A Review of Cue-Based Feeding in the NICU

Introduction

For infants in the NICU, especially those born prematurely, bottle feeding or nursing effectively can oftentimes be a challenge. Maturational and developmental issues impact a premature infant’s ability to adequately coordinate their sucking, swallowing, and breathing. Yet, according to the American Academy of Pediatrics, attainment of adequate oral feedings that fully support growth without physiologic instability is a skill that needs to be fully established prior to an infant’s discharge from the NICU.

But, what is the best way to achieve full oral feedings in a developmentally supportive manner? In our most recent podcast, we reviewed cue-based feeding programs and why there has been a recent shift in the paradigm to move away from volume-driven feedings in the NICU. I discuss what places NICU infants, especially those born prematurely, at an increased risk for oral aversion and how we as caregivers and parents can minimize the risk. I discuss the benefits of cue-based feedings including how it promotes a more positive feeding experience for the infant and caregiver, its ability to support an infant’s neurodevelopment, as well as the findings from some recent research studies.

If you are a clinician and curious about implementing a cue-based feeding program into your NICU, then stay tuned to hear all of the potential benefits. And for my parents who are listening, you will learn how beneficial it is to learn your infant’s behavioral cues which will ultimately support your infant’s development in the NICU and at home. You will not want to miss it, so stay tuned!

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Episode 45

Why is it difficult for preterm infants to effectively orally feed or breastfeed?

Premature infants face several short and long-term health consequences due to their preterm delivery. In regards to their ability to adequately breast and bottle feed, preterm infants are unable to effectively orally feed due to their inability to coordinate sucking, swallowing, and breathing. The ability to coordinate these reflexes is a neurodevelopmental skill that does not begin to develop until infants are 32-34 weeks corrected. Infants fed orally prior to this gestation are at an increased risk for coughing, gagging, aspiration, and apneic and/or bradycardic episodes with or without oxygen desaturations. But, attainment of adequate oral feedings that support adequate growth without respiratory compromise is a skill that needs to be established prior to an infant getting discharged safely from the NICU according to the American Academy of Pediatrics (AAP).

Additionally, infants in the NICU, but especially preterm infants are at risk for oral feeding issues. The feeding difficulties are multifactorial and may stem from the negative sensory experiences in the NICU which include intubation, nasal and/or oral gastric tubes, suctioning, and poorly timed feeding experiences. Not only due the feeding issues often prolong the infant’s length of stay, but it also increases their risk for readmission after discharge secondary to poor feeding. Sadly, studies have shown that infants with feeding difficulties are at a higher risk for negative cognitive and motor outcomes in the first year of life.

Effects of experiences and stress on brain development

When premature infants are initially introduced to oral feeding in the NICU, their motor and sensory neural pathways are developing. As Altimier & Philips state, maturation and developmental issues in premature infants do affect oral feeding success since only 53% of brain cortical volume is present at 34 weeks’ gestation right as they are beginning to attempt oral feeds. I think we often forget this since an infant at 34 weeks’ gestation may appear small, yet fully developed on the exterior. But, we must remember that their brain’s are still pruning and adapting based on their individual experiences.

Any stress that is brought on during feedings may alter the sensory-motor pathways in the brain and adversely affect the infant’s ability and desire to orally feed. The newborn’s brain is capable of making both temporary and permanent changes to the strength and number of its synaptic neuronal connections. With neuroplasticity, the adaptations are based on the influence and interaction upon sensory input from different stimuli, environmental factors and the infant’s unique experiences, whether they are positive or negative. While an infant is in the NICU, both functional and dysfunctional synapses are being pruned based on the infant’s experiences. Keeping this in mind, it is imperative that all efforts are made to minimize the negative NICU experiences to reduce subsequent impairment and disability and this includes an infant’s feeding experience.

To minimize the risks for oral aversion, the foundation and the initiation of optimal oral feedings should be done in a developmentally appropriate manner. With preterm infants, as they begin to orally feed, it becomes a “learned experience” and therefore every effort must be made to ensure it is a positive experience. Keeping this in mind, we have learned over time that we must also attempt to reduce the stress that may be accompanied with oral feeding attempts. The caregiver must attempt to create a safe, effective, nurturing, and pleasurable feeding experience for premature infants.

Shifting the paradigm away from volume-driven feedings

A major component of the effort to bring about a pleasant and non-stressful feeding experience for the infant, is the shift in paradigm to move away from a volume-based culture to implementation of a cue-based feeding approach. Back when I started working in the NICU, which crazily is over 20 years ago, I was initially trained in the culture of focusing on an empty bottle while feeding our little ones, regardless of how it got in. Sadly, it makes me cringe now, but we would “twist the bottle” or move the nipple in and out of the mouth. The nurses who were able to get the poor feeders to eat or those who could “get more in” were the more accomplished nurses! As Shaker (2013) states, the focus was more on increasing intake or volume rather than enhancing the quality of each feeding attempt. Within this culture, a successful feeding attempt was judged based on the volume of intake rather than mindfulness of the infant’s non-verbal cues or physiologic distress.

