suck-swallow pattern every 

3 to 5 sucks to allow for breathing. The pauses initially imposed by the caregiver can be integrated into the 

infant’s neuromotor patterns over time. They are essentially learned. Pacing should begin as soon as the caregiver 

determines that the infant is having feeding apnea. 

The steps in pacing are as follows: 

1. Select a slow-flow nipple for the bottle. 

2. Observe the rate, pattern, and quality of the infant’s prefeeding, baseline breathing. 

3. Offer the bottle by stimulating mouth opening or a turn toward the nipple or open lips. These movements 

may be slight. Insert the nipple; do not force the nipple into the mouth or insert it when the mouth opens 

for another reason (eg, to yawn). 

4. While the infant feeds, observe sucking, swallowing, and breathing while counting breaths. 

5. If the infant has taken a small catch breath, or has stopped sucking spontaneously, allow this naturally 

occurring rest for breathing to continue. Hold the nipple very still; do not stimulate sucking. 

6. When the infant spontaneously resumes sucking, again count 3 to 5 consecutive sucks, allowing up to 5 

sucks if the infant is stable overall and 3 if he is less so. 

7. If the infant does not take a catch breath by the third to fifth consecutive suck, interrupt the flow by shifting 

the baby and the bottle so that the liquid flows out of the nipple but the nipple is still securely held in the 

mouth. 

8. If the infant does not take a breath after this maneuver, remove the nipple from the central tongue groove, 

interrupting the sucking burst but leaving the nipple in the mouth. If the infant takes a breath, wait for the 

breathing rate to return to baseline and then allow the infant to again latch on spontaneously and liquid to 

again fill the nipple. 

9. If the infant does not take a breath after this maneuver, remove the nipple from the infant’s mouth. If the 

infant takes a breath wait for the breathing rate to return to baseline and again offer the nipple, as above. 

10. If the infant still does not take a breath, stimulate breathing and wait for it to return to the prefeeding 

baseline. If the infant is stable, resume feeding and begin the pacing algorithm at “3,” above. 

11. If the infant does not return to prefeeding stability, stop the feeding. 



aby name / 

hospital ID stamp 

Drowsy or 

alert with hunger 

signs? 

yes 

Hold in arms. Offer 

non-nutritive 

sucking. Guide F 

Is infant 

stable & more 

awake? 

yes 

Offer bottle; 

standard or 

alternate nipple. 

Guide G 

Assess stability. 

Guide B 

no 

no 

Major 

desaturation, 

HR/RR too high/low, 

multiple coughs, 

choking ? 

no 

Assess readiness 

to feed 

undisturbed. 

Guide E 

Assess level of 

participation 

Guide H 

yes 

Is infant 

stable? 

Defer 

no 

Guide C Stop 

Guide C, D 

Defer 

Guide C 

Entire feeding: 

assess 

stability, 

participation, 

efficiency, 

self-pacing. 

Advance per 

NICU protocol 

Guides B,I,J 

date _________ time ________ 

milk/formula _________________ 

oz: bottle _______ gav. ________ 

yes 

yes 

Actively 

trying to 

nipple? 

Stable with 

more support & 

pacing? 

no 

STOP 

Guide C, D 

no 

stop 

defer 

yes 

Assess stability in 

bed during routine 

care. Guide B 

Start 

Guide A 

person feeding ______________ 

nurse attending ______________ 

SOFFI 

Bottle 

Feeding 

Supporting 

Oral Feeding in 

Fragile Infants 

© E.S.Ross & 

M.K.Philbin 2008 

Stop feeding, stabilize, gavage as needed. 

Wait for readiness signs later, same day. 

Circle: “yess”/“no” stop 

decision 

Add support: Guide C 

Pace: Pacing Algorithm 

Guide J, Appendix B 

Assess effect. 

Spillage? 

> 3-5 sucks w/o breath? 

Gulping, noisy breathing 

& swallowing? 

Assess efficiency: 

Guide I 

Flow Rate Algorithm 

Appendix A 

yes 

Ross, Philbin. JPNN. 

yr., vol., pg. 

no


Assess sucking & breathing 

integration 


Continue feeding. 

Allow infant to self-pace. 

Continue feeding. 

Observe next sucking burst. 

date ________________ time ____________ 

person assessing ______________________ 

self pace _____ assistance____ unable_____ 

Start 

Offer bottle 

yes 

Breathes 

before 3-5 

consecutive 

sucks? 

no 

yes 

no 

yes Takes a 

breath? 

no 

yes 

Takes a 

breath? 

Takes a 

breath? 

no 


Pacing 

Supporting 



© E.S.Ross & 

M.K.Philbin 2008 

Interrupt flow: shift baby and/or 

bottle. Observe breathing. 

See Appendix II 

Move nipple from tongue groove & 

break seal. Observe breathing. 


Remove bottle from mouth. 

Observe breathing. 


STOP 

Stimulate breathing. Stabilize. 

Guide C 

Reassess in 2 days.


Assess quality of suck. 


Strong, 

rhythmic bursts 

of 3-5 sucks + pause 

and keeps pacifier 

in mouth with 

suction? 

Slow the flow. 

See Appendix I 

Start 

yes 

date _____________ time ______________ 

person assessing ______________________ 

nipple: former __________ new ___________ 

no 

yes 

yes 

Offer Pacifier. 

