Why a Feeding Therapist Might Recommend Side-Lying Position for Your Baby in the NICU or After Discharge

If your baby is in the NICU or has recently come home and a feeding therapist suggests using a side-lying position during bottle feeds, you might find yourself wondering why.

It can look different from the feeding positions many of us expect, and it is natural to want to understand the reason behind the recommendation.

Side-lying feeding is not about making feeding harder or more complicated.

It is about supporting how a baby’s body coordinates sucking, swallowing, and breathing, especially when that system is still developing. Research over the past decade has helped clarify when and why this position can be helpful, particularly for babies born preterm.

Feeding Is a Complex Skill for Preterm Infants

For babies born early, feeding is not just about hunger. It requires precise coordination between sucking, swallowing, and breathing.

Preterm infants often begin oral feeding before these systems are fully mature, which can make feeding more effortful and less efficient.

Research consistently shows that immature suck-swallow-breathe coordination can increase the risk of coughing, choking, prolonged breathing pauses, and physiologic stress during feeds. These experiences can make feeding feel exhausting for babies and stressful for families.

Because of this, feeding therapists focus on strategies that support stability, pacing, and safety while protecting the baby’s developing skills.

What Is the Side-Lying Feeding Position?

Side-lying feeding involves positioning the baby on their side rather than flat on their back or fully upright during bottle feeding. The baby’s head, neck, and body are aligned, and the bottle is offered in a way that allows milk to flow more gradually.

This position is often paired with paced feeding, where the feeder intentionally allows pauses to help the baby regulate breathing and swallowing.

How does Side-Lying Support Safer Swallowing and Breathing?

Several studies suggest that side-lying positioning can positively influence how preterm infants manage feeding.

In a recent study published in Early Human Development, researchers found that feeding in an elevated side-lying position led to fewer episodes of choking and coughing, shorter breathing pauses, and more stable swallowing patterns compared to feeding in a supine position. These findings suggest that side-lying may help infants better coordinate breathing during feeds.

Another comparative study examining bottle-feeding positions in infants born before 34 weeks gestation found that side-lying feeding was associated with fewer choking episodes and a higher proportion of milk consumed compared to a semi-elevated position. Importantly, infants feeding in side-lying showed improved overall feeding safety without increased physiologic stress.

When babies are on their side, gravity plays a different role. Milk flow can be more manageable, giving infants more control over the pace of feeding. This can reduce the likelihood of milk pooling in the mouth or overwhelming a swallow that is not yet well timed with breathing.

Supporting Physiologic Stability During Feeding

Physiologic stability refers to how well a baby maintains steady oxygen levels, heart rate, and breathing during activities like feeding. Feeding is one of the most demanding tasks a preterm infant performs.

A systematic review examining the evidence for side-lying feeding found mixed but promising results. Some studies demonstrated improved physiologic stability during feeds, while others found no significant difference compared to other positions. Importantly, the review emphasized that differences in infant maturity, medical complexity, and feeding readiness likely influence outcomes.

More recent research protocols have continued to explore this relationship by closely monitoring heart rate, oxygen saturation, respiratory rate, and behavioral cues before, during, and after feeds. This growing body of work reflects ongoing efforts to identify which infants benefit most from side-lying and under what conditions.

Why Do Therapists Individualize Feeding Recommendations?

It is important to know that side-lying feeding is not a one-size-fits-all solution. Feeding therapists assess many factors before making a recommendation, including:

• gestational age and medical history

• respiratory support needs

• signs of stress during feeding

• endurance and alertness

• coordination of sucking, swallowing, and breathing

For some babies, side-lying provides just enough support to improve comfort and safety. For others, different strategies or positions may be more appropriate. The goal is never to force a position, but to support the baby’s ability to feed with less effort and greater stability.

Is Side-Lying Appropriate After NICU Discharge?

For families at home, side-lying feeding may continue to be recommended if a baby still shows signs of feeding fatigue, coughing, or difficulty coordinating breathing during feeds.

Therapists often teach parents how to adapt the position safely at home, while also watching for cues that a baby is ready to transition to other feeding positions over time.

As babies grow and mature, feeding skills often improve naturally. Many infants do not need side-lying long term. When it is recommended, it is usually one part of a broader feeding plan that prioritizes responsiveness to the baby’s cues and gradual skill development.

A Gentle Reminder for Parents

If you have been advised to try side-lying feeding, it does not mean your baby is failing or that feeding is permanently difficult. It means your care team is paying close attention to how your baby feeds and is choosing strategies supported by emerging research and clinical experience.

Feeding is a relationship, not a performance. Small adjustments in positioning can make a meaningful difference in how safe, comfortable, and connected feeding feels for both you and your baby.

If you ever feel unsure, it is okay to ask your feeding therapist to walk you through the reasoning, demonstrate the position again, or reassess as your baby grows. You are an essential part of the feeding team.

References

Hübl, N., Hasmann, J., Riebold, B., Kaufmann, N., & Seidl, R. O. (2025). Effect of feeding in elevated side-lying and paced bottle feeding on swallow-breathe coordination in healthy preterm infants: First results. Early Human Development, 201, 106184. https://doi.org/10.1016/j.earlhumdev.2024.106184

Park, J., Thoyre, S. M., Smallcomb, J., Mcternan, M., & Kneeland, T. (2025). Biobehavioral efficacy of the elevated side-lying position for feeding preterm infants: Study protocol. Journal of Advanced Nursing, 81(2), 2819–2827. https://doi.org/10.1111/jan.16444

Park, J., Frisk Pados, B., & Thoyre, S. M. (2018). What is the evidence for the side-lying position for feeding preterm infants? A systematic review. Advances in Neonatal Care, 18(4), 285–294. https://doi.org/10.1097/ANC.0000000000000529

Raczyńska, A., Guzyńska, E., & Talar, T. (2022). Advantages of side-lying position: A comparative study of positioning during bottle-feeding in preterm infants (≤34 weeks GA). Journal of Mother and Child, 26(4), 269–278. https://doi.org/10.34763/jmotherandchild.20212504.d-22-00008