According to Mary Coughlin (2016), with the focus on volume, it can result in prolonged oral feeding times that may interfere with sleep. Proper sleep has the potential to optimize neurosensory and motor development, growth, brain plasticity, learning and memory which all in turn contribute to a foundation for successful feeding.

With volume-driven feeding, the nurse or caregiver will often push beyond some of the known infant stop signs of either disengagement or even worse, their signs of stress. And unfortunately, if the volume-driven feeding method is then taught to parents, it does not allow the parents to learn the infant’s behavioral signs and it can often lead to oral aversion.

It is a challenging task for a preterm infant to attempt an oral feeding. As I always explain to parents, it’s just like us adults attempting to run a marathon without proper training. Taking that into consideration, as I previously mentioned, infants often display physiologic stress during and after feeding attempts like an increased rate of or work of breathing, heart rate drops, apnea episodes, and oxygen desaturations. The caregiver who is feeding the infant must pay close attention to any of these variations which are indicative that the infant is under stress.

Understanding infant’s behavioral cues

Preterm infants actively communicate through their behaviors which help to guide the caregiver accordingly. It is necessary for the caregiver to understand and pay close attention to when the infant is on the cusp of becoming stressed. The infant’s communication should guide the initiation, timing, the need for necessary pauses, or whether or not the feeding attempt should be discontinued altogether. The caregiver must reflect and choose interventions that not only support the infant, but that also respect their limits. Shaker (2013) states, this co-regulated approach is guided by the infant and may change moment to moment. With co-regulation, the caregiver anticipates the infant’s needs throughout the feeding, responds accordingly and ultimately creates a positive infant-guided feeding approach.

Although the volume of intake is an important measure reflective of discharge readiness, it must be considered contextually alongside the infant’s development, gestational age and quality of each feeding attempt. The quality of the feeding trumps the quantity ingested. Therefore, individualized interventions like non-nutritive sucking and developmental care have been shown to be effective to support the transition from gavage or tube feeding to independent oral feeding. Because at the core of it, developmentally supportive care is based on the caregiver being able to interpret the infant’s behaviors and to proceed accordingly for each individual infant.

What is cue-based feeding?

Cue-based feeding is an approach in which the caregiver determines how and when an infant expects to be fed based on their behavioral cues and signals. Since NICU nurses care for infants for extended periods of time, especially if the unit utilizes primary nursing care, they are in an ideal position to identify cue-based feeding behaviors. The cue-based feeding methods are typically nurse driven which also allows for increased autonomy over traditional feeding protocols leading to an increased sense of empowerment.

Some of the common infant cues the caregiver should monitor for include arousal, moaning, fussing, relaxed facial expression, eyes fully open, bringing hands to mouth, grasping, rooting, or attempts to suck on a pacifier or finger all demonstrate hunger cues and readiness to feed.

Infant-driven feeding

One of the cue-based feeding programs, Infant-Driven Feeding (IDF) is a validated, research-based, structured feeding method that standardizes neonatal cue-based feedings and matches the neurodevelopmental stage of the preterm infant. It is a developmentally supportive and neuroprotective program that has been shown to reduce the length of time from initiation of oral feeds to full po feeds and decrease the NICU length of stay. It consists of 3 behavioral assessments that are based on a numeric scale and include evaluations for feeding readiness, measurement of the quality of feeding, and caregiver technique guide.

The caregiver starts by assessing the infant’s appearance and behavior prior to the feeding. Since we know that state organization and ingestive behaviors are regulated by the same autonomic nervous system, it makes sense that the infant’s appearance and state are great predictors in feeding readiness. The quality of feed is evaluated by assessing the suck, swallow, breathe pattern, and the physiologic markers of feeding quality. Finally the caregiver support portion tracks techniques which facilitate the infant’s quality of the nipple feeding.

The goal is to make each feeding more consistent with developmentally appropriate feeding practices. Additionally, the IDF method involves the family early on to seamlessly transition the family from NICU care to home care for more successful long-term feeding practices. Within the IDF program, there is a specific chapter that is also dedicated to breastfeeding and studies have shown that breastfeeding rates improved with implementation of the IDF Program.

Education of the staff and parents on evaluating and interpreting an infant’s cues, both stable and stressful cues, are the foundation to successful and developmental appropriate care. By implementing a validated tool it promotes consistency in assessing readiness and caregiver techniques which minimize oral aversion and ultimately encourage a positive feeding experience in the NICU and beyond!

What does the research show regarding cue-based feedings?

But you may be wondering, what does the research show? Well, in a 2021 study, Thomas et al. studied the implementation of cue-based feeding and found that its implementation supports best practices by demonstrating patient centeredness based on earlier attainment of full oral feedings, decreased LOS, and increased parent involvement. They also mentioned that it enhanced the nursing staff’s empowerment to take the lead as patient advocates in infant feeding practices.

A 2022 study by Samane et al. found that behavioral-cue based feeding in premature infants demonstrated multiple positive outcomes including weight gain, fewer oxygen desaturations, and a decreased need to use the gavage feeding tube. They recommended that implementation of a feeding protocol based on a close observation and a true understanding of the infant’s behavioral cues should be utilized.

