Received: 15 August 2016 Revised: 16 January 2017 Accepted: 16 January 2017

DOI 10.1111/jep.12721

ORIGINAL ARTICLE

Clinicians guide for cue‐based transition to oral feeding in

preterm infants: An easy‐to‐use clinical guide
Welma Lubbe PhD, MTech, BCur Honours, B Soc Sc

Associate Professor, School of Nursing

Science, INSINQ, North‐West University Abstract
(Potchefstroom Campus), South Africa
Rationale, aims and objectives This article aims to provide evidence to guide multidisci-
Correspondence plinary clinical practitioners towards successful initiation and long‐term maintenance of oral feed-
Welma Lubbe, School of Nursing Science, 22
Hoffman Street, Potchefstroom 2520, North ing in preterm infants, directed by the individual infant maturity.
West, South Africa. Method A comprehensive review of primary research, explorative work, existing guidelines,
Email: [email protected]
and evidence‐based opinions regarding the transition to oral feeding in preterm infants was stud-
ied to compile this document.

Results Current clinical hospital practices are described and challenged and the principles of
cue‐based feeding are explored. “Traditional” feeding regimes use criteria, such as the infant’s
weight, gestational age and being free of illness, and even caregiver intuition to initiate or delay
oral feeding. However, these criteria could compromise the infant and increase anxiety levels
and frustration for parents and caregivers. Cue‐based feeding, opposed to volume‐driven feeding,
lead to improved feeding success, including increased weight gain, shorter hospital stay, fewer
adverse events, without increasing staff workload while simultaneously improving parents’ skills
regarding infant feeding. Although research is available on cue‐based feeding, an easy‐to‐use clin-
ical guide for practitioners could not be found. A cue‐based infant feeding regime, for clinical
decision making on providing opportunities to support feeding success in preterm infants, is pro-
vided in this article as a framework for clinical reasoning.

Conclusions Cue‐based feeding of preterm infants requires care providers who are trained in
and sensitive to infant cues, to ensure optimal feeding success. An easy‐to‐use clinical guideline is
presented for implementation by multidisciplinary team members. This evidence‐based guideline
aims to improve feeding outcomes for the newborn infant and to facilitate the tasks of nurses and
caregivers.

KEY W ORDS

clinical guidelines, evidence‐based medicine, patient‐centered care, practical reasoning

1 | I N T RO D U CT I O N Attaining full oral feeding is an important milestone for preterm

infants, since it is a major discharge criterion indicating maturity1–4
The aim of this paper is to discuss the evidence underlying the and health of the preterm infant.5 However, the acquisition of safe
initiation and successful maintenance of oral feeding in preterm and efficient nipple feeding skills is a complex task and 1 of the most
infants based on infant feeding cues. This includes physiological and challenging milestones for most preterm or high‐risk infants to
developmental factors to be considered in the management of infant achieve,1,6 Preterm infants are especially at risk of feeding failure.
feeding, as well as practical (clinical) aspects of feeding advancement When compared to full term infants, preterm infants’ transition to full
towards full oral feeding, while considering nutritional needs, oral feeds are complicated by innate differences in muscle tone, state
without elaborating on nutritional requirements. The latter falls regulation, endurance, and independent or interdependent suck‐swal-
beyond the scope of this article, since it focuses on the “how and low‐breathe coordination.7,8 Prematurity can further disrupt brain
when” of oral feeding. development, leading to decreased myelination and white matter

J Eval Clin Pract. 2017;1–9. wileyonlinelibrary.com/journal/jep © 2017 John Wiley & Sons, Ltd. 1
2 LUBBE

