Supporting oral feeding in fragile infants: an evidence-based method for quality bottle-feedings of preterm, ill, and fragile infants

Historical Perspectives and Clinical Updates on Preterm Bottle Feeding With Noninvasive Ventilation

The controversial topic of oral feeding while on noninvasive ventilation remains at the forefront of preterm intensive care management. The intersection of pulmonary, neurologic, and gastrointestinal maturation coalesces at a postmenstrual age that requires changes in practices compared with those used in older infants. Various animal models in the past decades aimed to gain physiological knowledge of noninvasive ventilation effects on the suck-swallow-breathe coordination sequence. However, the preterm infant poses nuanced anatomic challenges. Although concerns for oral feeding while on noninvasive ventilation include aspiration risks and potential inpatient obstacles, there is evidence to support the feasibility, initiation, and progression of oral feedings while an infant is supported on high-flow nasal cannula and continuous positive airway pressure. There is evidence to support that this may accelerate attainment of oral feeding milestones and, thus, eventual hospital discharge. More recent multidisciplinary institutional protocols may provide cautious guidance on evaluation and algorithms to assess infants who may benefit from initiation and advancement of oral feeding versus awaiting further maturation.

Risk of dysphagia in a population of infants born pre-term: characteristic risk factors in a tertiary NICU

OBJECTIVE

To examine the prevalence and characteristics of dysphagia and suck-swallow-breath incoordination as phenotypes of oral feeding difficulties.

METHOD

A cross-sectional study with secondary data collected consecutively over 2 years from October 2020 to October 2022 to measure the prevalence of swallowing and oral feeding difficulty in preterm infants using Flexible endoscopic evaluation of swallowing examination at the tertiary Integrated Dysphagia Clinic.

RESULTS

The prevalence of swallowing disorders was 25 % and the prevalence of suck-swallow-breath incoordination was 62.5 %. The significant risk factor that may show a possible correlation with oral feeding difficulty was mature post-menstrual age (p = 0.006) and longer length of stay (p = 0.004). The dominant percentage of upper airway abnormality and disorder were retropalatal collapse (40 %), laryngomalacia (42.5 %), paradoxical vocal cord movement (12.5 %), and gastroesophageal reflux disease (60 %). The dominant characteristic of oral motor examination and flexible endoscopic evaluation of swallowing examination was inadequate non-nutritive sucking (45 %), inadequate postural tone (35 %), and inadequate nutritive sucking (65 %).

CONCLUSION

Dysphagia in preterm infants is mostly observed in those with mature post-menstrual age, longer length of stay, and the presence of gastroesophageal reflux disease with inadequate non-nutritive sucking and nutritive sucking abilities. Suck-swallow-breath incoordination is primarily observed in those with immature post-menstrual age, a higher prevalence of cardiopulmonary comorbidity, and a higher prevalence of upper airway pathologies (laryngomalacia, paradoxical vocal cord movement) with inadequate nutritive sucking ability.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' post-menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review.

OBJECTIVES

To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA.

SEARCH METHODS

Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

Following the updated search, two review authors screened the titles and abstracts of studies and full-text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) -4.07 days, 95% confidence interval (CI) -4.81 to -3.32 days, 6 studies, 292 infants; I2 =85%, very low-certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD -4.33, 95% CI -5.97 to -2.68 days, 5 studies, 249 infants; i2 =68%, very low-certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non-oral intervention Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non-oral intervention (MD -7.17, 95% CI -8.04 to -6.29 days, 10 studies, 574 infants; I2 =80%, very low-certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD -6.15, 95% CI -8.63 to -3.66 days, 10 studies, 591 infants; I2 =0%, low-certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD -2.85, 95% CI -6.13 to 0.42, 3 studies, 268 infants; very low-certainty evidence due to serious risk of bias, inconsistency and imprecision).

AUTHORS' CONCLUSIONS

There remains uncertainty about the effects of oral stimulation (versus either standard care or a non-oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta-analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions.

Assessment and management of feeding difficulties for infants with complex CHD

Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.

Effects of Swaddling During Bottle Feeding in Preterm Infants

BACKGROUND

Preterm infants have immature oral feeding skills, affecting length of hospital stay and long-term feeding outcomes. Swaddling has positive effects on pain and stress responses, state regulation, and physiological stability in preterm infants in the neonatal intensive care unit (NICU). Swaddling during bottle feeding may support preterm infant behavioral organization and oral feeding skills. Swaddling is used inconsistently during feeding in the NICU and has not been critically examined for effects on bottle feeding performance in preterm infants.

PURPOSE

To examine the effects of swaddling on bottle feeding quality and efficiency in preterm infants.

METHODS

A convenience sample of 30 infants born before 34 weeks of gestation was selected in an urban level IV NICU. Using an experimental, randomized crossover design, each infant was swaddled for one feeding and unswaddled for one feeding. Feeding efficiency was measured by rate and volume consumed. Feeding quality was examined by the Early Feeding Skills Assessment and frequency of physiological changes. Data were analyzed using dependent t tests and Wilcoxon signed rank test.

RESULTS

When swaddled, participants demonstrated significantly better scores on all related subtests of the Early Feeding Skills Assessment ( P ≤ .001). Infants demonstrated no difference in frequency of bradycardia or oxygen desaturations greater than 4 seconds. No significant differences were found in feeding efficiency outcomes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Swaddling can be used in the NICU to improve bottle feeding quality in preterm infants. Future investigation is needed on long-term effects of swaddling during bottle feeding on feeding performance, weight gain, and length of stay.

