Introduction
Just as I discussed on our last podcast episode, infants in the NICU, especially those born prematurely, encounter the challenge of effective bottle feeding and/or nursing due to their maturational development. For our 45th podcast episode, A Review of Cue-Based Feeding in the NICU, I discussed why there has been a recent shift in the paradigm to move away from volume-driven feedings in the NICU. We reviewed how cue-based feeding practices differ from volume-driven feeding, how the practice positively affects the infant’s ability to bottle feed or nurse, and how each oral experiences and feedings can impact the infant’s synaptic neuronal connections whether positive or negative.
For our most recent podcast, I sat down with a former colleague of mine, Lisa Kleinz. Lisa is a Speech Pathologist and a Developmental Care Specialist who is currently the Director of Education for Dr. Brown’s Medical. Lisa and I discuss The Infant-Driven Feeding™ Program, which is a developmentally supportive, individualized, cue-based feeding program. She explains why the The Infant-Driven Feeding™ (IDF™) Program is so beneficial for infants, their parents, and clinicians as well. We discuss recent evidence-based literature findings that have shown the positive effects of the IDF™program including a reduction in time to full oral feedings, decreased hospital length of stay, and a reduction in hospital costs as well as increased breastfeeding rates, increased time in kangaroo care, and increased parental involvement. The IDF™ program is beneficial for clinicians, parents and the infant. Once staff is educated, more consistent feeding methods are practiced which results in a positive feeding experience for the infant and caregiver.
Learn more about all of the benefits of the the The Infant-Driven Feeding™ Program and how it can be implemented in your hospital. After listening, NICU clinicians will learn why it is so crucial to provide positive oral experiences from day one to the infant and how it will impact their future and neurodevelopmental outcomes. Parents will learn specific ways that they can be involved with their infant that will positively impact their oral experiences from the moment they arrive into the NICU. Although we are unable to completely eliminate all of the negative experiences in the NICU, caregivers, including parents can help protect and support their infant from day one and the ability to create positive feeding experiences is a key component to that support.
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Episode 46
Our Guest
Lisa Kleinz, MA, SLP/L, CNT
Lisa Kleinz is the Director of Education for Dr. Brown’s Medical. Her role is to explore, create, and deliver valuable educational, developmental care-focused resources to the Dr. Brown’s Medical team as well as healthcare professionals in the field of infant feeding. In this role, Lisa provides evidence-based, researched data, supporting positive feeding experiences for infants and their families.
Prior to joining Dr. Brown’s Medical in 2016, Lisa worked as a Speech Pathologist and Developmental Care Specialist for over 25 years in both Level 3 and 4 NICUs in the Chicago, IL area. Her certifications include Newborn Individualized Developmental Care Assessment Program (NIDCAP), Developmental Care Designation (NANN), Infant Massage Instructor, and Certified Lactation Specialist. She is also a Certified Neonatal Therapist and a member of the National Association of Neonatal Therapists. In addition, Lisa was one of the founding members of the Neonatal Therapy National Certification Board that facilitated the sole certification for neonatal therapists.
Lisa received her Bachelor’s degree from the University of Illinois and Master’s at Indiana University. She is highly experienced with presentations at National conferences; created and presented webinars for NICU families and developed a 2-day course for Education Resources, Inc on Developmental Care in the NICU.
Lisa recently moved to Northwest Arkansas and while not absorbing all she can about infant feeding, she enjoys hiking, cooking healthy meals, and reading great books!
Lisa’s Professional Background
Lisa began working at a Children’s hospital in Chicago after graduating with a masters degree in Speech Pathology. She instantly fell in love with working in the NICU, therefore she pursued additional education related to the neonatal population. She became certified in NIDCAP (Newborn Individualized Developmental Care and Assessment Program) and developmental care, which led to a position change as a Developmental Care Specialist in the NICU. She also became a certified lactation counselor and infant
massage instructor. Around this time, she moved to the Chicago suburbs and transitioned to working for a suburban NICU, where she and I were colleagues. In this role, as a Developmental Care Specialist and Speech Pathologist, she initiated several educational projects, including cue-based feeding, and worked on additional quality improvement studies related to developmental care. This role made her realize that she wanted to pursue education and project improvement which led her to Dr. Brown’s Medical. Lisa has been with Dr. Brown’s Medical for almost 7 years now and she is now the Director of Education. In this role, she creates and delivers education on developmental care-focused feeding resources to the Dr Brown’s Medical team, as well as healthcare professionals in the field of infant feeding.