disturbances9 as well as disrupting the development of a specialized Google‐indexed scientific literature. Combinations of the following
neural circuit known as the suck central pattern generator (sCPG), keywords were used: cue‐based, feeding, newborn, neonate, infant,
often resulting in poor feeding skills.10 In addition, preterm infants preterm, ad‐libitum, demand‐feeding, semi‐demand, volume‐driven,
have higher nutritional requirements per kilogram than term infants oral, gavage, and transition. Only human studies addressing the key-
and are less tolerant of high fluid volumes.11 words and providing evidence to guide cue‐based feeding in preterm
Feeding challenges place these vulnerable infants at risk for infants were considered, including both original studies and reviews
prolonged hospitalization and readmissions after discharge.12 Poor published between 2000 and 2016. Official and national documents
feeding is a common reason for readmission to hospital within 2 weeks were included for review on the basis of their relevance to the review
after neonatal intensive care unit (NICU) discharge, especially in infants question. Documents published prior to 2000 were excluded, as well
born between 34 and 37 weeks postconceptual age. These late pre- as documents in languages other than English and Afrikaans, which
term infants are more prone to poor oral feeding because of medical did not address cue‐based feeding or preterm infant feeding
issues, such as respiratory distress, jaundice, hypoglycaemia, and tem- transition.
perature instability.13 Respiratory distress can be highlighted as a chal- Data were extracted from the selected documents and analysed
lenging condition influencing feeding, as preterm infants often using a thematic analysis approach of the recommendations made in
experience physiological instability and need assistance from care- the selected documents.
givers to maintain adequate oxygenation during the time when their
oral feeding skills are developing. This assistance towards optimal oxy-
genation during oral feeding requires an understanding of how the
2.1 | Discussion on current feeding regimes
14
infant expresses and aims to self‐regulate his or her oxygen status. Feeding regimes for the advancement from tube to oral feeds that are
Therefore a skilled and observant caregiver is essential to assist the followed and described in the literature are often inconsistent and con-
infant in a pleasurable feeding experience that maximizes intake and tradictory among clinicians and even NICUs and are based on custom
minimizes stress,7,14 rather than evidence.8,16 These regimes can be explained as either
Apart from acquiring physical skills towards oral feeding, nutri- quantitative or subjective approaches towards feeding. Within the
tional status needs to be considered as a parallel rather than an iso- quantitative regimes, gestational age and weight is the criteria relied
lated process. Nutritional status is important to prevent growth upon for the initiation of oral feedings,8 and weight gain is the main
restriction which in turn impacts on the physiological development indicator of infant feeding success, and as a result volume‐driven
influencing behavioural maturation that is important for oral feeding regimes, which allow for the measurement of nutritional intake, are
success. According to Hay,15 numerous studies have shown that a often standard practice for preterm infant feeding.17
deficiency in protein at critical stages of the development process Volume‐driven regimes implicate strictly scheduled interval
produces long‐term short stature, organ growth failure, and neuronal feeds.15,18 In addition, quantitative regimes include formal criteria to
deficits. It furthermore influences later behavioural and cognitive initiate feedings on the basis of criteria such as infant weight and/or
outcomes.15 When striving to ensure good nutritional status by post conceptual age,1,8,13,19 being free of illness,19 and emptying the
means of volume‐driven regimes, the risk emerges to overfeed the bottle; all opposed to considering infant development.20 For this rea-
infant. son, bottle or cup feeding was introduced as precursor for
Overfeeding also has a definite potential towards later complica- breastfeeding, since the volume taken could be measured, resulting
tions, since it has the potential to produce adipose tissue, or obesity, in measurable nutritional intakes judged to be sufficient to achieve a
which then leads to insulin resistance, glucose intolerance, and diabe- postnatal growth rate approximating that of the normal fetus of the
tes.15 Optimal nutrition is therefore important for successful oral feed- same gestational age.15 These criteria have, however, shown to com-
ing to prevent challenges associated with feeding failure. It is clear that promise the infant and increase levels of anxiety and frustration for
quantitative and subjective approaches towards the initiation of oral parents and caregivers.19,21
feeding in preterm infants do not incorporate infant skill, maturity, Subjective approaches, on the other hand, include caregiver intui-
and abilities. Therefore, a need was identified to explore the evidence tion,8 physician orders, or a “light‐bulb phenomena” where the infant
to support a good clinical regime to guide the transition to the oral all of a sudden “figures out” how to feed successfully.18 The
feeding process on the basis of the infant’s maturity and abilities, while approaches described above do not consider the energy expenditure
providing the caregiver with measurable milestones to progress associated with the physical actions involved in bottle‐feeding and
through the transition process. scheduled processes, leading to energy needs that are higher than
the fetal growth rate. Research indicates that bottle‐fed preterm
infants experience a significantly higher level of physical distress
2 | METHOD (based on the stress cues observed during feeding) than breastfed pre-
term infants,22 indicating that bottle feeding actually uses more energy
This narrative review was developed from primary research, explor- and present more physiological challenges.4
ative work, existing guidelines, and evidence‐based opinion. Publica- Cup feeding is another mode often recommended for preterm
tions were searched using electronic databases and websites, hand infants to precede breastfeeding and to align with baby‐friendly prac-
searching relevant journals, and contacting experts. The databases tices aiming to prevent the introduction of artificial nipples. During
searched included Embase, Medline and PubMed databases, and cup feeding, premature infants are physiologically more stable, with
LUBBE 3