Factors Affecting Oral Feeding Ability in Indonesian Preterm Infants

Most preterm infants exhibit atypical and immature feeding skills. Even though preterm infants have fulfilled the oral feeding readiness criteria, they still do not have optimal oral feeding ability. This study aimed to determine various factors affecting oral feeding ability in Indonesian preterm infants who have fulfilled oral feeding readiness criteria but still have not been able to feed orally. A cross-sectional study included 120 preterm infants admitted to five tertiary hospitals in Jakarta, Indonesia. Participants were preterm infants born at 28-34 weeks gestational age who had fulfilled the oral feeding readiness as the inclusion criteria: (1) stable cardiorespiratory status, (2) have achieved full enteral feeding via orogastric tube (OGT) 120 mL/kg/day without vomiting or bloating, and (3) strong and rhythmic non-nutritive sucking (NNS) through objective measurement. Infants' oral feeding ability and various factors that were assumed to affect oral feeding ability, including physiological flexion postural tone, physiological stability, rooting reflex, self-regulation, behavioral state, and level of morbidity were evaluated. Chi-square and multivariate analysis with Poisson regression were performed. Results indicated that postural tone, rooting reflex, physiological stability, self-regulation, behavioral state, and level of morbidity were significantly related to oral feeding ability in preterm infants. The most influencing factors were self-regulation with a prevalence ratio (PR) of 1.96 (1.16-3.34; CI 95%) and p = 0.012, followed by postural tone, high morbidity, and behavioral state (PR 1.91; 1.59; 1.56; CI 95%, respectively). In conclusion, despite meeting the oral feeding readiness criteria, most preterm infants were still not able to feed orally. There are other factors affecting oral feeding ability in Indonesian preterm infants.

Psychometric properties of the oral feeding assessment in premature infants scale

Professionals that work in neonatal units need to identify the strengths and weaknesses of the premature infant who is in the transition process from feeding through a gastric tube to oral feeding. The main aim of this study was to validate the Oral FEeding Assessment in premaTure INfants (OFEATINg) instrument. A psychometric validity and reliability study was conducted in Neonatal Intensive Care Units of two public, metropolitan, university hospitals. The study population were premature infants at a postconceptional age of 31-35 weeks. The study included evaluation of the reliability, convergent, discriminant and construct validity, sensitivity and specificity of the OFEATINg instrument. A total of 621 feedings of 56 preterm infants were evaluated. Confirmatory factor analysis identified 3 factors and 13 indicators with a good fit to the model. Cronbach's alpha coefficient was 0.78. The instrument showed high indices of inter-rater reliability (Pearson 0.9 and intraclass correlation coefficient 0.95). The OFEATINg scale is a valid and reliable instrument for evaluating the readiness for oral feeding of preterm infants. It may enable clinicians to evaluate the physiological and behavioral abilities involved in the oral feeding process and help them make decisions related to the transition to full oral feeding.Clinical trial registration: This study was prospectively registered at the two Institutional review boards.

Cue-based versus scheduled feeding for preterm infants transitioning from tube to oral feeding: the Cubs mixed-methods feasibility study

BACKGROUND

There is a lack of evidence of the effect of cue-based feeding compared with scheduled feeding on important outcomes for preterm infants.

OBJECTIVES

The objectives were as follows: (1) to describe the characteristics, components, theoretical basis and outcomes of approaches to feeding preterm infants transitioning from tube to oral feeding; (2) to identify operational policies, barriers and facilitators, and staff and parents' educational needs in neonatal units implementing cue-based feeding; (3) to co-produce an intervention for feeding preterm infants in response to feeding cues; (4) to appraise the willingness of parents and staff to implement and sustain the intervention; (5) to assess associated costs of implementing cue-based feeding; (6) to determine the feasibility and acceptability of a future trial; (7) to scope existing data-recording systems and potential outcome measures; and (8) to determine stakeholders' views of whether or not a randomised controlled trial of this approach is feasible.

DESIGN

This was a mixed-methods intervention development and feasibility study comprising (1) a systematic review, case studies, qualitative research and stakeholder consensus; (2) the co-production of the intervention; (3) a mixed-methods feasibility study; and (4) an assessment of stakeholder preferences for a future evaluation.

SETTING

Three neonatal units in the UK (two level 3 units and one level 2 unit).

PARTICIPANTS

Developmentally normal, clinically stable preterm infants receiving enteral feeds (n = 50), parents (n = 15 pre intervention development; n = 14 in the feasibility study) and health-care practitioners (n = 54 pre intervention development; n = 16 in the feasibility study).

INTERVENTION

An evidence-informed multicomponent intervention comprising training, a feeding protocol, feeding assessment tools, supplementary training materials [including posters, a film and a narrated PowerPoint (Microsoft Corporation, Redmond, WA, USA) presentation] and the 'Our Feeding Journey' document.

MAIN OUTCOME MEASURES

The main outcome measures were recruitment and screening rates, infant weight gain, duration of the intervention, feeding outcomes, implementation outcomes (contextual facilitators and barriers, acceptability, adoption, appropriateness and fidelity) and stakeholder preferences for a future evaluation.

