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For many years, scheduled feeding was the standard in the special-care nursery at Barnes- Jewish Hospital. Now, new focus, training and charting are in place to promote attention and response to an infant’s oral (PO) readiness cues, a practice known as cue-based feeding. Implementation of this form of feeding is based on evidence that indicates cue-based feeding should become the norm.

According to a study published in the Journal of Obstetric, Gynecologic and Neonatal Nursing in 2007 by Thoyre, the long-term implications of feeding problems during infancy include, but are not limited to, decreased emotional regulation, speech and language delays, and delayed acquisition of fine- and gross-motor skills.

Evidence shows that infants develop significantly fewer feeding problems and an improved nutritional status when cue-based feeding is well applied.

Cue-based feeding, generally described, is the skilled act of focusing the task of feeding on signals given by the infant. Trained in attending to the infant’s expression of readiness to eat and responses to feeds, the caregiver is better able to understand not only when to feed but also how the infant is handling the transition to oral feeds. The trained professional works to assess whether the infant feeds efficiently, repetitively and, most importantly, safely, with a steady rhythm of suck-swallow-breathe.

Advantages of Cue-Based FeedingIn the nurseries at Barnes-Jewish Hospital, the once-standard assessment forms provided a small space to chart that the infant had fed “well,” “fair” or “poor” and record the volume of intake in milliliters. Cue-based feeding reveals that the infant’s behavior before, during and after each feed is significantly complex and requires more intricate charting.

In 2011, a shared-governance committee of nurses and other volunteers from the special-care nursery at Barnes-Jewish Hospital convened with the intent of improving related practice. The committee reviewed the literature and chose to use the scales published in Newborn and Infant Nursing Reviews in 2007 by Ludwig and Waitzman for PO readiness and performance during feeding. This scale provides an additional level of attention to the baby’s performance during the moments of feeding and helps care providers convey additional, important information about the infant’s ability to feed.

According to another study by Thoyre published in Early Human Development in 2003, indicators that a baby is stressed during a feeding may include raised eyebrows, rapid eye flutter, hand held out in a “stop” sign, decreased upper extremity tone as feeding length progresses, oxygen desaturation, falling asleep, tongue placed against roof of mouth on attempts to insert pacifier or nipple, increased pause length in between suck bursts, drooling (beyond a slight dribble with removal of the nipple) and/or multiple swallows. This list is neither comprehensive nor prescriptive, but alludes to the complexity of infant cues and the need for close attention to them.

An infant may exhibit any combination of these signs during the course of her hospital stay and at home. Cues such as these can help alert care providers to the need for decreasing the stress of the feeding. There are many ways to accomplish this, including the following:

  • Postural modifications (swaddle/ unswaddle, side-lying posture)
  • External pacing by the caregiver
  • Changing nipple flow rate or bottle type
  • Use of a quiet environment free of extraneous noise
  • Use of an area away from bright lights
  • Limit jiggling of the nipple/bottle once placed in the baby’s mouth

Evidence shows that close focus on infant reactions to PO presentation, more accurate and comprehensive communication among members of the health care team related to feeding performance and ongoing efforts to standardize care result in short-term improvements to infant oral intake and long-term developmental progress.

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