Recognising Infant Swallowing During Feeds

Swallowing is an essential part of milk transfer during infant feeding. Sucking draws milk into the mouth, but getting milk into the mouth is only the beginning of the process. The milk needs to be contained and organised as a bolus, moved towards the back of the mouth, and then transferred onwards through the pharynx and oesophagus towards the stomach.

The tongue plays an important role in moving the milk posteriorly. As the milk bolus reaches the oropharyngeal area, sensory input contributes to the initiation of the pharyngeal swallow. The pharyngeal phase then propels the milk through the pharynx and into the oesophagus, followed by oesophageal transport towards the stomach (Lau, 2015; Jadcherla et al., 2017).

Swallowing is often described using a four-phase model: oral preparatory, oral transit or propulsive, pharyngeal and oesophageal phases. However, infant feeding literature also commonly describes three broader phases — oral, pharyngeal and oesophageal — with the oral phase incorporating the preparation and propulsion of the milk bolus. The terminology therefore varies between sources, but the underlying sequence remains the same: milk enters the mouth, is organised and moved posteriorly, the swallow is initiated, and the milk is transported onwards (Lau, 2015; Jadcherla et al., 2017).

During a feed, swallowing is coordinated with sucking and breathing. This coordination develops as an infant matures and can vary according to the baby's developmental stage, the feeding method and the rate at which milk is available (Mizuno, Ueda and Takeuchi, 2002; Mizuno and Ueda, 2003).

Although the swallow itself occurs internally, some of the associated movement can be observed externally. Learning what to look for can therefore help families recognise when active swallowing is taking place during a breast or bottle feed.

Recognising a swallow during a feed

One of the most useful places to observe swallowing is underneath your baby's chin, towards the upper front of the neck. During a swallow, this area draws inwards and deepens. Breathing movements can also be seen in the neck, but these are further down the neck, so they can be distinguished from the movement associated with swallowing.

The external movement does not mean that the swallow itself can be seen directly. The swallow takes place within the mouth and throat, while the movement underneath the chin provides an observable indication that the swallowing mechanism is occurring.

Ultrasound studies have been used to examine what is happening internally during breastfeeding. Geddes et al. (2010), for example, used ultrasound imaging to observe milk movement during infant swallowing and demonstrated the relationship between swallowing, milk movement and respiratory pauses. This provides a useful reminder that the movement seen from outside the baby's body is only one visible part of a much more complex physiological process.

Swallowing may also be audible, although an audible sound is not essential for a swallow to be occurring. A clear swallowing sound can accompany milk being transferred, but sounds heard during a feed need to be interpreted carefully. Noisy sucking, clicking or repeated gulping can also occur when air is being drawn into the mouth, particularly where the seal between the baby's mouth and the breast or teat is not being maintained. In that situation, the sound should not automatically be interpreted as evidence of effective milk transfer. Where audible air intake is accompanied by clicking, milk leakage, loss of suction or other signs of difficulty maintaining attachment, the wider feeding pattern is more informative than the sound alone.

For a visual demonstration of what swallowing can look like at the breast, Lucy Webber IBCLC's video *Recognising when a baby is swallowing effectively at the breast* shows the external signs to look for (Webber, 2026).

What can swallowing look like during a feed?

There is considerable variation in how sucking, swallowing and breathing are coordinated between babies and between different stages of the same feed. There is therefore no single pattern that every baby should demonstrate.

During active feeding, sucking draws milk into the mouth and swallowing moves that milk onwards. A baby does not necessarily need to swallow after every suck. The number of sucking movements between swallows can change according to milk flow, the baby's developmental maturity and what is happening during the feed.

At the breast, some babies may begin with a period of quicker sucking associated with stimulating milk ejection before settling into a pattern in which sucking and swallowing become more closely associated with active milk transfer. NHS guidance describes feeds as often beginning with a few rapid sucks before progressing to longer, rhythmic sucks and swallows, with occasional pauses (NHS, 2026).

Breastfeeding also serves purposes beyond nutritional intake. Babies may breastfeed for comfort, reassurance, closeness and regulation as well as to obtain milk. This means that a baby may move between periods of active milk transfer and periods of lighter or more comfort-focused sucking during the same breastfeeding episode. The presence of fewer visible swallows during such a period does not necessarily indicate a problem with milk transfer, because the purpose of the sucking may have changed.

