- Email: [email protected]
Cue-Based Feeding in the NICU
28 Days
Cue-Based Feeding in the NICU Cynthia H. Whetten
N Photo © iStock Essentials Collection / iStockphoto.com
Neonates born as early as 23 weeks gestation are surviving in many NICU settings. It has been enlightening and challenging to help these immature, extremely preterm neonates grow and develop into thriving infants, ready for life at home. Successful oral feeding is one key component in the decision to send an infant home. Hospitals have traditionally used a volume-based model to feed infants. This model is
designed to feed a required volume of milk to an infant at scheduled times, whether the infant is willing to participate or not. Advancement of feeds has traditionally been determined by the infant’s gestational age or weight and ordered by the medical team (Newland, L’Huillier, & Petrey, 2013). The goal was to have an infant reach full oral feeds as quickly as possible in the hopes of an early discharge home. Oral feeding is now recognized as a more
Abstract In NICU settings, caring for neonates born as early as 23 weeks gestation presents unique challenges for caregivers. Traditionally, preterm infants who are learning to orally feed take a predetermined volume of breast milk or formula at scheduled intervals, regardless of their individual ability to coordinate each feeding. Evidence suggests that this volume-driven feeding model should be replaced with a more individualized, developmentally appropriate practice. Evidence from the literature suggests that preterm infants fed via cue-based feeding reach full oral feeding status faster than their volume-feeding counterparts and have shorter lengths of stay in the hospital. Changing practice to infant-driven or cue-based feedings in the hospital setting requires staff education, documentation, and team-based communication. http://dx.doi.org/10.1016/j.nwh.2016.08.006 Keywords cue-based feeding | feeding advance | infant-driven feeding
nwhjournal.com
© 2016, AWHONN
507
28 Days
shown to decrease the time to achieving full feeds and ultimately the length of hospital stay
Cynthia H. Whetten, BSN, RNC-LRN, is a staff nurse at Connecticut Children’s Medical Center in Hartford, CT. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
508
complex developmental task than was originally appreciated (Thoyre, Park, Pados, & Hubbard, 2013). The suck, swallow, and breathing ability necessary to feed is related to an infant’s neurodevelopmental maturity and health status. Sucking is an early reflex. Coordinating swallowing and breathing is a developing skill in a preterm infant that comes over time with a maturing central nervous system. If infants are given breast milk or formula that they cannot swallow because of their state of alertness, maturity, or illness, they are at great risk for aspiration (White & Parnell, 2013). The volume-driven model would have an infant orally feed, even when unstable or developmentally immature. Cue-based feeds allow an infant to orally feed when able and to stop a feeding when unable to coordinate the sucking, swallowing, and breathing required to do so safely and effectively. Current literature supports an individualized, developmentally appropriate approach to an infant’s progression from introduction of oral stimulus
Nursing for Women’s Health
to full feeds. Cue-based feeding has been shown to decrease the time to achieving full feeds and ultimately the length of hospital stay (Shaker, 2013b).
Traditional Initiation and Progression of Oral Feeds Introduction of colostrum mouth care and “gut priming” (very low-volume feedings designed to enhance peristalsis) with drops of colostrum colonizes the infant gastrointestinal tract with essential organisms and flora to allow the infant to digest human milk and fight infections (White & Parnell, 2013). The neonate slowly advances in volume via the oro-/nasogastric tube feedings. Parental skin-to-skin contact with an infant during tube feedings also supports all aspects of an infant’s development (White & Parnell, 2013). Hospitals have differing protocols with regard to colostrum mouth care, skinto-skin contact, volume advance, pacifiers, and pacifiers dipped in breast milk, all leading up to the early oral feeding. When to initiate oral feeding is also decided by the health care team based on a unit’s policy.