RESULTS

The systematic review of 25 studies concluded that evidence in favour of cue-based feeding should be treated cautiously. The case studies and qualitative research highlighted contextual barriers to and facilitators of the implementation of cue-based feeding. The telephone survey found that many neonatal units are considering implementing cue-based feeding. We recruited 37% of eligible infants, and there was good retention in the study until discharge but a high loss to follow-up at 2 weeks post discharge. The mean number of days from intervention to transition to full oral feeding was 10.8, and the mean daily change in weight gain was 25 g. The intervention was acceptable to parents and staff, although there was dissatisfaction with the study documentation. Intervention training did not reach all staff. A cluster-randomised design with a composite outcome was suggested by stakeholders for a future study.

LIMITATIONS

The intervention was available only in English. Intervention training did not reach all staff. There was low recruitment to qualitative interviews and observations. Only a small number of medical staff engaged in either the training or the interviews.

CONCLUSIONS

It is feasible to implement a cue-based feeding intervention with improved training and documentation. Further work is needed to assess the feasibility of a future trial, noting evidence of existing lack of equipoise.

FUTURE WORK

The next steps are to digitalise the intervention and conduct a survey of all neonatal units in the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018097317 and ISRCTN13414304.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 74. See the NIHR Journals Library website for further project information.

Application of the Neonatal Behavioral Assessment Scale to Evaluate the Neurobehavior of Preterm Neonates

Background: The neonatal behavioral assessment scale (NBAS) was primarily developed to aid in the assessment of full-term neonates. The aim of this study was to detect if the NBAS was also valuable in the assessment of preterm neonates. Materials and Methods: We assessed 112 infants at a neonatal unit using the NBAS, 4th edition. The inclusion criteria included an oxygen saturation level between 88–95% and a heartrate of 100–205 beats per minute. Infant neurobehavior was assessed using the NBAS. Results: For full-term and preterm neonates, we observed that the NBAS enabled us to assess both groups of infants and gave relevant information pertaining to them. We found a significant correlation between the average week of gestation and response to touch, sensory input, peak of excitement, cost of attention, hand-to-mouth, and quality of alertness. Conclusions: The NBAS is a valuable scale for evaluating the neurobehavior of preterm neonates. The week of gestation at birth affects certain aspects of neurobehavior, such as response to sensory input, putting hand to mouth, peak of excitement, and cost of attention. The NBAS as an individually structured assessment may help in planning for early rehabilitation and intervention for this vulnerable population.

Implementation of Cue-Based Feeding to Improve Preterm Infant Feeding Outcomes and Promote Parents' Involvement

OBJECTIVE

To implement cue-based feeding for preterm infants and to assess its effects on time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process.

DESIGN

A quality improvement project with a pre-post evidence-based practice implementation design.

SETTING

Level III NICU in a quaternary hospital in the U.S. Northeast.

PARTICIPANTS

Medical records of preterm infants from 23 0/7 weeks to 31 6/7 weeks gestational age who were eligible for initiation of oral feeding.

INTERVENTION/MEASUREMENTS

We implemented cue-based feeding through staff education and training. We completed a retrospective review of the medical records of 82 preterm infants before implementation and 167 preterm infants after implementation for the outcomes of time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process.

RESULTS

For infants 23 0/7 weeks to 27 6/7 weeks gestation, time to achieve full oral feedings decreased by 7 days, length of stay decreased by 4.4 days, and parents' involvement in the feeding process increased by 80% from before to after implementation. For infants 28 0/7 weeks to 31 6/7 weeks, time to achieve full oral feedings decreased by 6.6 days, length of stay decreased by 2.7 days, and parents' involvement in the feeding process increased by 49% from before to after implementation. The organization saved $103,950 per year by decreasing length of stay.

CONCLUSIONS

Cue-based feeding decreased time to achieve full oral feedings, decreased length of stay, increased parents' involvement in the feeding process, and resulted in cost savings for the institution.

Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review

BACKGROUND

The aim of this systematic review was to determine whether introduction of oral feeding for infants and children receiving nasal continuous positive airway pressure (nCPAP) or high flow nasal cannula (HFNC) respiratory support facilitates achievement of full oral feeding without adverse effects, compared to no oral feeding (NPO; nil per oral) on CPAP or HFNC.

METHODS

A protocol was lodged with the PROSPERO International Prospective Register of Systematic Reviews. We searched Medline, Embase, CINAHL, CENTRAL and AustHealth from database inception to 10th June 2020. Study population included children (preterm to < 18 years) on nCPAP or HFNC who were orally feeding. Primary outcomes included full or partial oral feeding and oropharyngeal aspiration. Secondary outcomes examined adverse events including clinical signs of aspiration, aspiration pneumonia and deterioration in respiratory status.

RESULTS

The search retrieved 1684 studies following duplicate removal. Title and abstract screening identified 70 studies for full text screening and of these, 16 were included in the review for data extraction. Methods of non-invasive ventilation (NIV) included nCPAP (n = 6), nCPAP and HFNC (n = 5) and HFNC (n = 5). A metanalysis was not possible as respiratory modes and cohorts were not comparable. Eleven studies reported on adverse events. Oral feeding safety was predominantly based on retrospective data from chart entries and clinical signs, with only one study using an instrumental swallow evaluation (VFSS) to determine aspiration status.

CONCLUSIONS

Findings are insufficient to conclude whether commencing oral feeding whilst on nCPAP or HFNC facilitates transition to full oral feeding without adverse effects, including oropharyngeal aspiration. Further research is required to determine the safety and efficacy of oral feeding on CPAP and HFNC for infants and children.

TRIAL REGISTRATION

PROSPERO registration number:  CRD42016039325 .

