Cue-Based Feeding: Getting Past “But We’ve Always Done it This Way!” Jamie Fletcher-Hicks, MSN, APRN, NNP-BC Neonatal Nurse Practitioner University of Virginia Medical Center, Charlottesville, VA

The speaker has signed a disclosure form and indicated she has no significant financial interest or relationship with the companies or the manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation.

Session Summary

Recent evidence contradicts our decades-long feeding practices, but how do we depart from what we have always thought to be true? This presentation shows the evidence for cue-based feeding and illustrates the journey taken by one NICU that successfully transformed its culture.

Session Objectives

Upon completion of this presentation, the participant will be able to:

compare traditional medical model and cue-based feeding model;

examine the evidence for cue-based feeding;

describe the University of Virginia NICU’s transition to cue-based feeding, including what worked and what didn’t.

References

Bingham, P., Ashikaga, T. & Abbasi, S. (2010). Prospective study of non-nutritive sucking and feeding skills in premature infants. Archives of Disease in Childhood, Fetal Neonatal Edition, 95(3): F 194-200.

Kirk, A., Alder, S. & King, J. (2007). Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology, 27: 572-578.

Ludwig, S. & Waitzman, K. (2007). Changing feeding documentation to reflect infant-driven feeding practice. Newborn & Infant Nursing Reviews, 7(3): 155-160.

McCain, G. (2003). An evidence based guideline for introducing oral feeding to healthy preterm infants. Neonatal Network, 22: 45-50.

McCormick, F., Tosh, K., McGuire, W. (2010). Ad libitum or demand/semi-demand feeding versus scheduled interval feeding for preterm infants. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD005255. DOI:10.1002/14651858.CD005255.pub3.

McGrath,J. & Bodea Braescu, A. (2004). Feeding readiness in the preterm infant. Journal of Perinatal-Neonatal Nursing, 18: 353-368.

Pickler, R., Best, A., Reyna, B., Gutcher, G. & Wetzel, P. (2006). Predictors of nutritive suckling in preterm infants. Journal of Perinatology, 26: 693-699.

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A3b: CUE-BASED FEEDING: GETTING PAST "BUT WE'VE ALWAYS DONE IT THIS WAY!" Page 1 of 10

Puckett, B., Grover, V., Holt, T. & Sankaran, K. (2008). Cue-based feeding for preterm infants: A prospective trial. Journal of Perinatology, 25: 623-628.

Shaker, C. (2013). Cue-based feeding in the NICU: Using the infant's communication as a guide. Neonatal Network, 32(6): 404-8.

Thomas, J. (2007). Guidelines for bottle feeding your premature baby. Advances in Neonatal Care,7(6): 311-318.

Session Outline

See presentation handout on the following pages.

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Cue-Based Feeding: Getting Past “But We’ve Always Done It

This Way!”

Jamie Fletcher Hicks, RN, MSN, NNP-BCNeonatal Nurse Practitioner

University of Virginia Health SystemNeonatal Intensive Care Unit

“I can feed a ROCK!”

“I can feed a ROCK!”• Compare traditional medical model and cue-based

feeding model

• Examine the evidence for cue-based feeding

Objectives:

g

• Describe the University of Virginia NICU’s transition to cue-based feeding, including what worked, what didn’t

The Traditional Medical Model The Traditional Medical Model

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• Medical team orders volume/caloric density• Typically ~120kcal/kg/day• Nurse administers feeding by mouth, gavage, or a

combination or the twoV l d i l

The Traditional Medical Model

Volume-driven culture

• “Better nurses”—coax volume into babies

• “Poor feeders”—babies who don’t take volume prescribed volumes

The Traditional Medical Model: Attitudes

• “The light bulb turned on” • (Shaker, 2013)

• Nurses might say:

• “If I can just get him to take these last 5mL…”

The Traditional Medical Model: Attitudes

• Nurses less likely to say:

• “We had a positive feeding experience,he woke up, showed cues, no aversive behaviors.”

• RN documentation=volume NG vs. volume PO

• Little documentation of to how the baby fed

The Traditional Medical Model: Attitudes

• NNPs/MDs--we like quantitative measurements:

• Total fluids in mL/kg/day• Output in mLs/kg/hour• Weight gain in grams

(Thomas, 2007)

Oral Feeding: It’s Not That Simple!

• Oral feeding involves 5 subsystems:

• AutonomicMotorStateBehavioralSelf-Regulatory

Als’ Synactive Theory of Development

• Not just time for maturity, but caregiver/baby reciprocity

• Caregiver must recognize feeding cues and disengagement cues

(Thomas, 2007)

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Caregiver recognizes/responds to:

Rooting, sucking on hands, alert quiet state

Als’ Synactive Theory of Development

Just as important to pay attention to subtle “stop” signs:

Hiccupping, fanning fingers, gaze aversion, worried expression, yawning, looking exhausted

Als’ Synactive Theory of Development

• Caregiver should recognize physiological “stop” signs:

• Apnea, bradycardia, desaturations

Als’ Synactive Theory of Development:

• If not, can lead to oral aversion

Cue-Based Feeding: The Evidence

• Two prospective trials:– Kirk, Alder, & King, 2007:

• Full PO feedings 6 days sooner

– McCain 2003:

Cue-Based Feeding: The Evidence

– McCain, 2003:

• Full PO feedings 5 days sooner

• Preparing for PO feeding: Non-nutritive suck– Bingham et al, 2010: NNS=better organization and earlier transition to 

full PO feeds, average of 3 days earlier

Cue-Based Feeding: The Evidence

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What does Cochrane say?