Assess 

Suck-Swallow-Breathe 

Infant sucks 

spontaneously on 

pacifier. 

STOP 

Reassess when drowsy, awake 

and showing readiness to feed. 

Offer bottle with standard, 

single-hole nipple. 

Guide B, G 

Drooling, 

losing milk/formula; 

3-5 sucks & no 

breath? 

Keep current nipple. yes Taking a sufficient 

amount? 

no 

no 

no 

no 

yes 


Suck – Breathe 

& 

Flow Rate 

Supporting 



© E.S.Ross & M.K.Philbin 

2008 

Assess readiness to feed. 

Guide F 

Drowsy or awake? 

Assess amount 

ingested over 

15-20 minutes. 

(with rest periods) 

Offer faster flow nipple. 

Reassess 

See Appendix I

Teaching & Training Modules 

for Parents of Preterm, High Risk, and Fragile Infants 

Erin Sundseth Ross, PhD, CCC-SLP 

University of Colorado School of Medicine 

Children’s Nutrition Research Center, Queensland, Australia 

Parent Training Modules: 

1. Understanding your infant (How infants communicate when they are comfortable and when they want 

someone to change something/do something different) 

Objectives: 

• Describe how infants use their bodies and behaviors to communicate 

• Discuss communication signals for three areas (physical, movement/motor, arousal) 

• Describe the behaviors an infant uses to show stress and stability 

2. Feeding fundamentals (Learning the basic information about preterm infant feeding – why parents need to 

do most of the work in the beginning to help their infant learn to eat.) 

Objectives: 

• Discuss why feeding is usually the last developmental milestone to be achieved prior to going home 

• Discuss how breathing and digestion relate to the ability to eat 

• Describe common patterns of feeding (sucking, swallowing and breathing) 

• Discuss the importance of helping the baby stay focused on the feeding (remaining stable), and how the 

infant communication cues previously learned help to identify the need for additional supports 

3. Supporting your infant to focus on feeding (Practicing ways to support your infant to be comfortable and 

awake during feedings) 

Objectives: 

• Describe ways that the feeder helps the infant focus on the feedings 

• Discuss at least 2 general strategies to use to help the infant focus on the feeding, across the 6 main 

areas of caregiver supports 

• Describe how parents and caregivers influence the ability of the infant to focus on the feeding 

• Describe how feeding success over the first year can be related to what the infant learns about feeding 

in the NICU 

4. Specific feeding support: stability of the nipple and jaw (Specific activities to help your infant be able to get 

fluid out of a bottle) 

Objectives: 

• Describe the behaviors an infant shows to indicate a need for support to stabilize the jaw 

• Demonstrate gentle chin support 

• Demonstrate gentle, firm nipple pressure to the palate 

• Describe the rationale behind the use of these supports

5. Picking bottles and nipples – in the NICU and after going home (What makes bottles different? Learning 

about how to pick a bottle and a nipple to best help your baby eat safely and comfortably) 

Objectives: 

• Describe why slower flowing nipples/bottles may help coordinate breathing with eating 

• Discuss why some bottles/nipples are fast flowing and some are slow flowing (cross-cut, single hole, 

multiple holes, exchange of air and fluid, variable flow nipples) 

• Describe behaviors that an infant demonstrates that indicate a change in nipple/bottle may be 

helpful 

6. Helping your infant coordinate breathing with sucking/swallowing (Understanding how to help your baby 

breathe and eat safely, using specific techniques based upon your baby’s communication) 

Objectives: 

• Describe three different positions for the infant during feeding 

• Describe advantages/disadvantages for each position (sidelying, upright, supine) 

• Demonstrate pacing technique (recognizing and feeling breaths, counting 3-5 sucks and stopping 

fluid transfer if infant has not taken a breath, how to stop fluid (tilting nipple, moving nipple out of 

central tongue groove, removing bottle) 

E. S. Ross. Teaching Parents to Feed Page 2

Continuing Education 

DOI: 10.1097/JPN.0b013e318234ac7a 

J. Perinat Neonat Nurs Volume 25 Number 4, 349–357 Copyright C○ 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 

Supporting Oral Feeding in Fragile Infants 

An Evidence-Based Method for Quality Bottle-Feedings of Preterm, Ill, 

and Fragile Infants 

Erin Sundseth Ross, PhD, CCC-SLP; M. Kathleen Philbin, PhD, RN 

ABSTRACT 

Successful oral feeding of preterm and other ill and fragile 

infants is an interactive process that requires (1) sensitive, 

ongoing assessment of an infant’s physiology and 

behavior, (2) knowledgeable decisions that support immediate 

and long-term enjoyment of food, and (3) competent 

skill in feeding. Caregivers can support feeding success 

by using the infant’s biological and behavioral channels 

of communication to inform their feeding decisions and 

actions. The Supporting Oral Feeding in Fragile Infants 

(SOFFI) Method is described here with text, algorithms, 

and reference guides. Two of the algorithms and the reference 

guides are published separately as Philbin, Ross. 

