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 Julie Tuttle, MS, APN, a nurse practitioner in the NICU at Children's Hospital of Illinois, Peoria, appreciated a recent report from the Cochrane Library that links hunger-based feeding of premature babies with shorter lengths of stay (F.M. McCormick, et al, February 2010). "Using the old feeding techniques of moving the baby's jaw and wiggling the bottle around, we were essentially force feeding," she said. "Today, we identify the cues that let us know when the infant is ready to eat and when he's ready to stop. We can help mom and dad pick up on those cues as well, so they get to know their newborns well before they take them home. I believe babies who are fed when they're hungry are discharged earlier, but only after oral feeding is well-established."
I Can't Believe I Did That!
Lisa Ann Brock, BSN, RN, IBCLC, RLC, pediatric RN lactation consultant, member of the multidisciplinary Cue-Based Feeding Team, and a representative on the Nursing Research and Evidence-Based Practice Council at Children's Hospital of Wisconsin (CHW) , Milwaukee, described the transformation in oral-feeding practices for premature infants. "We performed 2 years of ongoing research and the CHW Nursing Research Council invited Rita Pickler, PhD, RN, PNP-BC, from Virginia Commonwealth University as a research scholar to assist us in the development of a cue-based feeding approach for our NICU babies," she said. "We developed videos of nurses feeding babies properly, as well as examples of the improper feeding techniques. As we made the video, we sometimes found ourselves thinking, 'I can't believe I did that in the past!' Then we trained all of the NICU nurses, physicians, residents and fellows in the evidence-based approach that we developed."
This approach is outlined in an infant-feeding document readily available to all members of the healthcare team and parents, which provides summarized information on laminated guideline cards at the bedside. "The cards feature our three readiness cues: 1) the ability to maintain energy, flexion and tone; 2) demonstration of signs like rooting, tongue descending and non-nutritive suck; and 3) the ability to maintain baseline oxygen saturation and respiratory rate," said Brock. "Our guideline cards also contain information about completion cues and stress cues. We want to pay attention to those cues and stop the oral feeding before we see changes in the baby's respiratory status."
Hands-On Support
NICU nurses offer a number of strategies to prepare premature infants for oral feeding. "We provide oral stimulation using colostrum for babies who will be breastfed," said Brock. "We'll have an RN use a cotton-tipped applicator and rub the colostrum inside the infant's mouth. A parent my dip her finger into the colostrum if she is comfortable doing that or use the cotton-tipped applicator to provide oral care for the baby. The baby enjoys the colostrum via oral stimulation, reducing the oral aversions that can develop when babies aren't able to feed orally right away."
Once a baby is able to successfully master the suck-swallow-breathe process needed for successful oral feeding, NICU nurses provide plenty of hands-on support. "We have cycled lighting in the babies' rooms we can turn on when we see the infant waking up, swaddle them to assist with flexion while allowing them to get their hands out and position for breast or bottle feeding," said Brock. "If mom is there and has been kangarooing the baby, it might become time to go to an empty breast. Mom can pump her breast milk, and then we'll help her position the baby in feeding mode at the breast. Mom holds the baby there while we gavage the feeding. You'd be surprised at how fast the baby realizes, 'Oh, that's where my milk is coming from and where I should be!'"
The results are very promising. "This supported cue-based feeding gets the baby to an oral-feeding stage sooner and definitely prepares the infant for an earlier discharge," said Brock. "We're going to do a research study to look at how much sooner babies go home with this approach, and [we] expect that will be an average of 3 days if not sooner."
A Team Approach
Emily Bewyer, MA, L-CCC-SLP, a speech-language pathologist at the University of Kansas Hospital, Kansas City, is part of a feeding team established in response to the latest research about oral feeding of premature infants. "We took the time to focus on the evidence base and completely overhauled our feeding process to follow the infant's cues and identify signs of stress versus stability in a preterm infant," she explained. "For the healthy preterm babies, nurses at the bedside are the driving force for oral feeding, rather than a randomly assigned schedule established by a physician's order."
"Our medical director, Prabhu Parimi, MD, always says, 'We're producing children, not discharges,' and is very committed to developmentally appropriate oral feeding for our babies," said Janet Wisner, BSN, RN, NICU unit educator at University of Kansas Hospital. "We now have five questions about feeding readiness built in to our electronic documentation. The answers to those questions provide a score that identifies babies ready to try oral feeding, usually around 32 weeks. We offer one bottle feeding and then go on to a feeding tolerance assessment."
Unit coordinator Amanda Terrill, BSN, RN, admitted it was a little difficult in the beginning. "But the electronic charting opened our eyes to realize, 'This kiddo isn't ready to feed, and here's why, based on the five questions,'" she said. "Having the guidelines posted at the bedside, along with evidence-based clinical pathways for oral feeding, helps us provide parents with the education they need. Parents are more willing to follow feeding recommendations after discharge because they understand the process and how it benefits their children."
The team approach is already paying off. "The clinic for babies discharged from the NICU used to be full of babies with feeding aversions, but we're not seeing that anymore since we're focusing on the babies' cues for oral feedings," said Wisner. "One of the hardest things to change was attitudes of nurses like myself who were proud of our ability to get the feedings down. I used to say, 'I can feed a rock.' We've moved beyond that to realize the baby has to want to feed and that forcing that feed is no longer appropriate."
Tuttle is pleased with the thoughtful way NICU nurses in Peoria approach the oral feeding process. "Instead of saying, 'I have three babies to feed, so I'll go down the row 1-2-3 and then repeat that process at 11:30,' the nurses are tending first to the baby who is waking up and showing signs of hunger," she said. "They attend to the neonate who is indicating, 'Hey, I'm ready over here' and allow the infants who need the rest to sleep a little longer."
Sandy Keefe is a frequent contributor to ADVANCE.
photos courtesy Children's Hospital of Wisconsin
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