Cue-Based Feeding in the NICU

To Feed or Not to Feed?

When Should Feeding Stop???

lead to....maladaptive feeding behaviours, feeding refusals and food aversions

feeding skills dictated by neural maturation

Cue-Based Feeding

in the NICU

Premature Infants and the NICU

Feeding Premature Infants

- 8% of children born in Canada are premature --> less than 37 weeks gestation

- Neuromuscular and gastrointestinal systems not mature for oral feeds

-Nasal-gastrointestinal tube implemented

- Challenges when transitioning from tube to oral feeding

- Delayed in transition--> delay discharge and parent interaction

- NICU --> Developmentally Supportive Care

- Large OT role is in feeding

- oral motor skills

- parent-infant relationships

- behavioural and physiological cues

Kirk et al. (2007)

McCormick et al. (2010)

- 3 out of 8 RCTs = time to establish full oral feed after randomization

2 = Ad Libitum Feeding vs. Scheduled Feeding

1= Demand Feeding vs. Scheduled Feeding

Assessed risk of bias--> Cochrane Neonatal Review Group Tool

Demand Feeding

Ad Libitum Feeding

- infant fed orally in response to hunger cues

- ceased when satiation cues demonstrated

- fed according to hunger cues; if did not demonstrate cues within five hours of last feed, aroused and fed

- ceased when prescribed volume reached

- retrospective control group

- clinical pathway for progression from tube to oral feeds --> at discretion of nurse

- signs of stress monitored

- OT consulted if displaying stress or delay in oral feeding progress

McCormick et al. (2010)

Kirk et al. (2007)

Ad Libitum - dec. by 2 days; no data

- statistically and clinically significant decrease by 6 days from entry to pathway

- confounding variables assessed --> no stat. sig. between groups

- due to overall cue-based mentality, not particular protocol

Demand - dec. by 5 days; pacifier to assess

What Does This Mean?

Strengths

Limitations

McCormick et al. (2010)

Kirk et al. (2007)

McCormick et al. (2010)

- retrospective control group; unidentified differences in care

- some studies did not include quantitative data

- included infants of all past medical histories

- comprehensive review of highest level of evidence

* stage of transition from tube to oral feeding at enrollment of intervention differed *

- some data demonstrating cue-based feeding is effective at attaining full oral feeding

- takes less time to attain full oral feed compared to schedule feeds

Future Directions

Application

Why do you think this is????

- longitudinal studies --> effects on feeding behaviours at 18-24 months

- protocols using same assessments/outcome measures to ensure objectivity

- qualitative studies --> family satisfaction and parent competence

You are an OT working in the NICU. You've heard about cue-based feeding being implemented in other NICUs across Canada. Hesitating to feed infants when they are not showing they are hungry, however physician wants scheduled feedings adhered to.

Decisional Balance--> pros and cons

As an OT, what are some considerations when beginning to implement this protocol?

*HINT*: think communication

Aune Hjartarson- McMaster

Back to Agenda....

Implications for OT and Take Home Messages

1. Understand feeding skills for premature infants

2. Understand historical feeding protocol and cue-based protocol in the NICU

3. Appraisal of evidence

4. Application of cue-based feeding for OT

5. Acknowledge future research needs

6. Take home messages

7. Discussion

- developmentally supportive care --> not about the numbers

- communication is key --> culture change doesn't happen over night

- taking babies current medical state, their hunger cues, and stress cues into consideration during feed

Discussion

Do you believe that this way of feeding aligns with OT values?

With limited quantitative data about protocols that have been implemented, should we still be using it?

Feeding Protocol

The Search

Inclusion Criteria

Exclusion Criteria

- random feeds

- specific cue-based protocol

- premature infant

- scheduled feeds

- any cue-based protocol

- peer reviewed

Searchable Question

Duplicates and titles not pertaining to research question excluded

National Clearing House

Dynamed

Cochrane Summaries

MEDLINE

CINAHL

- influence on attachment as better understanding of how to respond to cues

- no articles measuring this outcome

Full Oral Feeding

- sounds intuitive to respond to cues, but still effective for oral feeding skills???

- implications for discharge home and parent-child interaction

- uncertainty--> attain at same time, earlier or later compared to scheduled feeding?

Limits: English, human, date 2000-present

= combined 106 results

= 10 combined results

1 systematic review and 1 case-control study

In premature infants within the NICU, what is the effectiveness of cue-based feeding when compared to scheduled feeding on attaining full oral feeds?

P: premature infant

I: cue-based feeding

C: scheduled feeding

O: full oral feeds

Agenda

1. Understand feeding skills for premature infants

2. Understand historical feeding protocol and cue-based protocol in the NICU

3. Appraisal of evidence

4. Application of cue-based feeding for OT

5. Acknowledge future research needs

6. Take home messages

7. Discussion