A 2022 study by Ilahi et al., that looked at the impact of an Infant-Driven Feeding Initiative on feeding outcomes in preterm neonates and found that infants who utilized the IDF method had a shorter time from the first nipple feed to discharge, they attained ad lib feedings faster, and they were discharged home at a younger gestational age. In this particular study, they also found that infants included in the study had poorer overall weight gain, but attributed the slower growth velocity to earlier discharge and younger CGA. They also noted the impact of the IDF method on its ability to increase nursing autonomy and its ability to empower nurses which lead to an increase in advocacy for the infant and a strong desire to educate the parents.

Bridging the gap between best practice recommendations and current clinical practice in the NICU

Unfortunately, despite research showing many of the positive outcomes associated with cue-based feeding, a gap remains between what literature supports as best practice and what is commonly practiced in NICUs. There remain a large number of inconsistencies in practice throughout NICUs. As with any type of change, it is often met with resistance from the clinicians whether it be nursing, advanced practice providers, or neonatologists. I strongly encourage institutions to review their feeding protocols and practices and consider reviewing a cue-based feeding program that considers a more developmentally supportive, and individualized approach. To integrate the change in culture, it is recommended to establish a multidisciplinary team of clinicians with a subset group of champions to promote a smoother transition in practice.

Oral feeding is a key component of family-integrated care. A parent being able to feed their infant has been identified as one of the most significant activities between a parent and child. Positive feeding experiences for parents enhances their ability to bond with their child and it minimizes their parental role alteration. As I mentioned, it is essential that parents are educated on readiness cues and stress cues and are able to identify the infant’s behavioral signals early. In doing so, parents become more empowered and feel more confident in their parental role to feed their infant in the NICU and especially post-discharge.

Closing

I hope this podcast brought you some additional insight on just how important it is to ensure that premature infants have a positive feeding experience, each and every time. We mustn’t forget that their fragile brains are pruning and adapting based on each of their unique experiences and storing both temporary and permanent changes in their neuronal connections accordingly. How caregivers feed infants and respond to an infant’s cues prior to and during the feeding experience will impact their future ability to orally feed. Additionally, by creating a positive feeding experience, we prevent the risk for oral aversion and future feeding difficulties. Infants communicate with us, so we must learn to read their cues and most importantly, respect them during their daily care and with feedings.

If the hospital where you work does not currently follow a cue-based feeding method, inquire about it. There are programs available that will guide, educate, and support you through the process. Be the changemaker this year and help your unit move to a more developmentally supportive feeding program for your NICU!

For NICU parents, I encourage you to ask your provider or any of the clinicians questions regarding your infant’s oral feeding. Ask how and when they decide if your baby will attempt a po feeding. Believe me, I know that you want your baby home with you and oftentimes, it is their inability to “finish” feedings that keeps them in the NICU longer. And yes, it’s tempting to push past their stop signs and proceed with the feedings because they may in fact finish the bottle, but, ultimately, it is not what is best for your baby. So be patient and follow their cues, because it will be so much better for them and you in the long run!

Next time, we will be speaking with a guest from Dr. Brown’s Medical who is an expert on the Infant-Driven Feeding program, so make sure you subscribe to our podcast so you will not miss out!

As always, please consider sharing this episode with anyone who may gain some value from it!

References

Altimier, L. & Phillips, R. (2013). The Neonatal Integrative Developmental Care Model: Seven neuroprotective core measures for family-centered developmental care. Newborn & Infant Nursing Reviews, 16, 230-244.

Coughlin, M. (2016). Trauma-informed care in the NICU: Evidenced-based practice guidelines for neonatal clinicians. Springer.

Ilari, Z., Capolongo, T., DiMeglio, A., Demissie, S., & Rahman, A. (2022). Impact of infant-driven feeding initiative on feeding outcomes in the preterm neonate. Advances in Neonatal Care, 00(0), 1-7.

Infant-driven feeding. (2023). Dr. Brown’s Medical. Retrieved January 1, 2023 from https://www.infantdrivenfeeding.com/

Samane, S., Yadollah, Z., Marzieh, H., Karimollah, H., Reza, Z., Afsaneh, A., & Als, H. (2022). Cue-based feeding and short-term health outcomes of premature infants in newborn intensive care units: a non-randomized trial. BMC Pediatrics, 22(23), 1-8.

Settle, M. & Francis, K. (2019). Does the infant-driven feeding method positively impact preterm infant feeding outcomes? Advances in Neonatal Care, 19(1), 51-55.

Shaker, C. (2013). Cue-based feeding in the NICU: Using the infant’s communication as a guide. Neonatal Network, 32(6), 404-408.

Thomas, T., Goodman, R., Jacob, A. & Grabher, D. (2021). Implementation of cue-based feeding to improve preterm infant feeding outcomes and promote parents’ involvement. Journal of Obstetric, Gynecology and Neonatal Nursing, 50, 328-339.