lower heart rates, higher oxygen saturation levels, and fewer observation of and response to infant behaviour cues to regulate fre-
desaturations, than during bottle feeding. However, according to a quency, duration, and volume of oral feedings.”27 Thoyre et al (2013)
study by Marinelli et al,23
cup fed infants take less volume over a lon- defines cue‐based feeding as “maintain[ing] the goal to optimize the
ger time, than bottle‐fed infants for these initial feedings. On the basis feeding through assessment of infant cues.”28 Cue‐based feeding
of the better physiologic stability and no difference in untoward includes a variety of benefits for the preterm infant:
effects, cup feeding is regarded as safe, if not safer, than bottle feed-
ing. This study supports the use of cup feeding as a safe alternative 2.3.1 | Earlier transition to oral feeding
feeding method for premature infants learning to breastfeed.23 On Kirk et al 29
and McCain et al30 found that cue‐based and semidemand
the other hand, Dowling et al24 found that although infants remain fed infants reached full oral feedings 6 and 5 days earlier, respec-
physiologically stable, cup feeding has questionable efficacy and effi- tively, than infants transitioning to full oral feeds based on physicians’
ciency, since differentiating between actual intake and spillage of milk orders.
merits attention.24 Alternative feeding measures such as bottle and
cup feeding can easily lead to infants being force‐fed with negative
2.3.2 | Length of stay
impacts on physiological stability if feedings are not administered by
A significantly shorter hospital stay is evident in infants who received
a skilled person, or if the infant’s level of maturity to handle this burden
cue‐based feeding. Kirk et al showed a 4.5 day decrease, while other
of feeding skills is not considered.
authors reported a shorter duration of hospitalisation,13,17
Because of the short‐term volume success, many medical insur-
ance companies regard these “force‐fed” infants as able to oral feed
sooner on bottles but do not consider the sustainability and inability 2.3.3 | Fewer adverse events
29
to keep up the successful feeding when the infant is not yet mature Kirk et al showed a decrease of 9 adverse events when infants
enough. In addition, these approaches did not consider longer‐term received cue‐based feeding opposed to feeding on the basis of physi-
outcomes, such as feeding success after NICU discharge and the devel- cians’ orders and this decrease in adverse events was also reported by
opment of neurological maturity. These findings support the impor- Puckett et al.19
tance of enhancing care provider sensitivity with regard to
behavioural‐cue observation.22 2.3.4 | Behavioural maturity
On a neuro‐behavioural level, the infant who receives cue‐based feed-
ing elicit 2.8 more cues per feed29 and demand‐fed infants exhibited
2.2 | Results (Literature review supporting cue‐based
more hunger cues and had improved behaviour state organization,
feeding)
indicating a higher level of neurological maturity.13 Furthermore, this
Maturity at the first oral feed and experience in feeding seem to be infant‐led approach towards feeding allowed the infant to develop
important factors influencing oral feeding success. Pickler et al25 more efficient sucking patterns by discharge from hospital,31 since
found that the duration of the infant’s hospitalisation from the start experience with earlier oral feeding led to enhanced maturation and
of oral feedings until discharge was predicted by maturity at the first improved oral feeding success.8
oral feeding and that positive feeding experiences contributed
towards a more rapid transition to oral feeding regardless of the 2.3.5 | Improved physiological outcome
severity of illness.25 Furthermore, cue‐based feeding, opposed to
In support of the neurological improvement observed in cue‐based
volume‐driven feeding, lead to increased weight gain, shorter
feeding, these infants also benefited on a physiological level, since they
hospitalisation, fewer adverse events, and contrary to opinions, does
demonstrated a statistical and clinically significant decrease in
not increase staff workload while improving parenting skills with
bradycardiac incidences during feeding and pacing in NICU care prac-
regard to feeding.19
tices which appeared to be beneficial for preterm infants with respira-
The ability of a preterm infant to transition from gavage to oral
tory disease.31
feeds depends on a variety of “neurodevelopment” factors. These fac-
tors include the infant’s behavioural organization, a rhythmic, coordi-
2.3.6 | Increased nutrient intake
nated suck‐swallow‐breathe pattern and cardiorespiratory
McCormick et al17 stated that cue‐based feeding improved infants’
regulation.1,4,21 Gorski et al classified preterm infant development in
nutrient intake and some researchers reported an increase in weight
3 developmental stages: turning‐in, coming‐out, and reciprocity,26
gain during cue‐based feeding13 or at least at the same rate as infants
and only once the infant reached reciprocity will he or she be able to
fed with quantitative approaches.13,17,29–31
show signs (cues) of neurological maturity to support successful oral
feeding.
2.3.7 | No additional workload
An important factor to consider when motivating for the implementa-
2.3 | Cue‐based feeding
tion of cue‐based feeding is that it does not affect the workload.29
“Cue‐based feeding is a method that combines the use of non‐nutritive The literature provides sufficient evidence to support a cue‐based
sucking (NNS) to promote awake behaviour for feeding, use of behav- approach towards the transition of preterm infants from oral to tube
ioural assessment to identify readiness for feeding, and systematic feeding, and Table 1 provides a summary of this evidence.
4 LUBBE

