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CUE BASED FEEDING in the
NICU
Neonatal Intensive Care Nutrition
Committee
Ochsner Clinic Foundation
Lori Naquin, RNC, Jeanne Traylor, NNP, Christina Martin, RN,
Victor Lunyong, M.D., Billie Moore, NNP, Marcy McMenis, LOTR,
Tammy Abadie, RN, Jennifer Muller, RN, Angie Noya, RNC
Cue Based Feeding
Cue based feeding is defined as nipple feedings
initiated in response to the infant’s
behavioral cues and ends when the infant
demonstrates satiation (Tosh, K & McGuire
W, 2007).
POTENTIALLY BETTER PRACTICES (PBP)
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Practices are "potentially better" rather than
"better" or "best"
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Until the practices are evaluated, customized,
and tested you will not know whether they are
truly "better" or "best".
POTENTIALLY BETTER PRACTICES (PBP)
Measurable Aim:
 Establish consistent transition to full nipple
feedings in healthy preterm infants by 32-34
weeks PCA using cue based infant expressions.
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Infants will transition to full nipple feedings by
35-37 weeks using cue based feeding methods.
Review of Literature
 Initiation of oral feeding is feasible before
33 weeks post menstrual age
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There is a relationship between the
achievement of full oral feeds and the
timing of hospital discharge
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Full feedings can be attained when infants
provide cues to regulate feeding schedule.
Review of Literature
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Non nutritive sucking accelerates the
transition from tube to oral feedings
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Oral stimulation may accelerate and improve
outcomes related to oral feedings
Theoretical Perspective
Heidi Al’s Synactive Theory of Development
This framework emphasizes
integration of the physiologic
and behavioral systems and
how the maturing infant
balances input from the
environment while coping
with the internal physiologic
demands.
SUBSYSTEMS:
 Autonomic
 Motor
 State
 Attention/interactions
 Self-regulatory
Feeding Readiness Cues
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Ability to manage environment and
activity
Motor stability (tone, posture, quality of
movement
Feeding Readiness Cues
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Awake
Ability to maintain alertness
Crying but not excessive
Feeding Readiness Cues
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Rooting
Sucking
Tolerance of enteral feedings
DISTRESS SIGNALS
AUTONOMIC STRESS
MOTORIC STRESS
Bradycardia
Sneezing
Yawning
Gagging
Tremors or twitching
Flaccid tone
Hyperextension of extremities
Grimacing
Finger splaying
Arching
DISTRESS SIGNALS
STATE- RELATED STRESS
Diffuse sleep or awake states
Eye aversion
Irritability
Crying
Staring
Project Description
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Target infants will be 32-34 weeks post-conceptual age
The PDSA (plan-do-study-act) cycle for change will
guide the multidisciplinary team’s implementation of
this practice change.
Nursing staff will be educated on accurate assessment
of readiness for oral feedings in the neonate.
Related journal articles will be provided in the unit as
resources on protocols and behavioral cues.
A cue based tracking tool will be used for
documentation and analysis.
PDSA CYCLE
What is a PDSA cycle?
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Scientific method used for action-oriented learning
Guides the test of a change
Determines if the change is an improvement
Tests the change by planning it, trying it, observing
the results and acting on what is learned
PDSA CYCLE
PLAN
(Objective)
DO
(Carry out plan)
STUDY
(Analyze data)
ACT
(Actions for change)
Cue Based Feeding
Tracking Tool
Age at introduction of oral feeding: ______________________
Age at first successful oral feeding:______________________
Age/Date of full nipple feedings:________________________
Time from full nipple feeding to discharge:_________________
Breast:_______________
Bottle:___________________
Data to be tracked by Nutrition Committee members.
Potential Benefits
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Shorten length of stay
Earlier transition to full nipple feedings
Decreased incidence of oral aversion
Contingent caregiving
The infant controls the feeding progress.
The breast feeding experience is improved as
evidenced by infant’s ability to latch on and nurse.
Potential Risks
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Poor feeding
Poor weight gain
Increased stress and potential for failure
Bradycardia, apnea
Decreased oxygen saturations
Feeding intolerance with higher risk for
lung aspiration
Early Oral Feeding Protocol
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HOW DO FEEDINGS PROGRESS ?
If an oral feeding is successful the infant
progresses to an additional feeding the next day.
If the feeding is unsuccessful the previous day’s
feeding is repeated until success is accomplished.
The objective is to advance the infant to full oral
feedings ( 8 feeds per day).
Reproduced with permission from Pediatrics, Vol
110, No. 3, September 2002, p. 518, copyright 2008
by the AAP
Sensitive Indicators
Sensitive
Indicators
Should be within
Normal limits
Heart Rate
Respirations
Oxygen Saturations
Temperature
Sleep-Wake State
Digestion
Suck-Swallow-Breathe
Sequencing
Gavage/Oral Phase of Feeding
Assess Readiness to Feed
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Feeding should be offered when the infant
comes to an awake state
Offer nonnutritive sucking
A sleeping infant who does not suck on the pacifier and remains
asleep should be left to sleep 30 more minutes, after which the
pacifier should be offered again. If the infant shows interest he
may be fed by nipple.
Gavage/Oral Phase of Feeding
Assess Readiness to Feed
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If the infant continues to sleep, the feeding should
be completed by gavage.
Feedings should occur as ordered every 3-3 ½
hours.
Infant must receive seven-eight feedings in a 24
hour period.
Nippling Successfully?
Successful implies:
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the ability to take all of the prescribed volume by mouth
the entire prescribed volume was taken within 20
minutes without adverse events
adverse events: oxygen desaturation dropping ≥5% of
baseline values or bradycardia, heart rates ≤100
maintaining a sustained pattern of weight gain
RELEVANCE TO NURSING PRACTICE
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Nurse autonomy
Developmental support
Sensitive caregiving
Applying evidence based practice in clinical setting
Educating parents about behavior responses
Expected outcomes
75% of all preterm infants in our Neonatal
Intensive Care Unit will:
 reach transition from full tube to oral
feedings by 32-34 weeks post-conceptual age
 achieve full oral feedings by 35-37 weeks
 have consistent weight gain
 decrease length of hospital stay
Future Research
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Infants with a complicated medical course
Infants with high index for morbidity
Extremely low birth weight prematures
Infants with congenital anomalies