A 2018 World Health Organization report estimated that 15 million infants were born preterm with country rates ranging from 5% to 18%.1 In the United States, the 2017 preterm birth rate rose to a 3-year high of 9.93%, with late preterm births (34-36 completed weeks of gestation), accounting for the largest number.1 Many infant survivors of the newborn intensive care unit (NICU) face a variety of long-term health consequences related to their early birth including oral feeding issues.2–4 Oral feeding issues are thought to evolve from the exposure of the preterm infant's developing suck-swallow-breathing reflexes to the negative sensory experiences in the NICU, including intubation, nasal or oral feeding tubes, and poorly timed oral feeding experiences.5
Achievement of oral feeding is a major determinant of discharge2–4 and is often the cause for increased length of stay (LOS). Oral feeding advancement in many NICUs is volume driven, following a medical model in which the clinician determines the timing and amount of oral feeding an infant must consume.6 Prior research found that initiating feedings at a later gestational age7 and increasing oral feeding opportunities7–9 resulted in a more rapid transition to full oral feedings and a decrease in the LOS. However, accumulating evidence suggests that there is great variation between and within NICUs in the initiation and advancement of oral feeding.6,10,11 This variation may lead to delayed discharge as well as oral aversion and postdischarge feeding problems.2,3,5,6 With the focus on neuroprotection for preterm infants, there is renewed motivation to reduce the stressful experiences that may lead to the development of altered feeding pathways in the brain. This evidence-based brief reviewed research related to the Infant-Driven Feeding (IDF) method for the preterm infant.
To address the clinical question: Does the use of an IDF method positively affect the gestational age at initiation of oral feedings, length of time to achieve full feedings, and LOS in the NICU or level II nursery for preterm infants?
The literature was searched using 4 databases including CINAHL, Medline/PubMed, Ovid Nursing, and Embase. The search strategy included the following terms: “infant guided feedings” ab,ti OR “infant driven feeding” ab,ti OR “cue based feeding” ab,ti OR “co regulated feeding” ab,ti OR “coregulated feeding.” The use of ab,ti allowed for the search of terms in abstracts and journal titles. In addition, the reference sections of studies were reviewed to identify any other articles related to cue-based feeding research. The search was limited to English, research within the past 10 years (2008-2018). The inclusion criteria included research studies evaluating the effects of oral feeding advancement and LOS. Conference abstracts and studies that did not answer the clinical question were excluded.
The search yielded 32 reports with no randomized control, quasiexperimental, or retrospective studies utilizing a comprehensive feeding assessment method. The results included a conference abstract describing the use of the IDF method with 35-week gestation breastfeeding infants, clinician guidelines for cue-based transition to oral feeding, cue-based feeding research reviews,16–18 descriptions of the theoretical basis for cue-based feedings,15 and descriptions of implementation of IDF or cue-based feedings.19 Articles identified from reference sections of articles in the search included 3 observational studies, which amended the IDF scales to assess bronchopulmonary dysplasia20 and to test the predictive ability of the IDF method to identify infants who would be at risk for delayed oral feeding independency.21,22 These reports were not included in this review, as they did not answer the proposed clinical question.
There were 3 quality improvement projects that implemented the IDF method and the consistent outcomes measured included gestational age at first oral feeding, time from first to full oral feedings, and LOS.23–25 The findings for this brief include the quality improvement reports that evaluated the IDF method.
Infant-Driven Feeding Description
All reviewed articles evaluated the IDF method. This method is composed of 3 assessments including feeding readiness, quality, and caregiver support.11 Each assessment includes 5 categories, with feeding readiness and quality arranged by the numbers 1 to 5, and caregiver support arranged by letters A through E.11 These categories are intended as a method of communication among caregivers.11
Although each infant matures at a different rate, previous research suggests that the ability to coordinate the necessary reflexes, suck, swallow, and breath commences at 33 weeks' gestation.2–5 Therefore, this feeding method initiates an assessment of feeding readiness beginning at 33 weeks' gestation and continues the assessment prior to each feeding experience. Once the infant begins to orally feed, the clinician assesses the infant utilizing the quality of feeding assessment and the type of caregiver supports needed for a safe feeding experience.11 The psychometric testing of the IDF method is limited to 1 validation study utilizing the Delphi method.26 However, there is evidence that supports the readiness behaviors,10–12 quality of feeding,12,13 and caregiver supports.13–15 Throughout this article, the IDF scales are referred to as assessments or methods due to the paucity of psychometric testing.6,19,20
The 3 quality improvement projects compared the IDF method with traditional feeding practices and described the IDF method implementation a culture change.23–25 The process of educating nurses and other clinicians included education,23–25 online education,25 small group in-services,23–25 and refresher days along with multidisciplinary team meetings and daily check-ins with nursing staff.23–25 In addition, guidance for bedside nurses included an algorithm,24 a feeding assessment flow sheet,23 and items imbedded into the electronic flow sheet.25 Baseline data or historical controls were utilized to compare group outcomes including age at initiation of oral feedings, length of time to achieve full oral feedings, and LOS.