SOFFI Reference Guides: Text, Algorithms, and Appendices 

(in review). The information in all of these materials is 

drawn from sound research findings and, rarely, when such 

Author Affiliations: University of Colorado Denver School of 

Medicine, Department of Pediatrics, JFK Partners, Denver, Colorado; 

Children’s Nutrition Research Centre, University of Queensland, 

Brisbane, Australia Rocky Mountain University of Health Professions, 

Provo, Utah; HealthONE Hospital System, Denver, Colorado; SOS 

Feeding Solutions, The STAR Center, Denver, Colorado; Feeding 

FUNdamentals, LLC, Thornton, Colorado (Dr Ross); and The College of 

New Jersey, Ewing, and University of Pennsylvania School of Nursing, 

Philadelphia, Pennsylvania (Dr Philbin). 

The authors thank their colleagues and mentors in the global NIDCAP 

community and the many nurses, occupational therapists, speechlanguage 

pathologists, researchers, infants, and parents who have 

helped to develop our thinking over the years. Sharon Sables-Baus 

helped with early drafts of the algorithm. Manuscript preparation was 

supported by (E.S.R.) NIH 5 T32 DK 07658-17 (M.K.P.), The Children’s 

Hospital of Philadelphia, and The College of New Jersey. 

Disclosure: The authors have disclosed that they have no significant 

relationships with, or financial interest in, any commercial companies 

pertaining to this article. 

Corresponding Author: M. Kathleen Philbin, PhD, RN, School of 

Nursing, The College of New Jersey, PO Box 7718, Ewing, NJ 08628 

(kathleenphilbin@Comcast.edu). 

Submitted for publication: April 27, 2011; Accepted for publication: 

August 19, 2011. 

findings are not available, from expert, commonly accepted 

clinical practice. If the quality of a feeding takes priority over 

the quantity ingested, feeding skill develops pleasurably 

and at the infant’s own pace. Once physiologic organization 

and behavioral skills are established, an affinity for feeding 

and the ingestion of sufficient quantity occur naturally, often 

rapidly, and at approximately the same postmenstrual 

age as volume-focused feedings. Nurses, therapists, and 

parents alike can use the SOFFI Method to increase the 

likelihood of feeding success in the population of infants at 

risk for feeding problems that emerge in infancy and extend 

into the preschool years. 

Key Words: algorithm, behavior, bottle, feeding, guide, 

manual, NICU, nursing care, preterm infant, quality 

Infant feeding, by its nature, is an interactive, developmental 

task. 1 Current research in preterm infant 

feeding shows that the infant’s ability to feed 

well is closely related to the caregiver’s ability to understand 

and sensitively respond to his physiology and 

behavioral communications. 1,2 While breastfeeding is 

by far the superior means of feeding, the great majority 

of infants in American newborn intensive care 

units (NICUs) are fed by bottle. 3 This article describes 

a method that is primarily concerned with the quality 

of a feeding rather than its quantity. As it is used 

here, a quality feeding is defined as a complex event in 

which the infant is safe, physiologically stable, actively 

participating, behaviorally organized generally and in 

oromotor activity, and comfortable. The infant’s nutritional 

status and caloric intake are understood as 

baseline conditions. The quality of a feeding relies 

on the assessments, decisions, and actions of a caregiver 

who is knowledgeable about feeding the infant 

at hand, sensitive to the infant’s behavioral and physiologic 

communications, and who has competent feeding 

skills. Furthermore, this caregiver is oriented toward 



positively reinforcing an association between feeding 

and pleasurable human contact and toward supporting 

the infant’s individual manner and pace of acquiring 

feeding abilities. Such a caregiver may be either 

an accomplished feeder or an active learner with the 

supervision or coaching of an accomplished feeder. 

The SOFFI Method prioritizes the quality of the experience 

before the quantity ingested because many studies 

show that most infants who develop feeding problems 

are averse to food and feeding. Their consequent refusal 

to eat is a source of anxiety and self-doubt for their 

parents and long-term developmental difficulties for 

themselves. 4 

Parents come to the NICU with a wide range of understanding 

and capability for feeding an immature or 

ill infant. Knowing this, nurses and therapists can build 

parents’ competence and confidence by modeling and 

coaching high-quality feeding interactions. Many studies 

show that parents place a high value on their infant’s 

feeding and growth and judge their parenting competence 

by these metrics. 5,6 When the unique behavior of 

an infant is understood as a communicative attempt and 

parents know how to respond to it effectively, feeding 

generally becomes successful. In this context, the attachment 

relationship tends to strengthen and parents’ 

anxiety tends to diminish. 6 A knowledgeable and skilled 

nurse or therapist observing and coaching aparent during 

a feeding can measurably benefit this process. 7 Indeed, 

collaboration between a nurse or therapist and 

parent in understanding and responding to an infant’s 

behavior can benefit infant development and parent– 

infant interaction in many ways and over long periods 

of time. 1,6−12 

The literature offers various approaches to acquiring 

bottle-feeding skill. Clinical pathways, such as the 

one by Kirk et al, 13 base the progression of feeding 

on the volume ingested with little said about feeding 

skill. Scales, such as the one developed by Ludwig 

and Waitzman, 14 use holistic assessments to determine 

the infant’s readiness or skill but do not address 

the conduct of the feeding itself. Recently, Kirk et al 13 

published a decision pathway for feeding progression 

based in part on infant behavior but also on the infant’s 

age and the quantity ingested without addressing 

individual variation and skill development. While 

feeding ability during an isolated experience is one 

consideration, repeated experiences solidify over time 

into behavioral repertoires, and therefore the quality of 

the feeding experience should also be measured. 15 At 

present, there are no published methods that address 

both-feeding readiness and real-time feeding management 

with quality as the primary objective. SOFFI fills 

the gap. 