The overall pattern of the feed, the baby's coordination and the presence of sustained active milk transfer provide more useful information than whether an individual feed follows a particular sequence.

Rhythm, milk flow and swallowing

Observing swallowing over a meaningful period of active feeding is generally more informative than focusing on one isolated swallow. The rhythm of swallowing can change as milk flow changes, and this can happen naturally during both breast and bottle feeding.

When milk is readily available and flowing more quickly, swallows may occur closer together because the baby has milk available to move onwards. As the flow slows, there may be more sucking movements between individual swallows. The resulting pattern may therefore become less frequent without this necessarily indicating a problem.

At the breast, milk flow is dynamic rather than constant. It can change during milk ejection and as the feed progresses, so the spacing between visible swallows may change accordingly. A baby may therefore have periods in which swallowing is frequent and obvious, followed by periods in which more sucking occurs between swallows.

Bottle feeding also involves changes in milk flow. Teat flow, bottle angle and the way the feed is offered can all influence how quickly milk reaches the baby's mouth. This is one reason that the baby's swallowing pattern should be considered alongside the way the bottle is being offered rather than interpreted in isolation.

Counting visible swallows can sometimes be a useful observational aid. It can help a family or practitioner notice whether swallowing is occurring regularly during active feeding and whether the rhythm changes as milk flow changes. However, there is no prescribed number of visible swallows that a baby needs to achieve during a feed, and counting cannot determine the exact volume of milk transferred.

What can swallowing tell you about milk transfer?

Seeing repeated swallowing during a period of active feeding provides evidence that milk is being transferred beyond the mouth. It is therefore one useful part of observing milk transfer, but it cannot be used to calculate exactly how much milk a baby has taken.

The amount of milk transferred depends on more than the number of visible swallows. The volume of milk contained in each bolus can vary, as can milk flow, sucking patterns and the baby's ability to maintain feeding over time. Two babies may therefore show different swallowing patterns while both are transferring milk effectively.

Swallowing is best considered alongside the wider picture of feeding. This can include the baby's alertness and stamina, their ability to remain coordinated during the feed, whether they appear settled and satisfied afterwards, urine output, growth and other indicators of adequate milk intake.

For further information about observing milk transfer during feeds, see Signs of Poor Milk Transfer in Your Baby at Feeds.

Breastfeeding and swallowing

At the breast, the pattern of sucking and swallowing can change considerably during a single breastfeeding episode. A period of rapid sucking may occur as the baby stimulates milk ejection, followed by a more sustained pattern of active sucking and swallowing once milk is flowing more readily.

Ultrasound research has demonstrated the relationship between tongue movement, intra-oral vacuum and milk transfer during breastfeeding (Geddes, Kent, Mitoulas and Hartmann, 2008). Further ultrasound work has allowed researchers to observe the movement of milk during swallowing itself, providing information about the internal sequence that cannot be determined from external observation alone (Geddes et al., 2010).

As milk flow changes, the visible rhythm of swallowing may change too. A baby may swallow frequently when milk is flowing readily and then have longer intervals between swallows when the flow becomes slower.

It is also important to consider what the baby is using the breast for at that point in the feed. Breastfeeding is not exclusively about nutritional intake. A baby may continue to suckle for comfort or reassurance after active milk transfer has reduced, and the pattern of sucking and swallowing will consequently change. Periods of lighter sucking with fewer visible swallows can therefore occur within a breastfeeding episode without necessarily representing ineffective feeding.

The observation is therefore not simply whether a swallow can be seen at one particular moment, but whether swallowing is occurring during periods of active milk transfer and how the baby's overall feeding pattern develops throughout the feed.

Bottle feeding and swallowing

Bottle feeding also requires coordination between sucking, swallowing and breathing. A 1:1:1 suck–swallow–breathe pattern can occur for some babies and at some stages of a feed, but it is not a universal requirement for effective bottle feeding. Other babies may take several sucks before swallowing, followed by a breath or pause.

