A new feeding practice could become the standard of care in other neonatal ICUs

If you visit an American neonatal intensive care unit (NICU), you will likely see a ward governed by strict routine. Nurses look after preterm babies (born at less than 37 weeks gestation) by ministering care at prescribed intervals. Even the feedings will be given, like clockwork, every three hours exactly.

However, according to Ani Jacob, DNP, clinical assistant professor in the College of Nursing and Public Health, this approach to preterm infant care does not reflect the latest research. Feeding preterm infants on a rigid schedule inevitably means babies must sometimes feed when they aren’t ready and therefore experience stress, which initial research indicates is associated with negative stress-related symptoms.

To see just how much the prevailing feeding practice was adversely affecting babies, a healthcare team including Dr. Jacob implemented a new practice at a hospital in Manhasset, New York. “Instead of feeding preterm infants at scheduled times or prescribed intervals, it’s important to feed them based on the signs and cues the infants show that indicate they’re hungry and ready to feed,” she said. She shared the benefits of this approach in an evidence-based practice project of cue-based feeding in the hospital’s NICU, published as “Implementation of Cue-Based Feeding to Improve Preterm Infant Feeding Outcomes and Promote Parents’ Involvement” (Journal of Obstetric, Gynecologic & Neonatal Nursing, May 2021).1

Preterm infants, Dr. Jacob explained, exhibit several cues that indicate they want to be fed. Some are visual: “First, the baby must be awake. Second, they should turn their head when you touch their cheek. And, third, if you put a nipple near the baby’s mouth, they should open their mouth to suck.” But vital signs are equally crucial cues, and ignoring them can have serious health consequences for a preterm infant. “If you feed babies when they aren’t ready,” she emphasized, “they may become stressed. Stress can elevate their heart rate, increase their rate of respirations and affect their level of oxygen saturation. If we continue to feed despite these stress signals, the baby may need to be rescued, which often involves more invasive—and more costly—procedures.”

When Dr. Jacob and her team implemented a cue-based feeding approach in the hospital’s NICU as part of their project, they found positive results across the board. “After changing our feeding practice, the babies exhibited fewer stress symptoms when feeding. The babies’ length of stay in the NICU also decreased because the reduction in stress led to better outcomes. So, while improving the level of care we delivered, we simultaneously lowered the average total cost of NICU care.”

The shift also led to another improvement that surprised Dr. Jacob and her team: Parents started to feel more comfortable caring for their babies. “Usually, parents are afraid of feeding preterm babies because these infants are so small and usually have compromised respiratory systems,” she said. “We taught parents to look for cues of feeding readiness by giving them handouts and encouraging them to identify when they think their baby is ready to eat. At the end of the project implementation, they were more comfortable caring for preterm babies because they felt they could interpret their baby’s cues at home.”

Now that their hospital has adopted cue-based feeding, Dr. Jacob and her team hope that the practice will become the standard of care in NICUs elsewhere. More importantly, though, the project imparted a broader lesson she believes all healthcare workers would do well to heed.

“Too often in this field, we continue to provide care one way because that’s the way we were taught and know, instead of evidence-based care for better outcomes,” she concluded. “That’s a big problem. Instead, we should be looking for the best evidence that is out there, and then change our practice as we’ve done with cue-based feeding.”


1 Thomas, Tesi, and Rebecca Goodman, Ani Jacob, and Deborah Grabher. “Implementation of Cue-Based Feeding to Improve Preterm Infant Feeding Outcomes and Promote Parents’ Involvement.” Journal of Obstetric, Gynecologic & Neonatal Nursing, vol. 50, iss. 3, 1 May 2021, pp. 328-339.

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