• 8 RCTs

Cue-Based Feeding: The Evidence

• 3 trials showed 2-4 days earlier to PO feedings

• Trials were small, poorly designed• Inconclusive• Need a large RCT

(McCormick, Tosh, & McGuire, 2010)

• Is developmentally appropriate

• Decrease LOS/Healthcare costs

Cue-Based Feeding: The Benefits

• Can improve parent satisfaction

“But we’ve always done it this way!”

Despite the Evidence, Change is Difficult!

You can’t start soda soon enough!

Do your child a favor!

They will fit in better during those

The way things used to be…..

They will fit in better during thoseawkward preteen years!

A strict regimen of sodas and other sugary, carbonated beverages right now for a lifetime of guaranteed happiness!!

Laboratory tests have proven this!

• Some reasons for resistance are valid, others not

• Most experienced nurses—were in support of not “feeding a rock.”

Despite the Evidence, Change is Difficult!

• ”I have a 3 or 4 baby assignment and have to keep a schedule.”—Interruption of workflow

• NPs and physicians—uncomfortable with what we can’t measure and less than 120kcal/kg/day

• Champions—to get buy in• Who??

• Nurses

Making The Change: Step 1

• Physicians• Speech Therapists• Physical Therapists• Occupational Therapists• Dietitians• Parents

• Anyone could be a champion!

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Making The Change: Algorithm and Guidelines

• Begin with non-nutritive suck

• How early for PO feedings??

Making The Change: The Guidelines

• Is the baby showing cues? 30 weeks CGA or greater? On nasal cannula or room air? Then offer a PO feeding!

• Begins with Milestone One: 1 PO feeding/shift, progresses through Milestone Four, all PO feedings

• 75% of feeding, no need to gavage feed• Guidelines for breastfeeding, too• Can directly breastfeed and NOT know the volume (gasp!!)

Making The Change: The Guidelines

Ca d ect y b east eed a d O o t e o u e (gasp )• Measure growth/weight gain, not mLs or kcals• Champions sought approval of algorithm/guidelines

***Quality--not quantity--of PO feedings as a measure of success***

Making The Change: Documentation

Changes made to EMR for NNPs/MDs to order Cue-Based FeedingNurses now documenting qualitative assessment of feeding

• Extensive!• Many formats• Over 9 months• Small group mini-lectures for RNs

Making The Change: Education

• Lectures for residents at morning rounds• Captive audience—at RN staff meetings• Friday Footnotes-bi-weekly email• Quizzes with prizes—who doesn’t love a coffee card??• Shadow box• NICU Core Curriculum—newly hired RNs

Making The Change: Education--Shadow Box

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• Educate parents • Ideally, they do the feeding

Education: Don’t Forget Mom and Dad

• Can we go from Milestone #1 to Milestone #2? My patient showed cues every feeding. Too bad I had to use the NG tube!

Along The Way:

• Feed the baby! Infant-driven model. • Guidelines are to guide.

• What if the baby is showing cues more than every 3 hours?

• Feed the baby!

• What if the baby is showing cues less often than every 3 hours?

• Feed the baby! But use NGT if >3.5 hours and

Questions Along The Way:

yno hunger cues.

Guideline—not policy.

Not substitute for clinical judgment.

Not set in stone. 

Questions Along The Way:

My patient PO fed 75% of his breastmilk feeding. I can’t refrigerate the rest. You want me to DISCARD the remainder of the liquid gold?

Questions Along The Way:My patient PO fed 75% of his breastmilk feeding. You want me to DISCARD the remainder of the liquid gold?• Probably. Consider this:• 1.8kg baby

Questions Along The Way:

g y• Receiving 24kcal breastmilk• 150mL/kg/day• 34mL q 3 hours, if baby fed 25mL (75%), only 9mL

would be discarded• Allows baby to feel hunger• Maybe sooner to reach full PO feed/discharge sooner• Mom not low supply or terribly upset

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• What did all of those champions do?? Many jobs…..

• Developing algorithm

• Approval of Division of Neonatology

What Worked?

• Approval of Nursing Clinical Practice Committee

• Education

• Developing order sets and documentation through EMR

• Pre-intervention data collection

• Post-intervention data collection

• Remember this? Instead of this at bedside…..

What Worked?

• ….We used these:

What Worked?—Bedside Flip Cards

• ….We used these:

What Worked?—Bedside Flip Cards

• ….We used these:

What Worked?—Bedside Flip Cards

• ….We used these:

What Worked?—Bedside Flip Cards

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• More frequent feedings sometimes unrealistic

• The exception was breastfeeding! This worked really, really well.

What Did And Did Not Work?

y

• Several other changes—too much at once?? • LOS Reduction Taskforce:• Thermoregulation protocol• Oxygen weaning protocol

What Did Not Work?

• Increase in documentation• Recent change to EMR from paper charting

• Goal: to reach full PO feedings by 36 0/7 weeks• Excluded NEC, Grade IV IVH, or VP shunt

• Pre-intervention data

Outcomes

• Post intervention data

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