Cue-Based Feeding After about 32 weeks gestation, infants begin to show cues that they would like to be fed by
Volume 20
Issue 5
Photo © Sabryna Washington / stockadobe.com
Cue-based feeding has been
Photo © iStock Signature Collection / iStockphoto.com
mouth (Gelfer, McCarthy, & Spruill, 2015). Waking, fussing, sucking on hands and pacifiers, and stable tone and vital signs are all signs that an infant would like to orally feed (Davidson, Hinton, Ryan-Wenger, & Jadcherla, 2013). Hospitals have differing procedures for evaluating an infant’s readiness to initiate feeds and readiness to participate in any subsequent feed. However, the main concept is consistent throughout, and that is to individualize oral feeding advances according to each infant’s developmental status (Davidson et al., 2013). Once an infant has shown a capacity to maintain an alert state and has good muscle tone and stable vital signs, he or she can begin to feed orally (Shaker, 2013a). Paying attention to an infant’s cues to feed is developmentally safer and more successful than volume-driven feeding. This leads to shorter time to full oral feed and a shorter length of hospital stay (Newland et al., 2013). Cue-based feeding requires clinicians to pay attention to an infant’s behaviors in a different way and allows the infant to be an active participant in the feeding. If an infant has a need to stop a feeding, he shows disengagement cues, such as crying, arching, weak or absent suck, hands put in the stop position, losing tone, and going to sleep. An infant displaying these cues is stressed and unable to feed successfully (Gennattasio, Perri, Baranek, & Rohan, 2015). The strategies used to continue feeding in the volume-driven model, such as unswaddling the infant, prodding, twisting or pulling the nipple, and using a nipple with a fast flow rate, put the infant at risk for unstable vital signs, hypoxia, increased energy expense, and ultimately poor weight gain (Shaker, 2013a).
teams to support the change. Best practice evidence from the literature guides policies and plans for implementation (Newland et al., 2013). There are established documentation tools for feeding readiness assessment and quality of feeds in place. Ludwig and Waitzman (2007) have developed a comprehen-
feeds and a more enjoyable experience for infants, parents, and staff, should be discussed, as should the problems associated with volume-based feeds. Staff would then educate parents to recognize their infant’s readiness to feed and stress behavior and role-model safe, cue-based feedings.
It is important to recognize feeding as a complex, interactive, developmental task sive tool used for this type of documentation called Infant-Driven Feeding Scales. Quality of feed needs to be a priority over quantity of feed, with the goal of decreasing the time to full-volume oral feeds. Changing policy requires staff education on the neurodevelopment of infants, how to recognize behaviors and cues to feed, stress cues, and necessary documentation. Nursing education can take the form of identifying supertrainers and using slide presentations, videos, or in-service programs. The benefits of cue-based feeds, such as safer
Documenting an infant’s performance and response to feedings is key in individualizing and communicating his/her feeding readiness and ability to feed to other caregivers. Nurses have traditionally felt pressure to bottle-feed every feeding time, and breastfeeding women become discouraged when their infant does not feed. Using readiness scores and documenting disengagement cues empowers nurses to use sound, evidence-based judgment on whether to feed or not to feed. Each oral feeding requires an assessment of an infant’s ability to
Challenges in Implementing Change NICUs transitioning from implementing volume-driven feeds to cue-based feeds have established multidisciplinary
October | November 2016
Nursing for Women’s Health
509
28 Days
initiate a feed and safely continue to feed. Parents must be educated on an infant’s readiness to feed and on infant feeding behaviors indicative of stress. Nurses can mentor parents in how to recognize an infant’s behaviors and how to use skin-to-skin contact when the infant is not cueing or needs to stop a feed. This promotes attachment and involvement and, ultimately, parent satisfaction. Meetings or surveys are necessary to follow up on practice change and allow nurses’ opinions, suggestions, and concerns to be heard and addressed.
Practical Implications Cue-based feeding ensures the best, safest experience for infants and their families. It is important to recognize feeding as a complex, interactive, developmental task. Changing practice to enable an infant to feed when able and stop when unable ensures a safe, efficient oral feed experience. Quality over quantity is the underpinning of cue-based feeds. Education and teamwork for all levels of caregivers is necessary to maintain consistency in assessing and documenting each feeding experience.