BASIS OF THE SOFFI METHOD IN THEORY 

AND RESEARCH 

Synactive theory 16 provides the primary theoretical basis 

for the SOFFI Method because it is a construct 

with ample explanatory power consistent with the 

known physiology and behavior of preterm and other 

fragile infants. In addition, it is the most widely accepted 

model for understanding and using preterm 

infant behavior to guide care. 16 As such, NICU staff 

are likely to be familiar with SOFFI concepts and 

terminology. 

Synactive theory posits that infants are biologically 

striving, throughout development, toward the selfregulation 

of increasingly complex abilities. Caregivers 

can support this emerging competence by attentively 

and knowledgeably responding to each, individual infant’s 

autonomic neurophysiology, behavioral state, and 

motor (or movement) behavior so that the infant remains 

functionally organized and self-regulated. 10−12 

The SOFFI Method assumes the synactive stance and 

applies it to the achievement of safe, functional bottlefeeding 

in the context of pleasurable behavioral–social 

reciprocity. The theory places a high value on the 

parent as the ideal caregiver both physically and 

socially. 9,11,16 Clinicians are seen as sources of skillful 

support for the infant’s development and the expanding 

parent–child relationship. 10−12 The nurse, who typically 

provides the majority of feedings, uses the SOFFI 

Method herself and coaches the parent in understanding 

and adopting it. 

The details of the SOFFI Method are based on a review 

of the current and classic literature in the field. The 

databases OVID-CINAHL, PubMed, and the Cochrane 

Database were used to identify literature concerning 

(1) synactive theory, (2) the use of synactive theory in 

providing care to support infant development, (3) feeding 

development in the preterm infant, and (4) models 

for preterm infant feeding. The search was generally 

limited to the period of 2002 to 2010, but without limits 

for synactive theory and models of feeding preterm, 

ill, or healthy infants. Subsequently, the reference lists 

of entire articles were examined for potentially relevant 

material including editorials, commentaries, and case 

reports. All material was then reviewed for inclusion in 

the SOFFI Reference Guides. 17 

The literature review revealed a diverse body 

of research, commentary, and clinical practice. The 

major foci of these writings are the neuromotor 

and physiologic mechanisms of bottle-feeding, 18 

the immediate bottle-feeding experience, 19,20 and the 

long-term cumulative learning acquired during repeated 

feeding experiences. 2,19 There are also models 

of bottle-feeding readiness 2,21 and bottle-feeding 



outcomes, 22 methods of enhancing bottle-feeding 

efficiency, 23 and descriptions of suck-swallow-breathe 

coordination. 22 

The SOFFI Method, Algorithms, and Reference 

Guides have been modified over time on the basis 

of recommendations of nurse, therapist, and parent 

trainees, practicing clinicians, and by some of the experts 

whose studies are cited here. 

THE SOFFI BOTTLE-FEEDING ALGORITHM 

The SOFFI Bottle-Feeding Algorithm displays a sequence 

of assessments, questions with “yes” or “no” 

answers, and decisions that lead to consequent actions. 

These actions affect the feeding and lead to the next set 

of assessments, decisions, and actions. In each case, the 

options for action are: (1) proceed along the algorithm 

to continue the feeding as is, (2) make a change to support 

stability or otherwise improve the feeding experience, 

(3) defer the feeding to a later time and gavage the 

remaining milk/formula, or (4) stop this bottle-feeding 

and omit other closely following bottle-feedings. The 

SOFFI Reference Guides with Appendices and the remaining 

2 algorithms (The SOFFI Flow Rate Algorithm 

and the SOFFI Pacing Algorithm) provide the details for 

assessments, decisions, and actions referenced by letter 

in the SOFFI Bottle-Feeding Algorithm (Fig 1). 17 

A caveat regarding the use of the algorithm 

The SOFFI algorithm is meant to be learned away from 

the bedside. A caregiver or parent who is just acquiring 

skill in using them may want a quick visual check during 

a feeding but this must be accomplished without 

moving the hands or significantly changing the direction 

of gaze. The caregiver should maintain a virtually 

exclusive attention on the infant throughout the feeding. 

Such attention would preclude conversations with 

others, looking away from the infant, and stopping/ 

restarting a feeding to do tasks. 

Decisions to start a feeding (see “Start” on the 

SOFFI bottle-feeding algorithm) 

Physiologic stability 

The algorithm begins at “Start” with an assessment of 

the infant’s physiologic stability in bed during routine 

care or handling. 24 Tenuous physiologic stability 

is likely to be revealed during common handling (eg, a 

typical prefeeding routine: unwrapping, diaper change, 

axillary temperature measurement, rewrapping). Physiologic 

stability for feeding is influenced by medical 

morbidity, demands on the synactive systems by medical 

or nursing tasks prior to the feeding, prefeeding 

arousal level, oromotor maturity, and previous feeding 

experience. Keep in mind that an infant crying from 

hunger or other distress for a period of time before a 

feeding has spent precious reserves and may be unable 

to sustain a physiologically stable, behaviorally organized, 

and pleasant feeding experience afterward. 

