contributed by: raquel garcia m.s., ccc-slp, bcs-s · contributed by: raquel garcia m.s., ccc-slp,...

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Infant Driven Feeding In The Neonatal Intensive Care UnitQuality Versus Quantity Approach That Can Directly Impact Feeding Success From Infancy to Toddlerhood

Introduction: An infant’s road in the Neonatal Intensive Care Unit (NICU) can be long and arduous.After many weeks or months in the hospital, countless surgeries and setbacks, typically the last thingto hold an infant from being discharged is feeding. Historically in the United States, volume-drivenfeedings have been the standard approach to increasing infants’ nutritional intake to a pointsufficient to allow discharge from the NICU. Volume-driven feedings require an infant to feed on aschedule (e.g., every 3-4 hours), and to consume a pre-determined amount of liquid at every feeding.When an infant does not complete his/her prescribed volume (example 60ml/cc of formula) via oralfeeding then the balance is gavaged via nasogastric tube (NGT). A volume-driven approach may beadopted by the medical team, nurses, and caregivers in order to measure the infant’s success withoral feeds. This would be viewed as a QUANTITY approach to oral feeding, where the infant’sprogress is measured by how much he/she is feeding. Essentially, the infant’s success will becelebrated when he/she empties the bottle – no matter how it was completed (example – increasingflow rate). However, volume-driven intake can create a stressful feeding experience, because infantsmay be fed past their stopping point (Shaker, 2013). Shaker (2013) described how the speech-languagepathologist (SLP) can read an infant’s feeding by monitoring infant cues for engagement anddisengagement with oral feeding. In fact, volume-driven feedings may actually extend the infant’sNICU stay in comparison to cue-based feeding, i.e., feeding that emphasizes following the infant’slead regarding the amount and frequency of feedings (Puckett et. al., 2008; Kirk et. al., 2007; McCain et.al., 2001).

Contributed by: Raquel Garcia M.S., CCC-SLP, BCS-S

Why: Working in the NICU as an SLP, one can directly impact an infant’s developmental feedingskills. Often, the SLP is pressured by doctors, nurses, and caregivers to view infants’ feeding successby the amount of formula or breast milk that is consumed at any given feeding. The term “toughlove” is known in NICU culture, where a faster flow nipple and prodding the infant to completehis/her feeds is used to promote an earlier discharge from the NICU. Volume driven (quantity)feeding practices in the NICU can negatively impact an infant’s stability, safety, and behaviors.Recognizing infant behaviors during oral feeding is essential for a NICU SLP. It is the SLP’s role in theNICU to promote quality PO feedings that embrace positive oral readiness cues and recognizebehavioral changes that could impact feeding success in the NICU and as the infant maturesthrough toddlerhood. Instruction: Critically think about the infant’s oral readiness cues with “WH” questions. · What are PO readiness cues/hunger behaviors? · What are signs of infant disengagement before/during PO feeding? · Why is the infant disengaged with PO feeding? · When do I provide compensatory strategies during the feeding? · When do I stop feeding? · Who can impact the infants PO feeding positively or negatively? · How can I assess oral readiness cues? · How do I use infant driven feedings in my practice? How: This handout will review the principles of infant-driven, or cue-based feeding and how ittranslates to developmental feeding skills in older infants and toddlers. Use this handout to gain abetter understanding of oral readiness cues, infant driven feeding, and strategies to maximize“quality” oral feeds in the NICU to promote successful developmental behaviors.