Why are NICU infants at an increased risk for oral aversion?
There are medical contributions that may lead to feeding challenges, but after years of research, we also know that early experience plays a vital role in shaping infant behavior. As I discussed in more detail in episode 45, everything we do in the NICU shapes infants’ brains. An infant’s brain is 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. Especially with preterm infants, their brains continue to grow rapidly in the NICU as it would have in the third trimester. Therefore, if they are bombarded with frequent and unprotected negative experiences surrounding the oral structures, it can create negative pathways in the brain, which can lead to oral aversion or feeding difficulties in the future.
Research shows that around 40-70% of premature infants experience some type of feeding problem and some of that is attributed to their individual experiences. For NICU clinicians, our goal must be to change and lower that statistic. At Dr. Brown’s Medical, their goal is for every baby to receive positive feeding experiences from the start. Traditional feeding practices for infants are often inconsistent which leads to poor feeding outcomes. Dr. Brown’s Medical delivers valuable feeding solutions to help create the best possible outcomes for all infants. Feeding is not just about getting nutrition in, it is also relational, social, and it is at the center of the parent-infant relationship.
What can NICU clinicians and/or parents do to promote positive oral experiences?
Although we are unable to eliminate every negative aspect in the NICU, we as caregivers can protect and support the infants from day one. Every NICU caregiver should focus on feeding concepts from the first day of life on by supporting and protecting oral experiences with each and every interaction. NICU clinicians can focus on neuroprotection by protecting the infant’s sleep, decreasing their stress, providing pain support, positive touch, kangaroo care, and by providing positive oral experiences. These practices can be done by utilizing two-person care with any unpleasant procedures, like suctioning, ideally with the parent providing containment and support. Additionally, promoting daily skin-to-skin or kangaroo care when infants are medically stable beginning on the first day of life is essential. The infant should be offered colostrum as early as possible and positive oral experiences like licking, sucking, and/or nuzzling at the breast should be encouraged early. While the infant receives his/her nasogastric (ng) feeding, the infant should be held if possible and provided with a pacifier or the mother’s empty breast. There are many more practices that can be utilized to provide neuroprotection, but most importantly, the parents should be providing these
experiences. There are several additional ways that the parents can be involved in feeding practices prior to when breast or bottle feedings are initiated, but they need to be guided and supported through it.
How can parents become involved?
NICU parents often feel helpless and are unsure what they can do. It is so crucial that parents are aware that they can participate in caring for their infant very early on and that they can have an impactful role in their infant’s life. There are many ways that parents can support and promote positive feeding experiences for their infant. Containment, skin-to-skin care, and non-nutritive sucking promote neuroprotection and neuropromotion which will impact the infant’s neuronal pathways and ultimately their long-term neurodevelopmental trajectory. Once parents become involved and begin to learn ways they can support their infant, it increases their confidence and leads to better bonding and attachment.
When should conversations begin regarding feeding in the NICU?
As Lisa recalls, years ago, the speech-language pathologist (SLP) would show up once an infant was ready to begin feeding from a bottle or breast weeks into the NICU-stay. But conversations for feeding should begin on the first day of life to help prepare the infant and set them up for success later.
Cue-based feeding vs. Infant-driven feeding
Historically, in a volume driven-feeding culture, success of feeding is determined by how much the caregiver can get the infant to consume. The focus is on intake rather than the quality of the feeding. With the volume-driven feeding culture, it has led to caregivers feeding infants longer than the infant desires and beyond cues where the infant is signalling that they are done. Some of the common caregiver behaviors include twisting and/or prodding of the bottle, unswaddling premature infants, rubbing their backs to wake them up, or feeding times longer than 30 minutes. Not only do these behaviors create negative feeding experiences, but they are also unsafe. Feeding conversations with the volume-driven method focus on the volume the infant took. Unfortunately, this culture is passed onto the parents, who will then focus on volume as well rather than a safe, neurodevelopmentally-supportive feeding method. Parents often do as their caregivers do. If they observe caregivers, “the experts”, pushing infants to feed more, then they will learn and continue this behavior at home as well.