Physiologic stability is the primary requirement for 

bottle-feeding in the SOFFI Method for 2 reasons. First, 

feeding entails its own physiologic demands making 

it likely that an infant who is unstable before feeding 

would become even more unstable during a feeding 

and, therefore, less safe. Second, all other aspects of 

feeding are dependent on the infant’s physiologic stability. 

An infant might be able to ingest food while 

physiologically unstable but is unlikely to do so with 

self-regulation and comfort. Not surprisingly, physiologic 

stability during feeding is also shown to affect the 

long-term development of feeding skill. 22,25 

To be clear, physiologic stability is not defined here 

as recovery from critical illness. Rather, it is defined 

as stable vital signs, good color, and good muscle 

tone when the infant is alone in bed or during simple 

handling. 24,26 Stable vital signs are defined as a respiratory 

rate between 40 and 60 breaths per minute 

(or another range specified for that particular infant), a 

heart rate within 20% of recent resting levels (or a range 

specified for that particular infant), and blood oxygen 

saturation levels within the range specified by unit 

guidelines (or orders for that infant). The infant who 

is breathing outside of the acceptable respiratory rate 

is working very hard to maintain oxygenation. Good 

color is defined as pink in face and body with minimal 

to no paleness, mottled color, or localized duskiness/ 

cyanosis, and good tone is defined as moderate flexion 

across shoulders, neck, trunk, and hips. These stability 

parameters are drawn from well-established information 

in the feeding physiology literature and are consistent 

with synactive theory. 9,27 

Postponing or omitting a bottle-feeding on the basis 

of physiologic instability, as defined here, spares the infant 

several likely, deleterious outcomes: (1) worsened 

physiologic instability during the feeding, (2) practice 

in using disorganized behaviors to manage the feeding, 

(3) an increased likelihood of solidifying disorganized 

behaviors in the repertoire, and (4) a feeding-associated 

aversive experience. Repeated experiences, whether organizing 

or disorganizing, create readily available behavior 

repertoires because they develop well-defined 

neuronal connections. 15 The Theory of Neuronal Group 

Selection suggests that neural maps in the cortex of the 

brain are established through repetitive experiences and 

behaviors in the present as well as the past. 28 

If the infant is judged to be physiologically unstable 

(a “no” answer), the consequent action is 

to omit the bottle-feeding (“stop”) and intervene to 



Figure 1. SOFFI Method Algorithm for Bottle-Feeding. Beginning at START, the SOFFI 

Bottle-Feeding Algorithm guides the caregiver through a sequence of assessments, decisions, 

and actions to realize a safe, high quality feeding that builds competent feeding 

behaviors and enjoyment of food and feeding. Letters in the algorithm indicate identically 

lettered sections in The SOFFI Reference Guides: Text, Algorithms, and Appendices: A 

Manualized Method for Quality Bottle Feedings (Philbin & Ross, in review). The SOFFI 

Reference Guides provide details of assessment observations, decision explanations, and 

clinical action options. The algorithm is more easily followed in an enlarged format and 

printed in color. Contact the authors for a color copy. “No” decisions are shown in red and 

“yes” decisions in green. “STOP” indicates ending or pausing a feeding to stabilize the 

infant. The algorithm should be learned away from the bedside. Newly trained clinicians 

and parents may want to use the algorithm for a quick reference glance while feeding, but 

attention should be focused primarily on the infant and on the caregiver’s own behavior. 

The figure is used here with permission of the authors. 



improve stability. The caregiver is referred to specific 

lettered Reference Guides for the means of accomplishing 

stabilization. 17 The feeding is then completed with 

a slow gavage. 

Readiness to feed 

If the infant is stable enough to engage in bottlefeeding 

generally, the next assessment on the algorithm 

is the infant’s readiness to feed at that moment. Clinical 

opinion and research indicate that an infant will feed 

most competently when showing signs of hunger and 

readiness to feed. These readiness signs include moving 

extremities and head, moving hands onto face or 

mouth, moving the face against bed linens or hands, 

mouthing or sucking movements, and behavior state 

arousal. 25,29−31 In young preterm infants just learning to 

feed, these readiness behaviors may occur at short, irregular 

intervals and be subtle and fleeting. 32 Therefore, 

the nurse or parent must be watchful for them lest the 

arousal opportunity passes by and the infant returns to 

sleep. Should these readiness indicators be absent, the 

caregiver is directed to defer the bottle-feeding until 

they are present and to accomplish the feeding by slow 

gavage. 

If signs of readiness are judged to be present (a “yes” 

decision), the assessment continues with the infant held 

in arms and offered an opportunity to suck nonnutritively. 

McCain et al33 showed that infants acquired 

full oral feedings sooner when the basis for offering a 

feeding was the infant’s ability to maintain an alert behavioral 

state while sucking nonnutritively prior to all 

nutritive feedings. 

If the infant cannot maintain physiologic stability and 

a drowsy or alert state with nonnutritive sucking while 

held in arms (a “no” decision), the feeding is deferred 

because it is unlikely that comfort and physiologic stability 

will follow given requirements of the feeding itself. 

In this case, the action is to stabilize the infant and 

accomplish the feeding by slow gavage possibly with 

a positive oral experience such as tasting or smelling 

milk. 

If the infant is judged able and ready to feed at this 

point (a “yes” decision), the consequent action is to 

offer the bottle. 

