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Cue-Based Feeding

Area nurses encourage positive infant feeding, focusing on the experience rather than volume only, to promote earlier discharge.

Lisa McGee, MSN, RN, CCNS, neonatal clinical nurse specialist for the Kentucky Children's Hospital's NICU, appreciated a recent report that links hunger-based feeding of premature babies with shorter lengths of stay.1

"In the literature, there are not a lot of articles and studies that address the effect of cue-based feeding on discharge from the NICU," said McGee, "but those that are published show babies tend to do better and get out of NICU sooner if they're fed orally when they exhibit signs of hunger."

Baby-Driven Feeding

McGee described the baby-driven feeding model used in her unit. "Cue-based feeding depends on the infant's neurodevelopment and cues indicating readiness for oral feeding," she said. "It's based on infants showing they're hungry and ready to feed, and on nurses believing the infant will take in the volume of formula they need, regulate their intake, develop motor skills they need for successful oral feeding, grow and develop, and go home earlier."

Connie Teal, MSN, RN-C, NICU case manager at Akron Children's Hospital in Ohio, described the role nurses play in determining feeding readiness. "Cue-based feeding is different from on-demand feeding; we don't let the baby decide what times he'll eat," she said. "While we're not allowing the baby to pick the time, we are following his cues about how he will feed at designated times. It gives the nurses more autonomy to decide if the baby is showing readiness to orally feed, rather than following a physician's order to deliver oral feedings once, twice or three times a day."

Cue-Based Algorithm

Teal and her colleagues began working toward cue-based feeding in 2006. "Nurses, physicians, and speech language pathologists worked together to develop objective cues," she said. "If the baby met a certain score, we went ahead with the oral feed. If we saw continuation cues, we continued the feed. And if the baby showed disengagement behaviors, we stopped the oral feed and continued with an NG feed."

When nurses were evaluated on their knowledge of cue-based feeding as part of annual competency testing, it became obvious there were variations in the way different clinicians approached the situation. "Since then, we've put together a cue-based algorithm that makes the decision more objective," said Teal. "For example, the baby must have all of the initial behavioral cues in order to feed orally. These include a respiratory rate of less than 70, no significant increase in work of breathing while the baby is sucking on a pacifier, a baseline heart rate that stays normal when the baby is sucking on a pacifier, and a coordinated suck on the pacifier."

Small, Consistent Teams

At Cincinnati Children's Hospital Medical Center, one of only 17 Newborn Individualized Developmental Care and Assessment Program (NIDCAP) training centers in the world, babies from the U.S. and other countries spend weeks or even months in the Regional Center for Newborn Intensive Care (RCNIC). Successful feeding is critical to their recovery from medical issues, their healing after surgery, and their growth and development.

"We use cue-based feeding within a team-based approach, nurses working with OT, speech, and the medical or surgical team to determine where the baby is maturationally and when he or she is giving readiness cues," said Linda Lacina, RN, education specialist, newborn developmental specialist and NIDCAP trainer. "The ideal is for a consistent, small group of people such as mom and dad to feed the baby, watching the baby's cues and consistently interpreting and responding to them. We have primary nursing in place so there is a smaller team of consistent caregivers, which helps the baby respond more consistently as well."

Brenda Thompson, MA, CCC-SLP, a speech language pathologist assigned to the RCNIC, is part of an interdisciplinary team that helps develop individualized feeding plans. "We all feel babies can have common cues, but there are unique things that each baby does to indicate feeding readiness as well," she explained. Continuing education, including videos and case scenario discussion of individual babies, helps ensure team members have a common language for the feeding plans.

Satiation Cues

Once the baby is engaged in successful oral feeding, it's important to pay attention to signals that it's time to stop. "Our satiation cues are first of all time cues; we limit feedings to between 20 and 30 minutes depending on the age of the baby," said Thompson. "We also watch for cues such as the baby turning away from the nipple, pushing the nipple out of the mouth or leaving the nipple in but not sucking. We also watch for state changes, such as a baby who is getting really tired."

Lacina emphasized the need to observe babies for stability cues, such as a change in color, heart rate or breathing. "Those cues may lead us to stop feeding before the entire feeding volume is given," she noted. "It's important to individualize the feeding for each baby. We want the baby to find feeding a positive experience no matter how much volume he or she takes in."

At Akron Children's Hospital, nurses are taught to watch for disengagement cues. "These include a significant change from the baby's cardiac/respiratory baseline, decreased oxygen saturation, increased work of breathing, head bobbing, hiccoughing, sneezing, stridor, and avoidance behaviors like head turning and finger splaying that let us know the baby has had enough," said Teal.

To promote successful feeding experiences, Teal and her colleagues limit the first oral feed to 1/3 of the infant's usual feeding volume. "If he doesn't take that volume, we'll wait a period of time before we try again," said Teal. "We found through experience that giving a baby 1/3 or less of the volume several times a day was not a good start for oral feeds."

Moving Forward

Thompson and Lacina support the recommendations for further studies on cue-based feeding. Specifically, they're eager for more evidence-based information around an infant's ability to maintain oral feeding skills without becoming fatigued, so there is less chance of readmission. They'd also like to see studies about ways to make the feeding experience itself being a positive one for the infant - focusing on the experience rather than volume only.

Sandy Keefe is a frequent contributor to ADVANCE.


1.      McCormick, F.M., Tosh, K., & McGuire, W. (2010, Feb). Ad libitum or demand/semi-demand feeding versus scheduled interval feeding for preterm infants. Cochrane Database of Systematic Reviews, 2, Art. No.: CD005255. DOI: 10.1002/14651858.CD005255.pub3. 

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