TABLE 1 Summary of evidence to support nonnutritive sucking and positive oral stimulation, including nonnutritive sucking, determining
cue‐based feeding readiness to transition, the actual transition regime and sustaining suc-
Benefits of NNS Evidence cessful feeding after discharge.
41
Physiological stability Pinelli & Symington, 2005
Protects against aspiration Ludwig, 20077 2.5 | Preparing the gut
10
Increased absorption of feeds Barlow et al, 2008
Foster et al, 201644
Trophic feedings (small volume of feeds given at the same rate for at

Facilitates development Foster et al, 2016 44 least 5 days) during parenteral nutrition provide a strategy to enhance
of sucking behaviour the feeding tolerance and decrease the side effects of parenteral nutri-
Faster transition from Pinelli & Symington, 2005 41
tion and decrease the time required to achieve full feeding.33 At the
tube to oral feeds Bingham et al, 201045
same time, positive oral stimulation should be provided.
Greene et al, 201334
Bache et al, 201443
Engebretson & Wardell, 199748
2.6 | Positive oral stimulation
Greater weight gain (lead Bingham et al, 201045
to earlier discharge) Greene et al, 201334 Oral stimulation can have either a negative or positive influence on
Foster et al, 201644
Engebretson & Wardell, 199748 feeding success.32 The use of oral stimulation shows promise to
Soothing and self‐consolation Pinelli & Symington, 200541 improve nutritive sucking,2 however, more research is required to
Jenik & Vain, 200946 direct the multidisciplinary team in this regard.34 Preterm infants are
Improve muscle tone and Ludwig, 20077 exposed to noxious stimuli in the NICU and especially negative olfac-
coordination
tory stimulation is provided by strong alcohol hand rub, perfumes,
Promote awake behaviour McCain et al, 200130
before oral feeding Engebretson & Wardell, 199748 and other cleaning detergents. These negative stimuli may contribute
to feeding problems such as feeding aversion.35,36
Benefits of cue‐based feeding Evidence Positive oral stimulation can however be provided by providing
Earlier transition to oral Kirk et al, 2007 52 positive smells and taste to the preterm infant. The best way to pro-
feeding (up to 5 days) McCain et al, 200130 vide positive stimulation is by allowing mothers (and fathers) to keep
Pickler et al, 20154
the infant in skin‐to‐skin contact as often and as long as possible.37,32
Shorter length of stay Crosson & Pickler, 200413
McCormick et al, 201017 Skin‐to‐skin care should begin as soon as the baby is stable and has
Puckett et al, 200819 improved hemodynamic stability without increasing energy expendi-
Pickler et al, 20154
ture.11 Skin‐to‐skin care furthermore contributes to shaping the
19
Fewer adverse events Puckett et al, 2008
sleep‐wake cycle, as well as maturation of the autonomic nervous sys-
Kirk et al, 200752
13 tem, and improves maternal‐infant bonding and pain response.38
Behavioural maturity Crosson & Pickler, 2004
Kirk et al, 200752 In the instance of parent‐infant separation, positive smells should
Law‐Morstatt et al, 200331 be provided by putting a cotton wool or cloth with a few drops of
Thoyre et al, 201653
mother’s milk next to the infant in the incubator,39 providing a bonding
Improved physiological Law‐Morstatt et al, 200331
outcome Thoyre et al, 201653 blanket, which can be a baby blanket with which the mother had slept
Increased nutrient intake Crosson & Pickler, 200413 and is placed next to the infant in her incubator or crib.40 A drop of
McCormick et al, 2010 breast milk could in addition be placed in the infants mouth.37
McCain et al, 200130
Kirk et al, 200752 If preterm infants are not exposed to sucking opportunities, they
Law‐Morstatt et al, 200331 run the risk of losing the sucking reflex.4 Sucking opportunities should
Increased weight gain Puckett et al, 200819 be provided by means of the infant’s hands, thumb, or preferably the
Fewer adverse events Puckett et al, 200819 mother’s expressed breast or a suitable pacifier.37,41 Sucking on the
17
No additional workload McCormick et al, 2010 expressed maternal breast allows the infant to get used to the feeling,
Kirk et al, 200752
Puckett et al, 200819 taste, and smell of the breast under conditions where the infant is not
hungry. The baby should be placed in the skin‐to‐skin position
between the mother’s breasts and not necessarily positioned over
The conclusion can be drawn that feeding of preterm infants in the nipple.37,42 When ready, the infant will then lick and suck on the
response to their cues (hunger, satiation, and stress) rather than feed- nipple and be comforted without the need to learn the skill of feeding
ing at scheduled intervals might help to establish successful oral while being hungry.42 Sometimes, a mother is not available and then a
feeding.17,32 pacifier can be used, however Bache et al (2014) found that prefeeding
oral stimulation contributes to improved breastfeeding rates in
preterm infants and should therefore be provided.43
2.4 | Interventions to ensure successful feeding
transition and maintenance 2.7 | Nonnutritive sucking
Transition towards full oral feeding requires a structured process of Nonnutritive sucking (NNS) is used during gavage feeding and in the
activities following on each other: as preparing the gut, providing transition from gavage to oral feeding in preterm infants. The
LUBBE 5