Decisions during the feeding 

Supporting physiologic stability and 

self-regulation 

The caregiver continues to assess physiologic stability 

throughout the feeding noting particularly a major desaturation, 

vital signs outside the infant’s parameters for 

more than a moment or repeatedly, or multiple coughs 

or choking. Particular care in observation and decision 

is required for infants with respiratory distress syndrome 

as they are more likely to have atypical feeding skills including 

disorganized suck/swallow/breathe coordination 

resulting in apnea. 34 If these or equivalent signs 

of significant physiologic instability or compromise are 

present at any time (a “yes” answer), the caregiver is 

directed to stop the feeding, restabilize the infant, and 

give the remaining milk/formula by slow gavage. Physiologic 

events that do not indicate significant instability 

(a “no” answer) lead the caregiver to support selfregulation 

throughout the feeding as described in the 

SOFFI Reference Guides. 17 Measures supporting selfregulation 

may include holding in an upright or sidelying 

position to improve suck, swallow, and breathe 

coordination or pausing for a rest break. 

Engagement/participation 

If the infant is physiologically stable while feeding, the 

algorithm next indicates assessing engagement or participation. 

Is the infant actively trying to nipple? If the 

answer is “no” (eg, low tone, sleeping, not sucking 

spontaneously, or trying to escape), the feeding terminates 

in the central “stop” oval. Active participation is 

necessary for learning coordinated, well-regulated feeding 

behavior. The studies of Thoyre et al1 conclude that 

infant engagement and contingent caregiver responses 

are the best measure of feeding success. Similarly, 

McCain et al show a more rapid acquisition of feeding 

skills when the infant’s alertness and participation, 

rather than the volume ingested, determine the continuation 

of a feeding. 29,33 Of course infants can be 

made to suck by moving the nipple around in the 

mouth to stimulate the suck reflex. However stimulating 

involuntary sucking has deleterious consequences 

including protecting the airway with poorly coordinated 

and defensive feeding behavior, and, not surprisingly, 

an association between feeding and aversive 

experience. 

Feeding efficiency: nipple unit flow rate 

While the infant remains physiologically stable and engaged, 

the caregiver maintains an ongoing assessment 

of feeding efficiency; that is, the amount taken from the 

bottle compared to the amount swallowed and the effort 

expended. The amount taken from the bottle with 

one suck, the bolus, is determined by the infant’s suck 

strength and coordination and the rate of flow through 

the nipple with each suck. Feeding is not efficient if the 

nipple flow rate is too fast (delivers too large a bolus 

with 1 suck) or too slow (little or no flow despite coordinated 

feeding efforts). Feeding efficiency has been 

addressed in a number of studies. The SOFFI Flow Rate 



Algorithm, Appendix A 17 walks the caregiver through 

the process of determining the nipple with the most 

efficient flow rate for an individual infant and includes 

relevant references. 

Drooling out some of the milk/formula may indicate 

that the nipple flow rate is too fast for that baby. 35 

For example Chang et al, 19 showed improved efficiency 

(greater ingested volume in a shorter period of time) 

when infants used a slower flow, single-hole nipple 

rather than a faster flow, cross-cut nipple. Similarly, 

Amaizu et al 23 found that a nipple flow rate appropriate 

to the infant’s physiologic stability and oral-motor skill 

improved feeding safety, efficiency, and self-regulation. 

Gewolb et al showed that a slower flow nipple and rest 

breaks improved efficiency for infants with respiratory 

distress. 34,36 Slowing the rate of flow often improves 

suck-swallow-breathe coordination and reduces fluid 

loss. 19,23,37−39 The first strategy for slowing the flow rate 

is using a slower flow nipple because pacing, another 

strategy, requires more diligence and education to implement 

correctly. A single slower-flowing nipple unit 

provides consistency across caregivers and a common 

element for oromotor practice. 

Infants with chronic lung disease or conditions 

causing oromotor weakness may suck with a welldeveloped 

pattern of short suck-swallow bursts and 

pauses and yet have inefficient feeding because they do 

not have the suction strength to pull the milk/formula 

out of the bottle. They may appear to be feeding efficiently 

but take little in. For these infants, a nipple that 

is faster flowing (eg, the standard flow nipple) than the 

usually preferred or baseline slow-flow nipple may improve 

efficiency while delivering a flow rate that the infant 

can control with his typically weak suction strength. 

However, the effects of the faster-flowing nipple must 

be observed carefully. If it delivers more volume per 

suck than the infant can swallow between breaths, the 

interruption of regular breathing may result in apnea 

and oxygen desaturation, aspiration, or choking. To reiterate, 

a faster flowing nipple is seldom indicated and 

care must be taken with its use. The SOFFI Reference 

Guide Appendix A 17 guides the assessment of safety, 

efficiency, and comfort related to nipple flow. 

External pacing 

If the infant is feeding efficiently, whether with the original 

nipple or an alternative as selected earlier, the answer 

to the question regarding the presence of spillage, 

gulping, etc, would be “no.” That is to say, none of 

those behaviors is observed. The algorithm arrow then 

directs the caregiver to bypass other algorithm components 

to arrive at the long vertical rectangle. This 

component directs the caregiver to continue, through- 

out the feeding, to assess, decide, and act with respect 

to physiologic stability, engagement, efficiency, and coordinated 

suck-swallow-breathe sequences. 