Conclusion Cue-based or infant-driven feedings are replacing volume-driven feedings in some NICUs. Evidence suggests that feeding infants when they are able and willing participants has decreased the time to achieving successful full oral feeds. Changing from the volume-driven model to infant-driven or cue-based feedings disrupts hospital schedules and requires education, but it is more developmentally appropriate to have an individualized feeding plan that allows staff and parents to understand an infant’s feeding behaviors. Focusing on the quality of the feeding experience for the infant over the amount taken by the infant results in improvement in oral feeding overall (Newland et al., 2013). Infants have been shown to be more successful, and parents report satisfaction, when there is a plan in place specific to each infant. A cue-based feeding policy is associated with a shorter time to achieving full feeds and, therefore, an earlier discharge from the hospital (Wellington & Perlman, 2015). NWH
510
Nursing for Women’s Health
References Davidson, E., Hinton, D., Ryan-Wenger, N., & Jadcherla, S. (2013). Quality improvement study of effectiveness of cue-based feeding in infants with bronchopulmonary dysplasia in the neonatal intensive care unit. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42, 629–640. doi:10.111181552-6909.12257 Gelfer, P., McCarthy, A., & Spruill, C. T. (2015). Infant driven feeding for preterm infants: Learning through experience. Newborn & Infant Nursing Reviews, 15(2), 64–67. doi:10.1053/j. nainr.2015.04.004 Gennattasio, A., Perri, E. A., Baranek, D., & Rohan, A. (2015). Oral feeding readiness assessment in premature infants. MCN: The American Journal of Maternal/Child Nursing, 40(2), 96–104. doi:10.1097/NMC.0000000000000115 Ludwig, S. M., & Waitzman, K. A. (2007). Changing feeding documentation to reflect infant-driven feeding practice. Newborn & Infant Nursing Reviews, 7(3), 155–160. doi:10.1053/j. nainr.2007.06.007 Newland, L., L’Huillier, M. W., & Petrey B. (2013). Implementation of cue-based feeding in a level III NICU. Neonatal Network, 32(2), 132–137. doi:10.1891/0730-0832.32.2.132 Shaker, C. S. (2013a). Cue-based co-regulated feeding in the neonatal intensive care unit: Supporting parents in learning to feed their preterm infant. Newborn and Infant Nursing Reviews, 13(1), 51–55. doi:10.1053/j.nainr.2012.12.009 Shaker, C. S. (2013b). Cue-based feeding in the NICU: Using the infant’s communication as a guide. Neonatal Network, 32(6), 404–408. doi:10.1891/0730-0832.32.6.404 Thoyre, S., Park, J., Pados, B., & Hubbard, C. (2013). Developing a co-regulated, cue-based feeding practice: The critical role of assessment and reflection. Journal of Neonatal Nursing, 19(4), 139–148. Wellington, A., & Perlman, J. M. (2015). Infantdriven feeding in premature infants: A quality improvement project. Archive of Disease in Childhood: Fetal and Neonatal Edition, 100(6), F495– F500. doi:10.1136/archdischild-2015-308296 White, A., & Parnell, K. (2013). The transition from tube to full oral feeding (breast or bottle)— A cue-based developmental approach. Journal of Neonatal Nursing, 19(4), 189–197. doi:10.1016/j. jnn.2013.03.006
Volume 20
Issue 5
Cue-Based Feeding in the NICU Cynthia H. Whetten
N Photo © iStock Essentials Collection / iStockphoto.com
Neonates born as early as 23 weeks gestation are surviving in many NICU settings. It has been enlightening and challenging to help these immature, extremely preterm neonates grow and develop into thriving infants, ready for life at home. Successful oral feeding is one key component in the decision to send an infant home. Hospitals have traditionally used a volume-based model to feed infants. This model is
designed to feed a required volume of milk to an infant at scheduled times, whether the infant is willing to participate or not. Advancement of feeds has traditionally been determined by the infant’s gestational age or weight and ordered by the medical team (Newland, L’Huillier, & Petrey, 2013). The goal was to have an infant reach full oral feeds as quickly as possible in the hopes of an early discharge home. Oral feeding is now recognized as a more
Abstract In NICU settings, caring for neonates born as early as 23 weeks gestation presents unique challenges for caregivers. Traditionally, preterm infants who are learning to orally feed take a predetermined volume of breast milk or formula at scheduled intervals, regardless of their individual ability to coordinate each feeding. Evidence suggests that this volume-driven feeding model should be replaced with a more individualized, developmentally appropriate practice. Evidence from the literature suggests that preterm infants fed via cue-based feeding reach full oral feeding status faster than their volume-feeding counterparts and have shorter lengths of stay in the hospital. Changing practice to infant-driven or cue-based feedings in the hospital setting requires staff education, documentation, and team-based communication. http://dx.doi.org/10.1016/j.nwh.2016.08.006 Keywords cue-based feeding | feeding advance | infant-driven feeding
nwhjournal.com
© 2016, AWHONN
507
28 Days
shown to decrease the time to achieving full feeds and ultimately the length of hospital stay
Cynthia H. Whetten, BSN, RNC-LRN, is a staff nurse at Connecticut Children’s Medical Center in Hartford, CT. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
508
complex developmental task than was originally appreciated (Thoyre, Park, Pados, & Hubbard, 2013). The suck, swallow, and breathing ability necessary to feed is related to an infant’s neurodevelopmental maturity and health status. Sucking is an early reflex. Coordinating swallowing and breathing is a developing skill in a preterm infant that comes over time with a maturing central nervous system. If infants are given breast milk or formula that they cannot swallow because of their state of alertness, maturity, or illness, they are at great risk for aspiration (White & Parnell, 2013). The volume-driven model would have an infant orally feed, even when unstable or developmentally immature. Cue-based feeds allow an infant to orally feed when able and to stop a feeding when unable to coordinate the sucking, swallowing, and breathing required to do so safely and effectively. Current literature supports an individualized, developmentally appropriate approach to an infant’s progression from introduction of oral stimulus
Nursing for Women’s Health
to full feeds. Cue-based feeding has been shown to decrease the time to achieving full feeds and ultimately the length of hospital stay (Shaker, 2013b).