Three quality improvement projects (Table 1) utilized the IDF method, 2 projects with preterm infants born before 34 weeks' gestation23,24 and 1 with infants born at or greater than 30 weeks' gestation.25 The 2 projects with participants born less than 34 weeks' gestation reported no significant findings for the gestational age at the initiation of oral feedings in either study.23,24 One project evaluated the IDF method with preterm, full-term critically ill infants, infants requiring surgery.25
TABLE 1. -
Infant-Driven Feeding Quality Improvement Projects
|Wellington and Perlman23
||Quality improvement with case review and clinician survey
Infants born ≤34-wk gestation (153 control and 101 intervention)
3 groups: <28 wk, 28-32 wk, and >32 wk
Protocol: Implemented IDF protocol for RNs and MDs
DOL at first and full NF, LOS
First NF—No difference
Full NF—All significant:
<28 PMA P = .03
28-32 PMA P = .001
>32 PMA P = .004
28-32 PMA P = .001
>32 PMA P = .048
<28 PMA no difference
|Historical controls, observational, limited generalizability
|Gelfer and McCarthy24
born at ≥30-wk
guideline in 3
phases for RNs,
MDs, OTs, LCs
DOL at first and full NF, LOS
First NF—No difference
Full NF-No difference
Compliance to protocol not measured
|Chrupcala et al25
Sample: 150 infants with PMA
guideline in 3
phases for RNs,
MDs, OTs, LCs
DOL at first and full NF, LOS
Full NF—No difference
Compliance to protocol not measured
Abbreviations: DOL, day of life; IDF, Infant-Driven Feeding; LOS, length of stay; NF, nipple feedings; PMA, postmenstrual age.
Wellington and Perlman23 delineated their sample into postmenstrual age (PMA) birth categories including less than 28 weeks, 28 to 32 weeks, and more than 32 weeks. The implementation of the IDF method occurred over 3 phases: baseline, phasing in, and monitoring. Retrospectively, 153 preterm infant records were reviewed for the provider-driven feeding (PDF) arm, and 125 infants for the IDF arm. The PMA of all infants in the IDF group was higher and the birth weight for IDF infants born at less than 28 weeks' PMA was higher (P = .01). No difference was found in the remaining clinical characteristics including gender, race, delivery mode, antenatal steroids, patent ductus arteriosus ligation, surfactant, and mechanical ventilation.
There was no difference noted in the PMA for first oral feeding in either the PDF or IDF groups. The achievement of full oral feedings was significant for all infants in the IDF group. The LOS for the IDF group was shorter for infants with PMA at or above 28 weeks. Multivariable linear regression results revealed that the IDF method remained significantly associated with earlier attainment of full nipple feeding and earlier discharge with for infants with PMA at or above 28 weeks. These findings suggest that the IDF method reduces time to full oral feedings and reduces LOS with infants born with PMA at or above 28 weeks.
Gelfer and McCarthy24 implemented the IDF method and assessed the effects on healthy preterm infants born at greater than 30 weeks' gestation. A total of 124 (n = 64 pre- and 60 postintervention) infants were compared. The IDF intervention did not influence the age at the initiation of oral feedings or LOS. Infants in the IDF group did achieve ad libitum feedings earlier (P = .08) without compromising weight gain.
Chrupcala et al25 explored the use of the IDF method with infants in a level IV NICU that specializes in care of critically ill newborns, infants with complex medical and surgical issues as well as local, national, and international referrals. They amended their electronic medical record to include the items related to the assessment of readiness and quality of feedings as well as caregiver techniques. The LOS comparison suggests a decrease in total LOS by 6.63 days. This report demonstrates that the IDF method may be applicable for all infant populations.