A Delphi survey based construction and validation of test for oropharyngeal dysphagia in Indian neonates

BACKGROUND

SLPs have a crucial need to depend on comprehensive clinical swallowing assessments to determine the presence of dysphagia in neonates. A comprehensive clinical swallowing assessment that is ethnoculturally sensitive may help to identify the presence and severity of swallowing problems in neonates.

OBJECTIVE

The study aimed to construct and validate the contents of a test for oropharyngeal dysphagia in Indian neonates (TOD-IN).

METHOD

The test for oropharyngeal dysphagia in Indian neonates (TOD-IN) was developed using the Delphi process. Five expert panelists served as participants; two rounds of electronic questionnaire-based survey was carried out to develop and validate the contents of TOD-IN.

RESULTS

Round one rendered descriptive data that was analyzed quantitatively and qualitatively. At the end of round one, panelists unequivocally agreed on the need for research to develop a validated assessment tool for dysphagia in Indian neonates. The second round dealt with establishing the face and content validity of the final version of TOD-IN. A unanimous consensus was obtained regarding the format, scoring system, and the construct of the final version of the tool.

CONCLUSION

Practicing clinicians in India are met with several challenges such as resource constraints, limited infrastructure, increasing caseload, and a lack of trained workforce. We believe that inexperienced clinicians will benefit from the structured guidance provided by TOD-IN in a restrained resource context where prioritization of patients is the key. Further studies investigating the psychometric properties of TOD-IN are in progress.

Neonatal feeding performance is related to feeding outcomes in childhood

AIM

Define relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment.

STUDY DESIGN

Ninety-one infants (44 preterm infants born ≤32 weeks at term-equivalent age and 47 full-term infants within 4 days of life) had feeding evaluated using the Neonatal Eating Outcome Assessment and the Neonatal Oral Motor Assessment Scale (NOMAS). At 4 years of age, 39 of these infants (22 preterm infants and 17 full-term infants; 43% follow-up rate) had parent-report measures of feeding conducted using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Pediatric Eating Assessment Tool (PediEAT).

RESULTS

Lower Neonatal Eating Outcome Assessment scores were related to higher PediEAT scores (p = 0.01; r = -0.44), but were not related to BPFAS scores (p = 0.17; r = -0.23). Relationships were not detected between the NOMAS and BPFAS (p = 0.35; r = 0.17), and relationships between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34). There was a relationship between the BPFAS and PediEAT scores at 4 years (p < 0.001; r = 0.66). Preterm infants performed poorer than full-term infants on the Neonatal Eating Outcome Assessment (p < 0.001) and NOMAS (p < 0.001), but no differences were detected in preterm compared to full-term performance on the BPFAS (p = 0.87) and PediEAT scores (p = 0.27).

DISCUSSION

Neonatal feeding performance is an important predictor of feeding outcomes at 4 years of age. The Neonatal Eating Outcome Assessment has predictive validity, and the Pediatric Eating Assessment Tool has concurrent validity with relationships to another childhood feeding tool.

Turkish Neonatal Nurses' Knowledge and Practices Regarding the Transition to Oral Feeding in Preterm Infants: A Descriptive, Cross-sectional Study

PURPOSE

Neonatal nurses play an important role in preterm infants' safe and successful transition to oral feeding. Little is known about neonatal nurses' knowledge and practices regarding the transition to oral feeding in preterm infants. The aim of this study was to determine neonatal nurses' knowledge levels and clinical practices related to the process of transitioning preterm infants to oral feeding.

DESIGN AND METHOD

This descriptive cross-sectional study was conducted with 275 neonatal nurses working in the neonatal intensive care units of 9 different hospitals in Istanbul, Turkey. Data were collected using a participant demographic form and a questionnaire about the neonatal nurses' knowledge and practices regarding oral feeding.

RESULTS

The mean knowledge score of the nurses in this study was 64.7 out of 100 (SD = ±8.7; range = 40-87.5). Rates of correct responses were particularly low for items related to cue-based feeding, interventions to promote oral-motor development, non-nutritive sucking, and infant positioning for oral feeding. All of the NICU nurses participating in the study did not use the protocols developed for transitioning preterm infants to oral feeding.

CONCLUSIONS

Nurses need knowledge and practical training on evidence-based therapeutic interventions that promote oral feeding skills in preterm infants during the transition to oral feeding. The use of protocols developed for transitioning preterm infants to oral feeding is limited in NICUs.

PRACTICE IMPLICATIONS

In order to facilitate safe and successful feeding, nurses should improve their knowledge and practical skills regarding the transition to oral feeding and evidence-based therapeutic interventions for preterm infants.

Management of Oral Feeding Challenges in Neonatal Intensive Care Units (NICUs): A National Survey in China

Objectives: To investigate the current practices of oral feeding difficulties facing high-risk infants in Chinese NICUs. Methods: A questionnaire to survey infant oral feeding practices was distributed to 100 level II and III Chinese neonatal intensive care units (NICUs). Results: Responses were obtained from 88 NICUs. No Units had any structured guidelines regarding the management of infant oral feeding as they transitioned from tube to independent oral feeding. In 54 (61.4%) NICUs, nurses and physicians made shared decisions on when oral feeding were to be initiated. Fifty-four (61.4%) and 22 (25.0%) NICUs used postmenstrual age (PMA) or weight at PMA as a criterion for initiating oral feedings, respectively. The top three criteria to determine introduction of oral feeding were severity of disease, presence of sucking reflex, and trial feeding success. Adverse events were used by 78 Units as indices of oral feeding difficulty. Twenty (22.7%) and 25 (28.4%) Units had access to occupational therapists or nurses who provided oral motor interventions during feeding, i.e., oral support (chin and cheek support, aid to deglutition), non-nutritive sucking with pacifier, and oral stimulation. Conclusions: The management of oral feeding issues in NICUs vary widely in China in relation to the assessment of readiness to oral feeding, daily oral feeding practices and interventions used by staff. It is proposed that an educational program focused on the physiology of infant oral feeding, available evidence-based tools and interventions would assist NICU caregivers develop structured guidelines to improve infants' safe and efficient attainment of independent oral feeding.