1. What are PO readiness cues/hunger behaviors? · Awake state · Crying · Rooting · Arms/hands midline · Hands/fingers to mouth · Sucking on fingers and pacifier · Nuzzling, licking, lip smacking · Physiologic Stability · Appropriate muscle tone 2. What are signs of infant disengagement before/during PO feeding? · Falls asleep · Gaze aversion · Extended extremities · Turns head away · Thrust nipple out of mouth · Suck-swallow-breath disorganization · Decreased interested in bottle · Physiologic instability 3. Why is the infant disengaged with PO feeding? · Predominant state is not ready for PO feeding: Sleepy, Physiologic instability, disengaged · Flow rate is too much for infant to manage: Does baby need reduced flow rate nipple, co-regulatedpacing, position change? 4. When do I provide compensatory strategies during the feeding? · Observe infant’s behaviors during the feeding. · Is the infant’s cues telling you that he/she needs help managing the flow of milk, bolus size, lengthof suck burst, or calming (Shaker, 2013)? · Is there an increase in anterior bolus loss, gulping, multiple swallows, wet breathing, audiblebreathing? 5. When do I stop feeding? · Disengaged · Satiation cues observed · Physiologic instability · Quality of PO feeding declines despite use of positive co-regulated pacing, positioning, and nippleflow rate. 6. Who can impact the infant’s PO feeding positively or negatively? · Anyone who is feeding the baby – parents, caregivers, nurses, speech language pathologist,occupational therapists, physical therapists. 7. How can I assess oral readiness cues? · Informal Assessment: Monitor baby’s communications during diaper and touch time. Is he/sheproviding the positive behaviors that he/she wants to eat? Feeder has to have a keen eye on subtlebehaviors that may indicate infant disengagement. · Formal Assessment: Neonatal Oral Motor Assessment Scale (NOMAS), Early Feeding SkillsAssessment (Braun & Palmer, 1986). See Longoni et al., 2018, a systematic review, that describes thescoring issues and inter-rater reliability of the NOMAS.




References American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speechlanguage pathologists providing services to infants and families in the NICU environment [Knowledgeand Skills]. Retrieved from http://www.asha.org/policy/KS2004-00080/ Braun, M., & Palmer, M. (1986). A pilot study of oral-motor dysfunction in “at-risk” infants. Physical &Occupational Therapy in Pediatrics, 5(4): 13-25. Harding, C., Bowden, C., Leticia, L., Levin, A. (2016). How do we determine oral readiness in infants? Infant,12(1), 10-12 Kirk, A., Alder, S., & King, J. (2007). Cue-based oral feeding clinical pathway results in earlier attainmentof full oral feeding in premature infants. Journal of Perinatology, 27, 572-578. doi: 10.1038/sj.jp.7211791 Lau, C (2016). Development of infant oral feeding skills: what do we know? American Journal of ClinicalNutrition, 103, 616-621. Longoni, L., Provenzi, L., Cavallini, A. et al. Eur J Pediatr (2018). https://doi.org/10.1007/s00431-018-3130-1, asystematic review, that describes these issues. Abstract:https://link.springer.com/article/10.1007%2Fs00431-018-3130-1 McCain, G., Gartside, P., Greenberg, J. & Lott, J. (2001). A feeding protocol for healthy preterm infantsthat shortens time to oral feeing. The Journal of Pediatrics, 139(3), 374-379. Pados,B., Park, J., Estrem,H., Awotwi,A. (2016). Assessment tools for evaluation of oral feeding in infantsyounger than 6 months. Advances in Neonatal Care, 16(2), 143-150 Puckett, B., Sankaran, K (2008) “Please Can I Eat Now! I’m Hungry Now- Infant Driven Feeding Practice”. ,Perinatology, 10(4-5), 113-115. Ross, E.S. (2009) “Don’t be A Babies-R-Us therapist: thinking past the bottle in the NICU. PediatricFeeding and Dysphagia Newsletter, 9 (5), 1-4. Ross, E.S., Browne, J. (2002). Developmental progression of feeding skills : An approach to supportingfeeding in preterm infants. Seminar of Neonatology, 7, 469-475 Ross,E.S., Philbin, K. (2011). Supporting oral feeding in fragile infants: An evidence based method forquality bottle feeding of preterm, ill, and fragile infants. Journal of Perinatal and Neonatal Nursing,25(4): 349-357. Shaker, C. (2012). Feed me only when I'm cueing: Moving away from a volume-driven culture in the NICU.Neonatal Intensive Care, 23(3), 27-32. Shaker, C.S. (2013) “Reading the Feeding”. ASHA Leader, February Issue, 42-47 Shaker, C.S., Woida, AM (2007). An evidenced based approach to nipple feeding in a Level III NICU :Nurse autonomy, developmental care, and team work. Neonatal Network, 26, 77-83

contributed by: raquel garcia m.s., ccc-slp, bcs-s · contributed by: raquel garcia m.s., ccc-slp,...

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