If the caregiver has tried to solve the efficiency 

problem by changing the characteristics of the nipple 

but must still answer “yes” to the algorithm question 

about spillage, gulping, etc, the algorithm leads 

to the action “add support.” The caregiver then externally 

paces suck-swallow-breathe coordination using 

the SOFFI Pacing Algorithm and the SOFFI Reference 

Guides Appendix B. 17 

Pacing is a set of maneuvers that entrains sucking 

bursts to a pattern that allows sufficient opportunity 

and time to breathe. In pacing, the caregiver counts the 

number of sucks before a breath and interrupts flow after 

3 to 5 sucks with no breath. The number of allowable 

suck-swallow combinations without a breath (between 

1 and 5) is determined for each infant on the basis 

of the limits of respiratory effort necessary to maintain 

physiologic stability. For example, some infants who 

have more than 3 consecutive suck-swallows without 

a breath will maintain physiologic stability initially but 

gradually desaturate. They will benefit from external 

pacing to interrupt sucking after 3 suck-swallow combinations 

without a breath. The goal of the interruption 

is to maintain physiologic stability (eg, oxygenation), 

rather than respond to distress after desaturation or an 

untoward event (eg, choking) has occurred. 

The integration of suck-swallow-breathe is usually 

well developed in newborn term infants and appears 

as a seamless whole (inhale, suck, swallow, 

exhale) with each segment running into the next 

and breathing barely apparent. However, medically 

compromised term infants (eg, infants with a cardiac 

defect, or with neurologic impairment) often lack a mature 

or well-integrated suck-swallow-breathe sequence. 

Preterm and other fragile infants may have a sucking 

reflex that excludes breathing because it is very 

strong and difficult or impossible to interrupt, particularly 

when hungry. A series of more than 3 to 5 

suck-swallow combinations without a breath constitutes 

feeding apnea and has a variety of deleterious 

consequences. 34 For example, air hunger may force the 

infant to breathe while continuing to suck and consequently 

inhale or aspirate milk/formula. Alternatively, 

the infant may suck more than can be swallowed and 

reflexively protect the airway by adducting the false vocal 

fold; that is to say, the infant may choke. Lack of 

breathing while feeding, or feeding apnea, can lower 

blood oxygen concentration beyond limits set for that 

child. It can also induce the “diving response” in which 

a lowering respiratory rate triggers the fetal response 

of slowing the heart rate (ie, becoming bradycardic) 

thus causing hypoxia. For some infants, this apnea and 



adycardia can become self-sustaining and require intervention 

to reinstate breathing. The diving response 

is physiologically functional for the fetus, who does 

not need to breathe, but it is not functional for an 

extrauterine fetus (ie, a preterm infant). With pacing, 

however, physiologic stability can be maintained and 

sucking efficiency improved. 37 External pacing can also 

provide the neurobehavioral “practice” that facilitates 

development of mature suck-swallow-breathe coordination. 

Law-Morstatt et al found a decrease in bradycardic 

episodes and improved sucking efficiency when 

the infant was externally paced to maintain physiologic 

stability. 37 

Decisions to end a feeding 

At some point, the infant either will have taken the 

prescribed amount of milk/formula or qualified for a 

decision to “stop.” Decisions to end or “stop” a feeding 

are indicated throughout the SOFFI Feeding Algorithm. 

Decisions to “stop” are based on physiologic 

instability, lack of engagement in feeding, inefficient effort, 

and/or difficulty integrating suck-swallow-breathe 

combinations despite caregiver efforts. These bases for 

stopping are well supported in the literature. 1,21,29,30,33,40 

For example, McCain’s feeding protocol calls for stopping 

if the infant shows instability such as gasping or 

fatigue. 29,33 Thoyre et al 20 recommend stopping if the 

infant has motoric changes such as flaccidity in the face 

(particularly the lower face) or limbs, or if the infant 

tries to escape the bottle by extending arms and legs 

or arching the trunk or neck. With the exception of 

obvious physiologic compromise (eg, choking, bradycardia), 

ending a feeding on the basis of the volume 

ingested appears to be a common criterion despite the 

literature cited here showing the validity of other “stop” 

criteria. 38 

Philbin et al 38 conducted meticulous real time observations 

of 118 bottle-feedings of 20 preterm infants 

in a prominent academic NICU. These feedings were 

not noticeably different than those observed by any 

of the investigators over many years in many different 

hospitals. During the feeding, the nurse was asked to 

tell the observer the reason for each pause or stop in 

feeding as it occurred. If the nurse did not, the observer 

inquired in a neutral manner and otherwise refrained 

from interaction. The data show that quantity 

of intake rather than quality of feeding dominated decisions 

and actions. For example, the top 4 reasons 

for pausing/stopping a feeding concerned inefficient 

feeding even though 3 of 4 unstable physiologic conditions 

were observed more frequently. Multiple swallows 

without breathing (ie, feeding apneas) were observed 

10 times more often than cited as a reason to 

pause/stop. Overall, physiologic and behavioral indicators 

of distress were observed 3 to 10 times more 

frequently than cited as reasons to pause/stop and increased 

after the first pause (eg, to burp). A smaller 

study by Verno et al (n = 56) in a large suburban NICU 

compared the outcomes of infants fed as usual with 

outcomes of infants fed using a SOFFI-based method to 

guide decisions to stop a feeding. 41 The infants fed by 

the SOFFI-based method started bottle-feeding 5 days 

postmenstrual age older than the infants fed as usual 

but were completely bottle-feeding at the same age, 37 

weeks postmenstrual age. Furthermore, they were less 

likely to be transferred to a specialty hospital for feeding 

problems (P = .03) and less likely to be referred to 

a feeding clinic by 3 months corrected age (P = .04). 41 

Documenting infant progression and staff feeding 

activity using the SOFFI bottle-feeding algorithm 

An infant’s progression in feeding competence can be 

documented by circling the “stop” point on successive 

algorithm pages. 