Preterm infant feeding performance at term equivalent age differs from that of full-term infants

OBJECTIVE

To identify differences in feeding skill performance among preterm infants at term equivalent age compared with full-term infants.

STUDY DESIGN

Ninety-two infants (44 preterm infants born ≤32 weeks gestation at term equivalent age and 48 full-term infants within 4 days of birth) had a standardized oral feeding assessment.

RESULT

Preterm infants at term equivalent age had lower Neonatal Eating Outcome Assessment scores (67.8 ± 13.6 compared with 82.2 ± 8.1; p < 0.001) and were more likely to have poor arousal (p = 0.04), poor tongue positioning (p = 0.04), suck-swallow-breathe discoordination (p < 0.001), inadequate sucking bursts (p = 0.01), tonal abnormalities (p < 0.001), discoordination of the jaw and tongue during sucking (p < 0.001), lack of positive engagement with the feeder and/or discomfort (p < 0.001), signs of aspiration (p < 0.001), difficulty regulating breathing (p < 0.001), and have an inability to maintain an appropriate state (p < 0.001), and complete the feeding (<0.001).

CONCLUSION

A broad range of feeding-related difficulties appear to remain evident in preterm infants at term equivalent age.

Transition From Nasogastric Tube to Oral Feeding: The Role of Parental Guided Responsive Feeding

Background and Objective: Strategies to transition preterm infants from tube to oral feeding vary greatly and the transition may take days to weeks. The study objective was to evaluate the effect of parental guided responsive feeding (PGRF) on this transition. Methods: We conducted a randomized controlled trial on infants born at <32 weeks gestation. The PGRF intervention was performed by parents, and included feeding intervals and volumes which were guided by the infants' behavioral cues of hunger and satiety. If a minimum volume was not taken orally, an intermediate volume was supplemented via nasogastric tube. The control group was traditionally fed (TF), with pre-planned volumes of intake and at given scheduled intervals. Results: The study comprised 67 infants (PGRF 32, TF 35). PGRF infants reached full oral feeding within less days (median 2 vs. 8 days, p = 0.001), at an earlier age (median 34.28 vs. 35.14 weeks, p < 0.001), returned to baseline weight gain at 35 weeks (1.77 ± 0.70 vs. 1.25 ± 0.63 g/kg/day, p = 0.002), were discharged earlier (36.34 ± 0.6 vs. 36.86 ± 0.9 weeks, p = 0.001), were more likely to be fed by their parents (p < 0.001), and experienced less apnea/bradycardia events at 34 weeks (median 3.5 vs. 9 per week p = 0.047) compared to the TF infants. The regression model demonstrated that independent variables predicted 43.7% of the variance of time to full oral feeding [F _{(9, 65)} = 4.84 p < 0.001]. The only significant variable was feeding group (B = -6.43 p < 0.001); The PGRF infants were more likely to reach full oral feeding earlier. Conclusion: PGRF is safe, and associated with short-term advantages, higher parental engagement, and earlier discharge. Clinical Trial Registration: Identifier: SHEBA-12-9574-IM-CTIL; "Adjusted Individual Oral Feeding for Improving Short and Long Term Outcomes of Preterm Infants."

Aspiration and Dysphagia in the Neonatal Patient

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Feeding Infants with Neonatal Abstinence Syndrome: Finding the Sweet Spot

PURPOSE

The purpose of this study is to learn how caregivers who are expert in feeding infants with neonatal abstinence syndrome (NAS) successfully feed these infants during withdrawal.

DESIGN/SAMPLE

Focus group methodology was used to gather information from self-identified experts from three large regional NICUs. Twelve NICU nurses and speech therapists participated in open-ended, recorded discussions. Detailed flip chart notes were taken, reviewed, and verified by the participants before the group ended.

RESULTS

Four major themes emerged verified by the participants: (1) optimal medication management, (2) follow the baby's cues, (3) calm and comfortable, and (4) nurture the relationship. Participants reported using both common and creative techniques. Keeping the infant calm was crucial to being successful, as well as maintaining good control of withdrawal signs. Feeding the infant facing away from them to avoid eye contact was used, as well as vertical rocking, continuous butt patting, bundling, "shhing" sound, and a novel feeding position.

Effects of two different feeding positions on physiological characteristics and feeding performance of preterm infants: A randomized controlled trial

PURPOSE

The aim of this randomized controlled study was to determine the effect of semielevated side-lying (ESL) and semielevated supine (ESU) positions, which are used to bottle-feed preterm infants, on their physiological characteristics and feeding performance.

DESIGN AND METHODS

The sample consisted of preterm infants who were born in the 31st gestational week and below, and met the inclusion criteria. A randomization was provided in the sample group with a total of 80 infants including 38 infants in the ESL (experimental) group and 42 infants in the ESU (control) group. Both groups were compared in terms of their SpO2 values, heart rates, and feeding performances before, during, and after the feeding. The data were obtained by using a form for infant descriptive characteristics, feeding follow-up form, a Masimo Radical-7 pulse oximeter device, and a video camera.