In contrast, with cue-based and infant-driven feeding (IDF), the focus for the feeding is on quality. The caregiver learns to read the infant’s cues for when they are ready to eat, adjusts to any modifications that are needed during the feeding, and knows when to stop the feeding based on what the infant is telling them. The infant is in the driver seat. With cue-based feeding, the focus is on the relationship more than the the caregiver getting the infant to feed.
During rounds, if the question is asked, “how did baby Joe eat today?” With a volume-driven culture, the response might be “he did great and took almost his full bottle.” But, with cue-based feeding, the response would be, “Joe was awake and showing cues for his feeding, he fed with a low flow nipple with nice coordination of suck, swallow, and breathe.” If a hospital has implemented the IDF program, the caregiver would respond with a quality score. To add to the conversation, the clinician may add, “Joe displayed some cues toward the end of the feeding that he was done, so the remainder of the feeding was offered via ng he was held by his mother.” Cue-based feeding does also recognize volume, since infants have to complete their feedings eventually, but the initial priorities are skill, quality, and safety knowing that volume will come with time.
As parents listen to the feeding conversations, they will also begin to learn that the priority is the quality of the feeding, not the quantity that their infant took. Parents are also observing NICU clinicians and our behaviors, therefore forecasting how they will feed their infant in the NICU and once they are home. Our behaviors that will be mimicked by the parents have a large impact on the infant’s quality of feeding in the future and their neurodevelopment since they are all linked together.
The Infant-Driven Feeding Program
The Infant-Driven Feeding (IDF) is a type of cue-based feeding, but it is a specific program. The program was originally created by two occupational therapists who saw a need for an evidence-based feeding program in the NICU. Historically, NICU clinicians have had inconsistent education surrounding feeding, which has also contributed to poor outcomes for the infant. Cue-based feeding is not enough, so the IDF program takes cue-based feeding to the next level.
The IDF program is comprised of 3 scales including readiness, quality, and strategies for support. What sets the IDF program apart, is that all NICU staff members participate in the online educational program ensuring consistency throughout the NICU. The program not only provides the NICU staff with consistent education, but there is a focus on the proper scoring, language, and a process for feeding. To mitigate the common inconsistencies surrounding feedings in NICUs, the IDF program not only changes from a volume-driven unit to an infant driven one, but it also changes the culture. The once inconsistent culture is replaced with one of consistency that is focused on monitoring the infant’s cues, responding appropriately to them, and supporting the infant and family through the process.
The IDF program begins with a neurodevelopmental foundation and promotes positive feeding experiences from the first day of life. Additionally, a major component of the IDF program is breastfeeding and Dr. Brown’s Medical just added a breastfeeding module to the IDF program this past year.
What has the research shown from hospitals that have implemented the IDF program?
The research fully supports the success of the IDF program. Many hospitals who have implemented the program are sharing their quality improvement (QI) projects surrounding their IDF results. There have been published papers and QI projects presented by NICU clinicians at conferences.
Once hospitals have implemented the IDF program, results have shown a reduction in the total time to full oral feedings for infants. It is likely this finding has led to the reduced length of stay for infants with an average reduction of 8.8 days, which is so impactful for parents, but the hospitals as well. Hospitals with the program have shown increased breastfeeding rates and increased time in kangaroo care, which is so impactful. The results have also shown a reduction in hospital costs from the cost of savings on feeding supplies to the savings from the reduced length of stay. Some hospitals have reported a reduction of up to $45,000 per patient. Additionally, if breastfeeding rates are improving, it will also improve the overall healthcare dollars spent.
Hospitals with the IDF program also report an improvement in parent and staff satisfaction. According to Lisa, some of the emerging research is also showing that implementation of the IDF program may result in fewer feeding problems for the infants post-discharge as well.
The positive effects of cue-based feeding on parental involvement
One of the biggest reports of difficulties in the literature after discharge for parents of premature infants, is their discomfort during feedings and their inability to read their infant’s cues. With cue-based feeding, but more specifically with the IDF program, infants’ cues are read and responded to appropriately. The infant guides the feeding and the feeder or caregiver responds to the infant. Once cues are understood and feeding becomes a relationship, not only is it better for the infant, but parent-infant bonding is also improved. Parents in NICUs where IDF is used explain that the IDF program helped them learn more about their babies. Once parents are educated on their infant’s cues, they are able to understand them and respond appropriately, which also minimizes the common parental role alteration. A mother of triplets from Virginia reported that she is confident the IDF program helped her breastfeed and without it, she would not have stuck with it.