This is where paced bottle feeding can be particularly relevant. Paced feeding does not aim to make every feed follow a particular suck–swallow–breathe ratio. Instead, it can give the baby greater opportunity to regulate the rate of milk flow and take pauses according to their own feeding pattern. NHS guidance recommends keeping the bottle almost horizontal, allowing the baby to control the pace of the feed and providing opportunities for breaks when the baby shows cues that they need one (NHS, 2026).

The baby's pauses can therefore form part of the feeding pattern rather than being something that needs to be eliminated. A baby may pause to breathe, rest or regulate the amount of milk entering the mouth before returning to active sucking and swallowing. Following these cues can help the rate of milk flow fit more closely with the baby's ability to coordinate feeding.

The rate of milk flow can also influence the spacing between visible swallows. With a faster flow, milk may reach the mouth more readily and swallows may occur closer together. With a slower flow, more sucking may occur between swallows. Bottle position and feeding technique can influence this flow, which is why paced and responsive bottle feeding consider both the baby's cues and the way the bottle is presented (NHS, 2026).

More information about paced bottle feeding and ways of supporting a responsive feeding rhythm can be found in How to Pace Bottle Feeds: A Calm, Practical Guide.

When feeding may need further assessment

Occasional changes in feeding rhythm are not, by themselves, evidence of a swallowing problem. However, persistent difficulties with coordination or signs that a baby is struggling to manage milk flow may warrant further assessment.

Concerns can include repeated coughing, choking or spluttering during feeds, changes in colour, difficulty coordinating breathing with feeding, marked fatigue, frequent loss of milk from the mouth, or an inability to sustain effective feeding. A baby who repeatedly stops feeding because they appear unable to manage the flow of milk may also benefit from closer observation.

These signs can have many possible causes, and swallowing should not be considered in isolation. A feeding assessment may consider the baby's oral movements, sucking pattern, breathing, milk flow, positioning, stamina and overall feeding behaviour alongside growth and other indicators of adequate intake.

Recognising swallowing is therefore one part of observing infant feeding rather than a standalone test. Looking at the movement underneath the chin and upper front of the neck, and considering its frequency and rhythm across a substantial period of active feeding, can provide useful information about when swallowing is taking place. That observation becomes more meaningful when considered alongside the wider pattern of the feed and the baby's overall wellbeing.

References

Geddes, D.T., Chadwick, L.M., Kent, J.C., Garbin, C.P. and Hartmann, P.E. (2010) ‘Ultrasound imaging of infant swallowing during breast-feeding’, Dysphagia, 25(3), pp. 183–191. Available at: https://pubmed.ncbi.nlm.nih.gov/19626366/

Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008) ‘Tongue movement and intra-oral vacuum in breastfeeding infants’, Early Human Development, 84(7), pp. 471–477. Available at: https://pubmed.ncbi.nlm.nih.gov/18262736/

Jadcherla, S.R. et al. (2017) ‘Advances with neonatal aerodigestive science in the pursuit of safe swallowing in infants: invited review’, Dysphagia, 32(1), pp. 15–26. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC5303645/

Lau, C. (2015) ‘Development of suck and swallow mechanisms in infants’, Annals of Nutrition and Metabolism, 66(Suppl. 5), pp. 7–14. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4530609/

Mizuno, K., Ueda, A. and Takeuchi, T. (2002) ‘Effects of different fluids on the relationship between swallowing and breathing during nutritive sucking in neonates’, Biology of the Neonate, 81(1), pp. 45–50. Available at: https://pubmed.ncbi.nlm.nih.gov/11803176/

Mizuno, K. and Ueda, A. (2003) ‘The maturation and coordination of sucking, swallowing, and respiration in preterm infants’, The Journal of Pediatrics, 142(1), pp. 36–40. Available at: https://pubmed.ncbi.nlm.nih.gov/12520252/

NHS (2026) ‘Bottle feeding your baby’, NHS Best Start in Life. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-your-baby/

NHS (2026) ‘Bottle feeding your baby: Feeding on demand’, NHS Best Start in Life. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-your-baby/feeding-on-demand/

Webber, L. (2026) ‘Recognising when a baby is swallowing effectively at the breast’, YouTube, 25 January. Available at: https://www.youtube.com/watch?v=AjCd3wqMmwM