RESULTS

It was determined that the infants in the ESL group had statistically significantly higher SpO2 values (ESL: 96.77 ± 2.51; ESU: 93.48 ± 5.63) and lower heart rates (ESL: 155.87 ± 11.18; ESU: 164.35 ± 6.00) during the feeding compared to the infants in the ESU group (p < .05). Besides, oxygen saturation levels of the infants in the ESU group decreased more (p < .01) and their heart rates increased more (p < .05) during the feeding than those obtained before the feeding compared to the infants in the ESL group.

PRACTICE IMPLICATIONS

The ESL position has a more positive effect on oxygen saturation and heart rate of infants and it is more effective in providing a physiological stabilization during the feeding, compared to the ESU position. According to these results, the ESL position can be recommended for preterm feeding.

Implementing Co-Regulated Feeding with Mothers of Preterm Infants

PURPOSE

The purpose of this study is to describe implementation of the Co-Regulated Feeding Intervention (CoReg), when provided by mothers and guided by intervention nurses trained in methods of guided participation (GP). Co-regulated feeding intervention aims to prevent stress during feeding and ease the challenge very preterm (VP) infants experience coordinating breathing and swallowing during the early months. Guided participation is a participatory learning method to guide the complex learning required for mothers.

STUDY DESIGN AND METHODS

Sixteen mothers of 17 VP infants participated. Each mother received a median of five intervention sessions during the infant's transition to oral feeding. Intervention field notes, audio recordings of the sessions, and video recordings of the nurse-guided feedings were reviewed, organized, and content analyzed to evaluate implementation.

RESULTS

The co-regulated feeding intervention was well received by mothers; enrollment, participation, and retention rates were high. Most mothers chose to spread out the intervention sessions across the transition period. Scheduling sessions was the greatest barrier. Mothers had competing demands and infant readiness to eat could not be predicted. The top five issues identified as needing attention by the mother or nurse included reading cues, coregulating breathing, providing motoric stability, regulating milk flow, and providing rest periods. Main GP strategies included joint attention with the mother to the dyad's feeding challenges, auditory assessment of breathing and swallowing, and reflection with planning for future feedings using video playback.

CLINICAL IMPLICATIONS

Nurse presence while mothers feed affords rich opportunities to guide coregulated, cue-based feeding. Co-regulated feeding intervention would be enhanced if mothers are guided by the bedside nurse.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' postmenstrual age) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge.

OBJECTIVES

To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' postmenstrual age (PMA).To conduct subgroup analyses for the following prespecified subgroups.• Extremely preterm infants born at < 28 weeks' PMA.• Very preterm infants born from 28 to < 32 weeks' PMA.• Infants breast-fed exclusively.• Infants bottle-fed exclusively.• Infants who were both breast-fed and bottle-fed.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 25 February 2016). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

One review author searched the databases and identified studies for screening. Two review authors screened the abstracts of these studies and full-text copies when needed to identify trials for inclusion in the review. All review authors independently extracted the data and analysed each study for risk of bias across the five domains of bias. All review authors discussed and analysed the data and used the GRADE system to rate the quality of the evidence. Review authors divided studies into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model.

MAIN RESULTS

This review included 19 randomised trials with a total of 823 participants. Almost all included trials had several methodological weaknesses. Meta-analysis showed that oral stimulation reduced the time to transition to oral feeding compared with standard care (mean difference (MD) -4.81, 95% confidence interval (CI) -5.56 to -4.06 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days), as well as the duration of initial hospitalisation compared with standard care (MD -5.26, 95% CI -7.34 to -3.19 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days).Investigators reported shorter duration of parenteral nutrition for infants compared with standard care (MD -5.30, 95% CI -9.73 to -0.87 days) and compared with another non-oral intervention (MD -8.70, 95% CI -15.46 to -1.94 days). They could identify no effect on breast-feeding outcomes nor on weight gain.

AUTHORS' CONCLUSIONS

Although the included studies suggest that oral stimulation shortens hospital stay, days to exclusive oral feeding and duration of parenteral nutrition, one must interpret results of these studies with caution, as risk of bias and poor methodological quality are high overall. Well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should use reliable methods of randomisation while concealing treatment allocation, blinding caregivers to treatment when possible and paying particular attention to blinding of outcome assessors.

Effectiveness of a nurse educational oral feeding programme on feeding outcomes in neonates: protocol for an interrupted time series design

INTRODUCTION

Oral feeding is a complex physiological process. Several scales have been developed to assess the ability of the neonate to begin suck feedings and assist caregivers in determining feeding advancement. However, feeding premature neonates remains an ongoing challenge and depends above all on caregivers' feeding expertise. We will evaluate the effect of a nurse training programme on the achievement of full oral feeding with premature neonates.

METHODS AND ANALYSIS

The study design will be an interrupted time series design with 3 phases: (1) A 6-month baseline period; (2) a 22-month intervention period and (3) a 6-month postintervention period. The intervention will consist of an educational programme, for nurses and assistant nurses, on feeding patterns in neonates. The training modules will be composed of a 2-day conference, 2 interactive multidisciplinary workshops, and routine practice nurse coaching. A total of 120 nurses and 12 assistant nurses, who work at the neonatal unit during the study period, will participate in the study. All premature neonates of <34 weeks postmenstrual age (PMA) will be included. The primary outcome will be the age of tube withdrawal PMA and chronological age are taken into account. The secondary outcomes will be the transition time, length of hospital stay, competent suckle feeding without cardiorespiratory compromise, rate of neonates presenting with feeding issues or feeding rejection signs, and current neonatal pathologies or deaths during hospital stay. A segmented regression analysis will be performed to assess the impact of the programme.