rationale for this intervention is that nonnutritive sucking facilitates 2.9 | Determine readiness for transition from tube to
the development and maturation43 of sucking behaviour and oral feeds
improves digestion of enteral feedings.44 Nonnutritive sucking on
A limited number of instruments indicating individual infant readiness
the expressed breast (mother pumps first and then places the baby
to commence either breast or bottle feeding have been developed.6
to the breast) can be attempted as soon as the baby is extubated
There is currently no evidence to inform clinical practice, with no stud-
and stable with success noted as early as at 28 weeks corrected
ies meeting the inclusion criteria for this review. Research is required in
gestational age.11
this area to establish an evidence base for the clinical utility of
Nonnutritive sucking precedes nutritive sucking and is
implementing the use of an instrument to assess feeding readiness in
characterised by shorter sucking bursts. Nonnutritive sucking is bene-
the preterm infant population.6
ficial to the newborn infant as it contributes to physiological stability,
In determining when a preterm infant is ready for oral feeds differ-
including higher levels of oxygenation and a decreased heart rate. It
ent areas of maturity should be assessed. Feeding maturity is depen-
protects against aspiration, since sucking inhibits swallowing and
dent on neurological maturity which can be accelerated by starting
improves glucose usage because of an increase in insulin secretion.
with human milk feeds immediately after birth and allowing skin‐to‐
Nonnutritive sucking increases absorption of feeds due to an increase
skin care even for the ventilated infant. These 2 interventions contrib-
gastrin secretion, decreased somatostatin secretion, and enhanced
ute to the myelination process of the nervous system resulting in neu-
functioning of the gastro‐intestinal track. Nonnutritive sucking during
rological maturity.35 Some indicators for feeding readiness include
gavage feedings contributes to the faster transition from tube to oral
sucking well on a finger, fist, pacifier or expressed breast, showing
feeds and better bottle feeding outcomes,43,34 due to an acceleration
mouthing activity and the handling of the infant’s own secre-
in maturation and greater weight gain result in earlier discharge from
45,34 tions,1,42,32 The infant should be medically stable,42 although it might
hospital Nonnutritive sucking is beneficial for pain relief, soothing,
still be receiving oxygen supplementation. The infant should have com-
and self‐consolation,46,41 since it increases self‐regulatory state
fortable, stable breathing with no rib retraction or grunting, the resting
modulation with increased levels of alertness and increased duration
breathing rate should be less than 60‐70 breaths per minute,32,29 and
of sleeping and finally improving muscle tone and coordination.
the infant should need less than 40% oxygen. The heart rate should
According to a study by Bingham et al,45 higher nonnutritive sucking
be stable between 120 and 160 beats per minute during caregiving
organization scores predicted a shorter transition to full oral feeds
and holding.1 Sufficient bowel sounds should be audible, and the infant
(P <.05) or 3 days earlier than infants with more chaotic patterns of