Such documentation can also assist in tracking staff 

consistency in using the SOFFI Method indicating a 

need for further guided practice in its use. More precise 

documentation of infant progression and staff consistency 

can be achieved with a modified version of the 

algorithm available from the authors. 

Decisions to increase feeding frequency 

and/or volume 

There is little evidence for strategies to “advance feedings” 

(ie, offering additional feeds within a certain period 

of time). The authors’ clinical experience, research, 

and consultations in the United States and internationally 

is that most nurseries add feedings based on a 

measure of the volume previously ingested with a secondary 

regard for the quality of the feeding behavior. 38 

For example, Simpson et al 42 demonstrated more rapid 

progression when feedings were advanced by one feeding 

a day only when the current number of oral feedings 

were fully completed. Many NICUs use this strategy, 

which appears to be based on the idea that stamina 

rather than skill is the key factor in feeding development. 

Other NICUs give several bottle-plus-gavage 

feedings within a 24-hour period, increasing the amount 

taken by bottle over time. McCain et al, 33 shortened time 

to full bottle-feedings by 5 days using this protocol. 33 

This approach could provide more beneficial practice 

opportunities if the feedings were done with attention 

to quality. On the contrary, it could provide more nonfunctional 

practice (defensive, uncoordinated feeding 

behaviors) if the feeding is focused on quantity. Decisions 

about the number of bottle-feedings are also 



influenced by the method of gavage supplementation. 

Neonatal intensive care units that use intermittently 

placed orogastric or nasogastric tubes for feeding frequently 

require the infant to complete a full feed before 

attempting a second because of the stress of placing 

the tube after a partial feeding. In contrast, NICUs that 

use flexible, indwelling feeding tubes tend to attempt 

bottle-feedings more frequently in a 24-hour period. 

The SOFFI Feeding Algorithms and Reference Guides 

remain applicable whatever the means of advancement 

because they involve continuous assessment, decision, 

and action based on the infant’s behavior. 

The SOFFI method in practice 

SOFFI concepts and decision parameters have been disseminated 

to NICU clinicians through many consultations 

and training conferences (eg, the Rocky Mountain 

Fragile Infant Feeding Institute.) 43,44 The SOFFI 

Method is an established clinical practice in a relatively 

small number of NICUs across the United States and 

internationally with a thorough adoption of more than 

10 years in the first author’s practice site. In randomized 

controlled trials, a similar approach to overall caregiving 

(including feeding) showed that sensitive responding to 

feeding behaviors resulted in earlier acquisition of competent 

feeding skills and full feedings by bottle. 9,11,12,41 

Refinements to the SOFFI Feeding Algorithm have been 

suggested by practicing clinicians and by some of the 

experts whose studies are cited here. 

In a systematic, online evaluation completed 2 

months after SOFFI training (E. Ross, unpublished 

work, 2009), 90% of respondents judged the SOFFI 

Method as “easy to understand,” and 100% judged that 

it “helps to think aloud about the decisions made during 

a feeding.” Ninety-four percent thought the SOFFI 

Method was helpful in making decisions about supportive 

interventions, and 82% thought it was useful in explaining 

why a feeding was stopped to family members. 

During training, some participants thought the SOFFI 

Bottle-Feeding Algorithm was “intimidating” when they 

first saw it. However, this appraisal was nearly always 

eliminated with explanation of the algorithm and use 

in practice. Identified benefits of the SOFFI Method 

for clinicians and parents include (1) a common language 

for communication about feeding between staff 

and with parents, (2) a systematic, theory-based means 

of evaluating feeding development, (3) a means of providing 

anticipatory guidance to parents, and (4) a means 

of assessing staff performance. 

CONCLUSION 

The SOFFI Method for bottle-feeding preterm and other 

fragile infants is based on established, tested theory with 

details drawn almost exclusively from the research literature. 

It integrates readily with staff education and clinical 

practice programs that are based on synactive theory 

because both use the same vocabulary and indicators 

of physiologic and behavioral organization. As a whole, 

it provides a common language and concrete feeding 

plan (the algorithm) orienting feeding to the quality of 

the infant’s experience and long-term feeding success. 

The shared SOFFI orientation supports staff–staff and 

staff–parent collaboration in successful feeding development. 

By building common goals for feeding, a common 

knowledge base and feeding path, and a common 

skill set for nurses, therapists, and parents, the SOFFI 

Method supports the infant’s physical growth, expands 

the infant’s behavioral repertoire, establishes feeding as 

a pleasurable activity, and strengthens mutually beneficial 

infant–parent interaction and attachment. 

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For more than 15 additional continuing education articles related to 

obstetrics, go to NursingCenter.com/CE

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