ETHICS AND DISSEMINATION

Approval for the study was obtained from the Hospital Ethics Committee, and the Institutional Review Board, as well as the French Data Protection Agency. The findings from the study will be disseminated through peer-reviewed journals, national and international conference presentations and public events.

TRIAL REGISTRATION NUMBER

NCT02404272 (https://clinicaltrials.gov).

A Continuous Quality Improvement Project to Implement Infant-Driven Feeding as a Standard of Practice in the Newborn/Infant Intensive Care Unit

OBJECTIVE

To increase the number of neonates who were fed according to cues prior to discharge and potentially decrease length of stay.

DESIGN

Continuous quality improvement.

SETTING

Eighty-five bed level IV neonatal intensive care unit.

PATIENTS

Surgical and nonsurgical neonates of all gestational ages. Neonates younger than 32 weeks gestation, who required intubation, continuous positive airway pressure (CPAP), high flow nasal cannula (HFNC), or did not have suck or gag reflexes were excluded as potential candidates for infant-driven feeding.

INTERVENTION/MEASUREMENTS

The project was conducted over a 13-month period using the following methods: (a) baseline data collection, (b) designation of Infant Driven Feeding (IDF) Champions, (c) creation of a multidisciplinary team, (d) creation of electronic health record documentation, (e) initial staff education, (f) monthly team meetings, (g) reeducation throughout the duration of the project, and (h) patient-family education.

RESULTS

Baseline data were collected on 20 neonates with a mean gestational age of 36 0/7(th) weeks and a mean total length of stay (LOS) of 43 days. Postimplementation data were collected on 150 neonates with a mean gestational age of 36 1/7(th) weeks and a mean total LOS of 36.4 days. A potential decrease in the mean total LOS of stay by 6.63 days was achieved during this continuous quality improvement (CQI) project.

CONCLUSIONS

Neonates who are fed according to cues can become successful oral feeders and can be safely discharged home regardless of gestational age or diagnosis.

Effect of four approaches to oral feeding progression on clinical outcomes in preterm infants

Background. The purpose of this study of preterm infants was to test the effect of four approaches to the time of transition from gavage to full oral feedings, time to discharge, and weight gain during the transition. Methods. A randomized experimental design was used with four intervention groups: early start (32 weeks' postmenstrual age)/slow progressing experience (gradually increasing oral feedings offered per day); early start/maximum experience (oral feedings offered at every feeding opportunity); late start (34 weeks' postmenstrual age)/slow progressing experience; and late start/maximum experience. Results. The analysis included 86 preterm infants. Once oral feedings were initiated, infants in the late start/maximum experience group achieved full oral feeding and were discharged to home significantly sooner than infants in either early start group. Although not significantly different, these infants also achieved these outcomes sooner than infants in the late start/slow progressing experience group. There were no differences in weight gain across groups. Conclusions. Results suggest starting oral feedings later in preterm infants may result in more rapid transition to full oral feedings and discharge although not at early postnatal ages. Provision of a more consistent approach to oral feeding may support infant neurodevelopment and reduce length of hospitalization.

Supporting Oral Feeding Skills Through Bottle Selection

Infants who have feeding difficulties often struggle with coordinating sucking, swallowing, and breathing, and have difficulty eating sufficient quantities for adequate growth. Speech-language pathologists (SLPs) need advanced expertise across a number of areas (e.g., development, medical, swallowing) to work effectively with these young infants, and they use a variety of strategies when treating this population. Therapists working with infants who have feeding difficulties use bottles as a primary therapy tool; how the infant tolerates the flow rate from the bottle/nipple is a major consideration. Caregivers must understand the influence of bottle/nipple flow rates on eating skills, so they can support the emerging oral skill development for these fragile infants, and help parents decide what bottle system to use in their home. Both infant and equipment factors influence bottle/nipple flow rates. This article discusses the influencing factors that need to be considered when determining the optimal flow rate for an individual infant.

Safety and Efficacy of Oral Feeding in Infants with BPD on Nasal CPAP

Safety and efficacy of oral feeding was examined in infants with bronchopulmonary dysplasia (BPD) on nasal continuous positive airway pressure (NCPAP). We hypothesized that repetitive oral feeding enhances aero-digestive outcomes and reduces resource utilization. Data from infants with BPD (37-42 weeks post menstrual age) that were orally fed while on NCPAP (n = 26) were compared with those that were exclusively gavage fed on NCPAP (n = 27). Subject assignment was random and physician practice based. Specifically, we compared the differences in aero-digestive milestones, resource utilization, and safety metrics. Demographic characteristics such as gender distribution, gestational age, and birth weight, clinical characteristics such as frequency of intraventricular hemorrhage and patent ductus arteriosus needing surgical ligation were similar in both groups (p > 0.05). Characteristics of respiratory support and airway milestones were similar in both groups (p > 0.05). However, infants in NCPAP-oral fed group had earlier acquisition of full oral feeding milestone by 17 days (median) versus infants who were not orally fed during NCPAP (p < 0.05). Discharge weights and the frequency of gastrostomy tube placement were also similar in both groups (p > 0.05). There were no tracheostomies in either group. There was no incidence of clinically significant aspiration pneumonia in infants during the period of the oral feeding while on NCPAP. Controlled introduction of oral feedings in infants with BPD during NCPAP is safe and may accelerate the acquisition of oral feeding milestones.