should be tolerating 2‐3 hourly tube feeds well,40,32 With regards to
suck bursts. The use of pulse training and pacifier‐activated lullaby
growth, the infant should gain 15 g/kg/day on oral feeds.42
systems were found to significantly increase oral feeding ability with
On the neurological level, the infant’s gestational age should be
infants at 34 weeks’ gestation.2 Opposed to traditional believe,
more than 28‐32 weeks to be able to coordinate sucking, swallowing
pacifiers do not affect breastfeeding in preterm infants.47
and breathing.37 Furthermore, the infant must be able to maintain its
own body temperature outside the incubator or when in skin‐to‐skin
care.1,42The infant is ready for the initiation of oral feeds when it can
2.8 | Choose a pacifier to support sucking maintain a quiet alert state,1,32 is able to relax, and has a bright, healthy
development look.42 The infant should also shows cues for engagement, such as
making a mouthing “ooh” configuration, making eye contact, and mov-
For a pacifier to support preterm infant development, it is important
ing hands to mouth while mouthing. The preterm infant must show
that it should be as close as possible to what the fetus would have
sufficient mouthing, rooting and sucking reflexes, and hunger cues
been using in utero. In infants who are unable to coordinate their
together with waking up for feeds and finally be able to focus on the
suck‐swallow and breathing reflex, a pacifier with an upward angle,
48 food source (Table 2).
similar to the infant’s thumb in utero should be used. When suck‐
swallow and breathing is coordinated, the pacifier should be similar
to the mother’s nipple in size and shape, since this infant should be
starting to feed on the breast.
2.10 | Transition from tube to oral
48
Choose a 1‐piece pacifier made of a tasteless and odourless Assistance from an experienced nurse or lactation consultant to guide
medical grade plastic.48 The nipple of the pacifier should be cylindrical the transition is invaluable. When transitioning from tube to oral feeds,
to support tongue cupping—similar to fetal thumb size in infants less the following approach is suggested. Correct positioning is the first
than 32 weeks or the mother’s nipple size in infants older than step when initiating feeding. The infant should be positioned in a
32 weeks or who are able to coordinate sucking, swallowing, and way to support a flexed orientation around the midline,49,37 and the
breathing. It should have a small bolus at the end of the nipple, and cross‐cradle and football holds seems to be the most suitable for the
the optimal nipple length should reach the ridge between the soft initiation.50,32
48
and hard palate to stimulate the limbic system of the brain. Finally, Select the time of day that the infant is more awake,51,4 and pro-
the mouth shield should be big and soft to stimulate nerve endings vide NNS for 10 minutes before the planned oral feeding, and if the
around the mouth and prevent aspiration 48
and have a “handle” on infant enters a wakeful state,30 then only try to breastfeed once. If it
the shield to provide for hand‐to‐mouth positioning, grasping, self‐ is unsuccessful, try again the following day until the infant can manage
soothing, and midline positioning. the feed. Then continue with 2 oral feeds per day in a sequence of 1
6 LUBBE