Traditional Initiation and Progression of Oral Feeds Introduction of colostrum mouth care and “gut priming” (very low-volume feedings designed to enhance peristalsis) with drops of colostrum colonizes the infant gastrointestinal tract with essential organisms and flora to allow the infant to digest human milk and fight infections (White & Parnell, 2013). The neonate slowly advances in volume via the oro-/nasogastric tube feedings. Parental skin-to-skin contact with an infant during tube feedings also supports all aspects of an infant’s development (White & Parnell, 2013). Hospitals have differing protocols with regard to colostrum mouth care, skinto-skin contact, volume advance, pacifiers, and pacifiers dipped in breast milk, all leading up to the early oral feeding. When to initiate oral feeding is also decided by the health care team based on a unit’s policy.
Cue-Based Feeding After about 32 weeks gestation, infants begin to show cues that they would like to be fed by
Volume 20
Issue 5
Photo © Sabryna Washington / stockadobe.com
Cue-based feeding has been
Photo © iStock Signature Collection / iStockphoto.com
mouth (Gelfer, McCarthy, & Spruill, 2015). Waking, fussing, sucking on hands and pacifiers, and stable tone and vital signs are all signs that an infant would like to orally feed (Davidson, Hinton, Ryan-Wenger, & Jadcherla, 2013). Hospitals have differing procedures for evaluating an infant’s readiness to initiate feeds and readiness to participate in any subsequent feed. However, the main concept is consistent throughout, and that is to individualize oral feeding advances according to each infant’s developmental status (Davidson et al., 2013). Once an infant has shown a capacity to maintain an alert state and has good muscle tone and stable vital signs, he or she can begin to feed orally (Shaker, 2013a). Paying attention to an infant’s cues to feed is developmentally safer and more successful than volume-driven feeding. This leads to shorter time to full oral feed and a shorter length of hospital stay (Newland et al., 2013). Cue-based feeding requires clinicians to pay attention to an infant’s behaviors in a different way and allows the infant to be an active participant in the feeding. If an infant has a need to stop a feeding, he shows disengagement cues, such as crying, arching, weak or absent suck, hands put in the stop position, losing tone, and going to sleep. An infant displaying these cues is stressed and unable to feed successfully (Gennattasio, Perri, Baranek, & Rohan, 2015). The strategies used to continue feeding in the volume-driven model, such as unswaddling the infant, prodding, twisting or pulling the nipple, and using a nipple with a fast flow rate, put the infant at risk for unstable vital signs, hypoxia, increased energy expense, and ultimately poor weight gain (Shaker, 2013a).
teams to support the change. Best practice evidence from the literature guides policies and plans for implementation (Newland et al., 2013). There are established documentation tools for feeding readiness assessment and quality of feeds in place. Ludwig and Waitzman (2007) have developed a comprehen-
feeds and a more enjoyable experience for infants, parents, and staff, should be discussed, as should the problems associated with volume-based feeds. Staff would then educate parents to recognize their infant’s readiness to feed and stress behavior and role-model safe, cue-based feedings.
It is important to recognize feeding as a complex, interactive, developmental task sive tool used for this type of documentation called Infant-Driven Feeding Scales. Quality of feed needs to be a priority over quantity of feed, with the goal of decreasing the time to full-volume oral feeds. Changing policy requires staff education on the neurodevelopment of infants, how to recognize behaviors and cues to feed, stress cues, and necessary documentation. Nursing education can take the form of identifying supertrainers and using slide presentations, videos, or in-service programs. The benefits of cue-based feeds, such as safer
Documenting an infant’s performance and response to feedings is key in individualizing and communicating his/her feeding readiness and ability to feed to other caregivers. Nurses have traditionally felt pressure to bottle-feed every feeding time, and breastfeeding women become discouraged when their infant does not feed. Using readiness scores and documenting disengagement cues empowers nurses to use sound, evidence-based judgment on whether to feed or not to feed. Each oral feeding requires an assessment of an infant’s ability to
Challenges in Implementing Change NICUs transitioning from implementing volume-driven feeds to cue-based feeds have established multidisciplinary
October | November 2016
Nursing for Women’s Health
509
28 Days
initiate a feed and safely continue to feed. Parents must be educated on an infant’s readiness to feed and on infant feeding behaviors indicative of stress. Nurses can mentor parents in how to recognize an infant’s behaviors and how to use skin-to-skin contact when the infant is not cueing or needs to stop a feed. This promotes attachment and involvement and, ultimately, parent satisfaction. Meetings or surveys are necessary to follow up on practice change and allow nurses’ opinions, suggestions, and concerns to be heard and addressed.