Influência do estado comportamental nos padrões de sucção de recém-nascidos pré-termo

Objetivo Verificar a influência do estado comportamental na sucção não nutritiva, na sucção nutritiva e na performance alimentar de recém-nascidos pré-termo, no momento da liberação da via oral. Métodos Participaram 32 recém-nascidos pré-termo, clinicamente estáveis, internados em uma unidade de terapia intensiva neonatal. Foram realizadas, por um fonoaudiólogo, as avaliações do estado comportamental, padrão postural, reflexos orais, características dos órgãos fonoarticulatórios, sucção não nutritiva e nutritiva, número de suções por bloco de sucção, taxa de transferência e desempenho alimentar, após a liberação médica para início da alimentação por via oral. Resultados Não foi possível verificar associação do estado comportamental com a sucção não nutritiva. Na sucção nutritiva, verificou-se influência do estado comportamental sobre o número de sucções nos três primeiros blocos, ou seja, o estado de alerta, ao iniciar a mamada, possibilitou aos recém-nascidos apresentarem maior número de sucções, quando comparados aos recém-nascidos em estado de sono. Isto se refletiu na performance alimentar, por meio da maior taxa de transferência e melhor desempenho, embora não tenha sido observada significância estatística quanto a esses aspectos. Conclusão Os achados mostram que o estado comportamental não influenciou os aspectos de sucção não nutritiva, considerados, entretanto, na sucção nutritiva. O estado de alerta apresentou associação com maior número de sucções por bloco, em relação ao estado de sono.

Setting the stage for successful oral feeding: the impact of implementing the SOFFI feeding program with medically fragile NICU infants

To evaluate the impact of implementing the Supporting Oral Feeding in Fragile Infants (SOFFI) program in a tertiary-level neonatal intensive care unit (NICU) on the oral feeding, growth, and length of stay outcomes of a heterogeneous population of medically fragile infants at discharge and feeding and growth outcomes postdischarge at 3 to 5 months postterm. Data related to feeding, growth, and length of stay from a convenience sample of 81 infants recruited pre-SOFFI training were compared with data for 75 infants recruited post-SOFFI training of the NICU staff. Subjects were not excluded on the basis of level of illness or medical diagnoses. To establish comparability of subject groups, infants were assigned scores using the Neonatal Medical Index. At 3 to 5 months postterm, semistructured parent phone interviews related to feeding and growth at home were conducted (n = 128). Post-SOFFI infants born at less than 37 weeks' gestation achieved full oral feedings in significantly fewer days than pre-SOFFI infants (P = .01). Time to achieve full oral feedings was not significantly different in post-SOFFI infants born at 37 or more weeks' gestation. Growth and length of stay were not significantly different at discharge. At follow-up, parents of post-SOFFI infants reported significantly fewer feeding problems overall (P = .01), less arching (P = .003), less vomiting (P = .006), and fewer infants seeing feeding specialists (P = .03). Results of the study support that NICU implementation of the SOFFI feeding program positively influences feeding outcomes before and following discharge.

Cue-based feeding in the NICU: using the infant's communication as a guide

Although studies have shown cue-based feeding can lead to earlier achievement of full oral feeding, the successful implementation of cue-based feeding has been constrained by the volume-driven culture, which has existed for many years in the NIC U. This culture was built on the notion that a "better" nurse is one who could "get more in," and infants who are "poor feeders" are ones who "can't take enough." The infant who feeds faster is often viewed as more skilled in this task-oriented approach. The feeding relationship and the infant's communication about the experience of feeding may not be nurtured. This article will explain the central role of the preterm infant's communication in successful cue-based feeding. When the infant is perceived as having meaningful behavior (i.e., communicative intent), the focus changes from a volume-driven to a co-regulated approach, through which the infant guides the caregiver. This is cue-based feeding.

The SOFFI Reference Guide: text, algorithms, and appendices: a manualized method for quality bottle-feedings

The Support of Oral Feeding for Fragile Infants (SOFFI) method of bottle-feeding rests on quality evidence along with implementation details drawn from clinical experience. To be clear, the SOFFI Method is not focused on the amount of food taken in but on the conduct of the feeding and the development of competent infant feeding behavior that, consequently, assures the intake of food necessary for growth. The unique contribution of the SOFFI method is the systematic organization of scientific findings into clinically valid and reliable, easily followed algorithms, and a manualized Reference Guide for the assessments, decisions, and actions of a quality feeding.A quality feeding is recognized by a stable, self-regulated infant and a caregiver who sensitively (responsively) adjusts to the infant's physiology and behavior to realize an individualized feeding experience in which the infant remains comfortable and competent using his nascent abilities to ingest a comfortable amount of milk/formula. The SOFFI Reference Guide and Algorithms begin with prefeeding adjustments of the environment and follow step by step through a feeding with observations of specific infant behavior, decisions based on that behavior, and specific actions to safeguard emerging abilities and the quality of the experience. An important aspect the SOFFI Reference Guide and Algorithms is the clarity about pausing and stopping the feeding on the basis of the infant's physiology and behavior rather than on the basis of the amount ingested. The specificity of each observation, decision, and action enables nurses at all levels of experience to provide quality, highly individualized, holistic feedings. Throughout the course of feeding in the NICU, the nurse conveys to parents the integrated details (observations, decisions, and actions) particular to their infant, thus passing on the means for parents to become competent in quality feeding, to enjoy feeding time into the future, and to gain in confidence as they watch their infants grow.