What impact does the IDF program have on neonatal weight gain
In most of the published research and QI studies, weight gain has not been a factor in hospitals where the IDF program is implemented. Hospitals have report success with IDF including a reduction in time to attain ad lib feeds without compromising weight gain. One study recently reported the IDF group of infants had a larger drop in weight z score. The z score expresses the weight-for-age as the number of standard deviations or Z score below or above the reference mean or median value. The authors
of this particular study speculated that the weight loss was attributed to earlier discharges and younger gestational ages at discharge as well. If an infant is discharged a week earlier at 35 weeks as opposed to 36 weeks, then they will likely weigh less at the time of discharge. Hundreds of hospitals across the country use the IDF program and have shown positive results. Close follow-up and individualized care is key.
The IDF program is grounded in a safe and nurturing culture, but it is also meant to be developmentally and individually appropriate. Therefore, feeding is not a generalized recipe book, but rather, that each infant and their path to full oral feeding
is considered individually. For breastfeeding infants, close and individualized management of breastfeeding is essential during the NICU and beyond discharge. With IDF, breastfeeding is emphasized from the start, with a protected breastfeeding window exists that encourages no bottle feeding. Each unit needs to make sure that all of the staff take the program, parents are properly educated, and a large amount of support is given. With IDF, if supplementation after breastfeeding is needed, the breastfeeding algorithm or test weights are used. But, if the staff is not properly trained, supplementation may not be provided accurately, which can impact weight gain. Once an infant reaches the milestone that they ready for full feedings by mouth, the entire team has a conversation to make sure each team member believes the infant will be successful with the transition. With IDF, it is a team approach and that also includes the parents.
What advice would you given to hospitals or clinicians who are interested in implementing the IDF program?
Lisa encourages all units to take a look at their current feeding practices and evaluate them. Dr. Brown’s Medical has a tool called the oral feeding practice review that can help units get started. Next, establish a team, begin discussions, and review the research. Dr. Brown’s Medical encourages you to speak with other hospitals or staff who have completed the IDF program. To successfully implement the program, it takes a whole team and a commitment. The IDF program is so much more than a tool or a learning module – it’s a culture change with the potential for great benefits and their team at Dr. Brown’s Medical can help. From the very beginning, the IDF advisors will walk through the process with your organization every step of the way and they can assist with ideas for funding, how to purchase the program and how to implement it.
Not all hospitals have the IDF program, but for any parents or NICU clinicians interested in learning more, ask about it! Hospitals who have implemented the IDF program are changing baby’s lives!
Contact information for Dr. Brown’s Medical or Lisa Kleinz
Email Dr. Brown’s Medical: medinfo@drbrownsmedical.com
Email Lisa Kleinz: lisa.kleinz@drbrownsmedical.com
Closing
I hope you enjoyed learning more about the Infant-Driven Feeding program from Dr. Brown’s Medical and why it is so crucial that we learn and respect an infant’s cues and provide them with positive feeding experiences. Our brains our amazing, but with that in mind, we must remember that with infant’s, especially those born prematurely, their brain’s are still pruning and adapting based on their individual experiences. So we all must intentionally protect and support them throughout their time in the NICU and beyond!
How we introduce or provide oral experiences will not only impact how they will orally feed in the future, but it also impacts their future development. Every NICU caregiver needs to support and protect oral experiences with each and every interaction starting on the first day of life. In doing so, the parents will also observe and learn early on how they can support and protect their infant throughout their NICU journey and beyond.
The consistency provided to the infant by all of their caregivers helps to provide the most optimal patient outcomes, which is one of the key components of the IDF program. The research supports the IDF program with a reduction in time to full oral feedings, a reduction in the length of hospital stay, reduced hospital costs, improved breastfeeding rates, and increased parental involvement including kangaroo care. As Lisa mentioned, there is more research coming out in the near future on the IDF program, but thus far, the benefits are significant!
Thank you so much to Lisa Kleinz for joining me and sharing her vast knowledge on neonatal neurodevelopment, tangible ways caregivers can provide positive feeding experiences, and the IDF program. I am so grateful that are professional paths have crossed again!
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.
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