Synthesis of Projects
The 3 quality improvement projects in this review found contrasting results with the use of the IDF method. The age at initiation of oral feedings was not found to be statistically significant in any project. The LOS decreased in 2 reports. In addition, 1 study found achievement of ad libitum feedings earlier than the comparison group.
There is conflicting evidence, as described earlier, to answer the clinical question: Does the IDF method positively impact preterm infant feeding outcomes? However, there is empirical support for each scale. The 2013 NANN position statement on Infant-Directed Oral Feeding for Premature and Critically Ill Hospitalized Infants28 is consistent with the research supporting the IDF method. In addition, 1 study included in this review reported that the number of observed feeding readiness behaviors predicted increased feeding success, leading to a more rapid advancement to independent oral feeding.12 The intervention group in another feeding readiness study removed the indwelling feeding tube when infants demonstrated feeding readiness behaviors. The intervention group infants were found to have achieved independent oral feeding earlier and discharged home sooner, with no difference in weight gain for both groups.9 The IDF Readiness scale is composed of behaviors described in the above 2 studies.11
The Quality of Feeding scale describes the preterm infant's skill in coordinating the suck-swallow-breathing- reflexes necessary for independent oral feeding. A nonrandomized control trial compared pacing as a treatment technique to support the development of more efficient sucking patterns in 18 control and 18 experimental preterm infants. Their findings suggest that paced infants demonstrated statistically and clinically significant decreases in bradycardic episodes and had more efficient sucking patterns at discharge.14 A randomized experimental design was utilized to test the effects of 4 different approaches to oral feeding progression. Preterm infants were randomized into 4 groups, early start (32 weeks)/slow progressing experience (gradually increasing daily oral feeding), early start (32 weeks)/maximum experience (oral feeds offered at every feeding), late start (34 weeks)/slow progressing (gradually increasing daily oral feeding), and late start (34 weeks)/maximum experience (oral feeds offered at every feeding). Once oral feedings were initiated, infants in the late start-maximum experience achieved independent oral feedings sooner and were discharged home significantly sooner than the other groups. This study suggests that initiation of oral feedings at a later gestational age may lead to a rapid transition to independent oral feedings.7 The IDF Quality of Feeding categories delineate the development and coordination of suck, swallow, and breathing behaviors as described in the research earlier.
The IDF Caregiver Techniques scale describes actions that caregivers can utilize to support an infant during an oral feeding. Positioning,15 external pacing,14 specialty nipples, frequent burping, and chin support have been found to aid the preterm infant achieve independent oral feedings. Collectively, the research described earlier supports the validity of the IDF method.
Recommendations for Practice
Each project described the implementation of the IDF method as a culture change in their NICU. A multidisciplinary team of clinicians with dedicated champions was utilized by each unit and found to be a successful strategy to continue the momentum of this culture change. In addition, including parents in the feeding readiness assessment and quality of feeding created a learning opportunity that enabled parents to feel more successful feeding their infant.
Recommendations for Research
Emerging evidence suggests that consistent oral feeding assessments may improve the preterm infant's progression from gavage to full oral feeding and reduce the LOS.23–25 However, there is a lack of psychometrically tested feeding assessment tools.26,27 Many of the tools in the literature focus on 1 aspect of the feeding progression from gavage to full oral feeding. A comprehensive feeding assessment method that is psychometrically validated is needed to facilitate feeding progression for preterm infants. Given that there were no randomized control, quasi-experimental, or retrospective research studies utilizing the IDF feeding method, further research is necessary to evaluate the applicability of the IDF method. Longitudinal studies are needed to investigate the long-term benefits of the IDF method. There is concern regarding the potential crossover of the intervention if randomization occurs in the same unit. One option to overcome this concern is to randomize infants in 2 units, 1 that provides the cue-based feeding method and 1 that does not.
There were no randomized or quasiexperimental research studies located evaluating a the IDF feeding method. All 3 quality improvement studies reviewed for this evidence-based practice brief reported conflicting results regarding age at initiation of first oral feeding and LOS. With the current information, we are unable to determine whether the IDF positively benefits the preterm infant. Further research is needed to validate the IDF method.
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