TABLE 2 Readiness to initiate transition from tube to oral feeding 2.11 | Assessment during the feed
Readiness to transition from tube Thoyre et al (2013) states that assessment during the feed includes the
to oral feeds Evidence
infant’s ability to (1) sustain attention and energy for the duration of
Neurological maturity Bingham et al, 201045
feeding, (2) control and organize oral‐motor functioning, (3) coordinate
Dodril et al, 200435
McCain et al, 200130 swallowing, and (4) maintain physiologic stability.28
White & Parnell, 201332
Reliance on preterm infant behavioural cues will be insufficient for
Nonnutritive sucking and Pinelli & Symington, 200541
detection of oxygen desaturation during oral feeding, but absence
handling own secretions Holloway, 20141
Cape MPIGW, 2007 apnoeic incidents is a good indication of infant success, therefore oxy-
Medically stable with or Pinelli & Symington, 200541 genation levels should be observed during the feed. Attention to
without oxygen supplementation changes in breathing sounds and to the pattern of sucking are poten-
of less than 40%
tially important intervention strategies for the prevention of and
Comfortable, stable breathing Pinelli & Symington, 200541
White & Parnell, 201332 appropriate response to oxygen declines during feeding. Sucking
Resting breath rate less than 52
Kirk et al, 2007 pauses may indicate periods when preterm infants aim to regulate their
60‐70 bpm White & Parnell, 201332 breathing patterns and thereby increase oxygenation. Interventions
Stable heart rate between Holloway, 20141 that focus on detection and minimization of apnoea during feeding,
120 bpm and 160 bpm
and which aim to protect infant sucking pauses, may reduce the num-
Sufficient bowel sounds Kirk et al, 200752
ber and severity of desaturation events preterm infants might experi-
Tolerate 2‐3 hourly tube feeds well Raimbault et al, 200739
White & Parnell, 201332 ence during bottle feeding.14 Nurses should observe changes in

Gain an average of 10‐15 g/kg/day Kirk et al, 200752 respiratory control and fatigue during feeding to determine the length
once on a normal caloric intake of a feeding. Feedings should be stopped when the infant fall asleep,
of about 120 kcal/kg/day enterally.
do not resume sucking after pausing or is clinical instable (apnea and
Gestational age older than Ben, 200833
bradycardia).30 An increase in eye flutter is a precursor for apnoeic
28‐32 weeks
spells observed immediately prior to a desaturation event.14 During a
Coordinate suck, swallow and Ben, 200833
breathing desaturation event, infants typically relax their arms and hands and
Maintain body temperature Cape MPIGW, 200742 stop sucking.14
outside incubator/in skin‐to‐skin Pinelli & Symington 200541
Rooting and sucking reflexes Cape MPIGW, 200742
Pinelli & Symington, 200541 2.12 | Assessment of the feed
White & Parnell, 201332
It is important to be able to rate the effectiveness of the feed as being
Grow 15 g/kg/day on oral feeds Cape MPIGW, 200742
Pinelli & Symington, 200541 good, fair, or poor. A good feed can be identified when the infant
Transition to and maintain Cape MPIGW, 200742 latches well, has good positioning, and sucks continuously
quiet alert state Pinelli & Symington, 200541 (>15 minutes)29 with or without stimulation and where no additional
Kirk et al, 200752
White & Parnell, 201332 feed needs to be given via the naso‐gastric tube.32 The first let down
can produce almost half of the total volume of milk in the breast, there-
fore the following management decisions are acceptable.50
A fair feed is identified when the infant latches and starts to suckle
oral feed followed by 2 tube feeds to allow the infant time to rest in nonrhythmically,32 but loses grip and “fights” on the breast. Active
between. When the infant is able to manage this, continue to alternate sucking for 5‐15 minutes is considered half the intended volume of
breast and tube feeds and when this is well established the infant may the feed was taken and half should be given via the naso‐gastric
take the breast with every feed.40 Most premature infants can begin tube.29
nutritive sucking at about 32 weeks’ gestation,30 and there is no evi- A poor feed is identified when the infant remains sleepy, does not
dence that oral feeding started earlier than 34 weeks contribute to latch, or has a few sucks (less than 5 minutes) and then releases. The
sooner full oral feeds, however maximum oral feeding experience full feed should be given via the naso‐gastric tube.29,32
does.4 Early use of nipple shields increases milk intake and duration Feeding should be a pleasant experience for all involved in the
of breastfeeding11 and can be used to aid initial latching. Infants should process, and if the previously stated information is followed, this aim
be observed and assessed during, as well as, after every feed to deter- can be achieved. Figure 1: Transition protocol for feeding initiation,
mine how they are coping with the activity. aims to provide a visual guide for the clinician to make decisions on
Semidemand feeding is more suitable for preterm infants than the transition regimes for each individual infant. The author are pro-
demand feeding. With semidemand feeding, the infant is assessed posing this transition protocol based on all the evidence already pre-
every 3 hours for behavioural signs of hunger. If the infant is sleeping, sented in this article.
reassess 30 minutes later, and if the infant is still sleepy give a tube
feed.30,32 If the infant wakes up and demonstrates hunger signs
before the 3 hours are over, the feeding can be provided earlier.
2.13 | Safety measures
These infants reach full oral feeding 5 days earlier than infants on According to Crosson and Pickler,13 1 or all of the following safety
scheduled feed. measures should be included with cue‐based feeding: (1) There
LUBBE 7