Practical Implications Cue-based feeding ensures the best, safest experience for infants and their families. It is important to recognize feeding as a complex, interactive, developmental task. Changing practice to enable an infant to feed when able and stop when unable ensures a safe, efficient oral feed experience. Quality over quantity is the underpinning of cue-based feeds. Education and teamwork for all levels of caregivers is necessary to maintain consistency in assessing and documenting each feeding experience.
Conclusion Cue-based or infant-driven feedings are replacing volume-driven feedings in some NICUs. Evidence suggests that feeding infants when they are able and willing participants has decreased the time to achieving successful full oral feeds. Changing from the volume-driven model to infant-driven or cue-based feedings disrupts hospital schedules and requires education, but it is more developmentally appropriate to have an individualized feeding plan that allows staff and parents to understand an infant’s feeding behaviors. Focusing on the quality of the feeding experience for the infant over the amount taken by the infant results in improvement in oral feeding overall (Newland et al., 2013). Infants have been shown to be more successful, and parents report satisfaction, when there is a plan in place specific to each infant. A cue-based feeding policy is associated with a shorter time to achieving full feeds and, therefore, an earlier discharge from the hospital (Wellington & Perlman, 2015). NWH
510
Nursing for Women’s Health
References Davidson, E., Hinton, D., Ryan-Wenger, N., & Jadcherla, S. (2013). Quality improvement study of effectiveness of cue-based feeding in infants with bronchopulmonary dysplasia in the neonatal intensive care unit. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42, 629–640. doi:10.111181552-6909.12257 Gelfer, P., McCarthy, A., & Spruill, C. T. (2015). Infant driven feeding for preterm infants: Learning through experience. Newborn & Infant Nursing Reviews, 15(2), 64–67. doi:10.1053/j. nainr.2015.04.004 Gennattasio, A., Perri, E. A., Baranek, D., & Rohan, A. (2015). Oral feeding readiness assessment in premature infants. MCN: The American Journal of Maternal/Child Nursing, 40(2), 96–104. doi:10.1097/NMC.0000000000000115 Ludwig, S. M., & Waitzman, K. A. (2007). Changing feeding documentation to reflect infant-driven feeding practice. Newborn & Infant Nursing Reviews, 7(3), 155–160. doi:10.1053/j. nainr.2007.06.007 Newland, L., L’Huillier, M. W., & Petrey B. (2013). Implementation of cue-based feeding in a level III NICU. Neonatal Network, 32(2), 132–137. doi:10.1891/0730-0832.32.2.132 Shaker, C. S. (2013a). Cue-based co-regulated feeding in the neonatal intensive care unit: Supporting parents in learning to feed their preterm infant. Newborn and Infant Nursing Reviews, 13(1), 51–55. doi:10.1053/j.nainr.2012.12.009 Shaker, C. S. (2013b). Cue-based feeding in the NICU: Using the infant’s communication as a guide. Neonatal Network, 32(6), 404–408. doi:10.1891/0730-0832.32.6.404 Thoyre, S., Park, J., Pados, B., & Hubbard, C. (2013). Developing a co-regulated, cue-based feeding practice: The critical role of assessment and reflection. Journal of Neonatal Nursing, 19(4), 139–148. Wellington, A., & Perlman, J. M. (2015). Infantdriven feeding in premature infants: A quality improvement project. Archive of Disease in Childhood: Fetal and Neonatal Edition, 100(6), F495– F500. doi:10.1136/archdischild-2015-308296 White, A., & Parnell, K. (2013). The transition from tube to full oral feeding (breast or bottle)— A cue-based developmental approach. Journal of Neonatal Nursing, 19(4), 189–197. doi:10.1016/j. jnn.2013.03.006
Volume 20
Issue 5