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.
In 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.