FIGURE 1 Transition protocol for feeding initiation (with permission from Little Steps® 2016)

should be a limit on the interval between feedings (such as 4 hours Although scheduled feeding will ensure sufficient caloric intake,
maximum), (2) daily fluid minimum should be calculated to ensure feeding preterm infants in response to their hunger and satiation cues
reaching the caloric intake goals, (3) routine assessment of growth (ad libitum or demand/semidemand) might help in the establishment of
should be done, and (4) assessment of blood glucose levels with any independent oral feeding,4 increase and ensure sufficient nutrient
clinical suspicion, or at the extended time limits of demand feeding intake and growth rates, and ensure feeding success.
should be done. Demand‐fed infants will take fewer feeds per day, can be discharged
from hospital 5‐6.2 days sooner than infants on scheduled feeds,13,17,30
exhibit more hunger cues, and may consume fewer calories in 24 hours.
2.14 | Guidelines on preterm infant feeding after However, there is no difference in their weight gains compared to infants
discharge on scheduled feeds, contributed to longer sleep periods.
A preterm baby should gain between 142 g and 170 g per week,
It is important to teach mothers to read their infants’ cues with regard
but the change of environment from hospital to home has a large
to feeding instead of letting them rely on monitors, such as scales to
impact on the energy use that may influence weight gain in the first
indicate feeding success, since this engages parents and enhance their
week. To compensate for the additional energy requirements during
nurturing and caregiving skills.1 The most important guideline is that a
the first week at home, rather track weight gain bi‐weekly.
mother should hear her baby swallow. The infant should gain weight
on any type of feed at a rate of 15 g/kg/day,42 whether it is formula
or breast feeding. The infant might receive supplemental feeds if nec-
essary, provided that an experienced lactation consultant assists the 3 | CO NC LUSIO NS
mother to ensure lactation and breast feeding establishment. The
infant must be physiologically stable and parents must be confident Transition from gavage to oral feeding in preterm infants based on
in handling him or her.42 infant maturity may result in more successful oral feeding with less
Semidemand feeding should be continued after discharge, since energy expenditure, higher rates of success, and even better parental
hunger cues may be unreliable in preterm infants, therefore the functioning.
feeding schedule that was used in the NICU should be continued. Clear, evidence‐based guidelines should be available for the
Eight feeds per 24 hours is required, which does not necessarily have healthcare professional/care giver to enable effective assessment of
to in 3‐hourly intervals. Infants feeding every 2 to 2.5 hours during infant maturity and readiness for oral feeding.
the day may stretch night feed intervals to four hours, allowing more Clear recommendations must be available to healthcare profes-
rest for the mother‐infant dyad. However, infants less than 2.5 kg sionals to direct the transition process ensuring optimal feeding
should be woke every 3 hours during the day for feeds and should success.
not sleep for more than four hours consecutively without a feed. Findings portrayed in this article should be summarized in the for-
After 2.5 kg these intervals may stretch to five hours to allow more mat of an informational pamphlet understandable by mother and
rest for the dyad. infant caregivers.
8 LUBBE

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167.
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