Improving Feeding Outcomes in the NICU: Moving From Volume-Driven to Infant-Driven Feeding

Current research on feeding outcomes after discharge from the neonatal intensive care unit (NICU) suggests a need to critically look at the early underpinnings of persistent feeding problems in extremely preterm infants. Concepts of dynamic systems theory and sensitive caregiving are used to describe the specialized needs of this fragile population related to the emergence of safe and successful feeding and swallowing. Focusing on the infant as a coregulatory partner and embracing a framework of an infant-driven, versus volume-driven, feeding approach are highlighted as best supporting the preterm infant’s developmental strivings and long-term well-being. The Impact of Prematurity Neonatal intensive care units (NICUs), along with technological advances, have contributed to the survival of tinier preterm infants. This has been particularly true for extremely low birth weight (ELBW) infants, defined as weighing less than 1000g (Hack, Friedman, & Fanaroff, 1996). In addition, over 40,000 infants born each year in the United States (approximately 1% of live births) are extremely preterm (EP) infants, defined as less than 28 weeks gestation at birth (Hamilton, Martin, & Sutton, 2004). The majority of these very small and extremely preterm infants survive. However, these improved survival rates bring an increased risk for motor, sensory, nutritional and growth problems (Hack et al., 2005; Hacket al., 1996; Msall & Tremont, 2002; O’Shea, Klinepeter, Goldstein, Jackson, & Dillard, 1997; Vohr et al., 2000). Early feeding difficulties that arise with the transition from tube feeding to oral feeding are prominent. Extreme immaturity alone may be sufficient to alter the typical path to learning feeding skills and predispose the infant to later feeding problems as well. Even at the time of discharge, these ELBW and EP infants may be sufficient feeders (able to take in adequate volumes) but not skilled feeders. They lack consistent and stable feeding skills across the day and are unable to flexibly adapt their feeding skills to changing conditions (Thoyre, 2003). While most infants are discharged from the hospital to home taking full breast or bottle feedings, many of these infants over time show negative feeding behaviors and slow velocity in their growth (Ross, 2009). While Kirkby and colleagues (Kirkby, Greenspan, Kornhauser, & Schneidermann, 2007) found that less than one percent of preterm infants required supplemental tube feedings at the time of discharge from the NICU, Hawdon and colleagues (Hawdon, Beauregard, Slattery, & Kennedy, 2000) found that over 50% of parents report problematic feeding behaviors in former preterms at the age of 18-24 months. The incidence of feeding problems in EP infants after discharge has been reported to range from 19-80% (Cerro, Zeunert, Simmer, & Daniels, 2002; Mathisen, Worrall, O’Callahan, Wall, & Shepherd, 2000; Sweet et al., 2003; Wood et al., 2003). Given these adverse feeding outcomes, it is critical to consider how the preterm infant experiences feeding early on and the conditions and strategies that may serve to be protective from developing a feeding problem that endures (Thoyre, 2007).