Suck-Swallow-Breathe Coordination

In order for newborns to successfully breastfeed, babies need to suck, swallow, and breathe in a coordinated rhythm. Most babies develop this “Suck-Swallow-Breathe Coordination” naturally, but some preterm infants (usually those before 32-34 weeks gestation) and some full-term infants have challenges.1

The natural development of this coordination is due to a combination of the baby’s reflexes, anatomical structures, and neurological systems. The “sucking reflex” is an innate response that appears when an infant’s lips or mouth are stimulated; with this reflex babies are able to feed right after birth without needing to learn the skill.2

The sucking reflex: 

  • Onset: Present at birth in full-term infants.
    • May not exist in preterm infants.
  • Activated by: The stimulation of the infant’s lips or roof of the mouth (eg, by a nipple, finger, or bottle teat).
  • Function: Supports feeding by enabling the infant to latch and begin the rhythmic suck-swallow-breathe sequence necessary for milk extraction.
  • Has a powerful soothing/calming effect. Sucking helps infants regulate their emotional state and cope with distress.2
    • This is why pacifiers are effective! 

This reflex is only one part of the equation.  A newborn’s anatomy is uniquely adapted for them to switch between suction, swallowing, and breathing safely to ensure safe feeding. This anatomy includes:

  • Small, retruded jaw = facilitates birth & grows with breastfeeding.2
  • Buccal fat pads on the cheeks = provides suction stability.2
  • Wide, flat palate within the mouth = helps create a seal around the breast & prevents air intake.2
  • Flat jaw join = allows for the movement of sucking.2
  • Triangular upper lip = improves latching to the breast.2
  • Fibrous gum ridge = strengths the latch.2
  • Pronounced palatal ridges (connective tissue around the roof out the mouth) = enhances the latching to the breast.2
  • Mobile movement = enables efficient milk extraction.2
  • Higher larynx = lengths the space between trachea and esophagus, lowers the choking risk during feeding.3

The baby’s anatomy allows for safe feeding without interfering with breathing, as babies cannot actually breathe and swallow at the same time!.2 So these mechanisms are coordinated by innate reflexes. 

  • When a baby swallows, their breathing pauses for a less than a second to let milk pass safely into the esophagus. The pause is so brief that breathing resumes immediately afterward.

Babies’ anatomy offers protection early on but as their anatomy changes their risk for issues with “Suck-Swallow-Breathe Coordination” increases. This is because as the baby grows the larynx gradually moves lower in the neck (allowing for new abilities such as a large vocal range & mouth breathing), however, this shortens the space between trachea and esophagus which raises choking risk during feeding.2 

There are stages of infant feeding:

  • Mature: Integrated suck-swallow-breathing pattern.
  • Intermediate: Bursts of multiple suck-swallows followed by the baby’s self-imposed break to catch a breath.
  • Beginner: Bursts of multiple suck-swallows without a break to catch a breath.
    • Feeder needs to assist the infant to take breaks to catch their breath.4

 Caregivers should be alert to signs of poor suck-swallow-breathe coordination: 

  • Frequent coughing, choking, or gagging during feeds.
  • Trouble latching / staying latched.
  • Milk leaking from the nose or pooling in the mouth.
  • Rapid / loud breathing while feeding.
  • Very long feeds (over 45 minutes) or very short feeds (under 10 minutes) with poor intake.
  • Poor weight gain or slow growth.
  • Excessive crying during feeding.5

Several factors can disrupt an infant’s suck-swallow-breathe coordination.  Common causes include: 

  • Prematurity: feeding skills are not fully mature.
  • Tongue tie (ankyloglossia): restricts tongue movement for effective sucking.
  • Airway obstruction (eg, enlarged tonsils/adenoids, nasal congestion, or structural differences).
  • Neurological conditions that affect coordination of motor skills.
  • Reflux or gastroesophageal reflux disease (GERD): causing painful feeding which leads to avoidance or difficulty.
  • Low tone in the lips, tongue, or jaw muscles.5

Fortunately, there are several techniques that help infants who are struggling to coordinate sucking, swallowing, and breathing by giving them greater control over the pace of feeding.4

1. Slower flowing bottle nipples

  • Different bottle nipples that can help reduce the volume and speed of milk released per suck, allowing more time to swallow and breathe.
  • Examples:
    • Ultra-Preemie Nipple (e.g., Dr. Brown’s Ultra Preemie)
    • Preemie/Level 0 Nipple (e.g., Dr. Brown’s Preemie)
    • Newborn/Level 1 (Slow Flow) Nipple

2. Horizontal milk flow feeding position

  • Holding the bottle horizontally (parallel to the floor) slows down flow, allowing the infant to actively suck to draw milk. A vertical bottle increases flow speed.
  • Recommended Positions:
    • Side-Lying: Infant is on their side, with ear, shoulder, and hip aligned facing upward. Mimics breastfeeding posture and promotes optimal airway alignment.
    • Semi-Upright: Infant is held upright with head above chest and hips, with neck well-supported (eg, in the crook of the feeder’s arm). The bottle is then held horizontally.
  • Positions to Avoid:
    • Fully Reclined: Lying flat on the back with a vertical bottle increases flow rate and aspiration risk.

3. Apply external pacing

  • The feeder actively helps the infant take breaks to swallow milk and catch their breath.
  • Techniques: 
    • Tip the bottle down to drain milk from the nipple, stopping the flow while keeping the nipple in the mouth.
    • Gently remove nipple from infant’s mouth completely, to impose a break in sucking.

Mastering the suck-swallow-breathe rhythm is one of an infant’s first achievements. By understanding its mechanics, recognizing the signs of struggle, and using supportive techniques, caregivers can help ensure feeding is a safe, positive, and nourishing experience for every baby! 

REFERENCES

  1.  Pickler R. H. (2004). A Model of Feeding Readiness for Preterm Infants. Neonatal intensive care : the journal of perinatology-neonatology, 17(4), 31–36.
  2. Prospect Kids EI. (2025, July 23). Can babies breathe and swallow at the same time? Prospect Kids. https://prospectkidsei.com/blog/can-babies-breathe-and-swallow-at-the-same-time/
  3. Salty, M. (2025, September 17). Suck–swallow–breathe: The infant anatomy behind feeding coordination. Margaret Salty. https://margaretsalty.com/2025/09/17/suck-swallow-breathe-the-infant-anatomy-behind-feeding-coordination/
  4. Brigham and Women’s Hospital. (n.d.). Feeding strategies [Appendix E1]. Brigham and Women’s Hospital. Retrieved January 26, 2026, from https://www.brighamandwomens.org/assets/BWH/pediatric-newborn-medicine/pdfs/feeding-appendixe1.pdf
  5. Breatheworks. (n.d.). Baby suck-swallow-breathe coordination: Infant feeding cues & signs. Retrieved January 26, 2026, from https://breatheworks.com/baby-suck-swallow-breathe-coordination-feeding-signs/