To Feed or Not to Feed: Implementation of an EBP Project on Infant Driven Feedings™

Kelly Ackerman, BSN; Kyle Cassel, BSN; Margaret Chagnon, RNC; Deena Pendleton, RN; Stephanie Thompson, MSN, MBA, RN;

Mary Walters, MS, CRNP, RNC; Ann Johnson MSN, NNP-BC, RNC

Lynn Funk, OTR/L.CEIM; Bethany Roberts, MS, CCC-SLP; Susan J. Dulkerian, MD; & Shiv Kapoor, MD

Mercy Medical Center, Baltimore, Maryland

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infants: A prospective trial. American Journal of Perinatology, 25.13.Ross, E.S., & Philbin, M.K. (2011). Supporting oral feeding in fragile infants (SOFFI): An

evidence-based method for quality bottle-feeding of preterm, ill, and fragile infants. Journal of Perinatal & Neonatal Nursing, 25(4).

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Evidence was obtained from: Pub Med Cumulative Index to Nursing and Allied Health Cochrane Review National Clearinghouse for Clinical Guidelines Professional organizations from entire team

Articles: 28 articles and 16 were appraisedKey words: cue-based, infant-driven, feeding cues, feeding readiness, behavioral cues, demand-feeds, with related words neonatal and preterm.

Staff education will consist of: Utilize Online Infant-Driven Feeding® course

by Ludwig & Waitzman for medical providers & RNs

Mandatory hands-on session for RNs and nursing techs Review of feeding techniques – external

pacing and side lying positioning What not to do (chin & cheek support,

rolling and pumping the nipple) When to stop a feeding attempt Overview of feeding guideline How and when to using a feeding pump

Develop educational program for RNs pulled to NICU

Preterm infants transition from tube feedings to nipple at approximately 32-34 weeks post-menstrual age, when the infants’ neurodevelopmental status becomes more organized. This transition requires coordination of the suck-swallow-breath reflex, an organized state, and regulation of the autonomic system.⁶ However, the feeding practice in our 26-bed Level III Neonatal Intensive Care Unit (NICU) was based on a medically-driven feeding model (MDFM), which prescribes when to initiate feeds and the frequency of nipple feedings (NF) for preterm infants.

It was noted our practice related to feeding varied considerably and many NF were initiated prior to 33 weeks. Feeding techniques were based on rote and old practices passed down from nurse to nurse. It was common practice to encourage infants to take the prescribed volume, which equates to the nurses’ success, rather than focusing on a quality driven NF.

Areas of staffs’ concern: When to discontinuing a feeding attempt Type of nipple to use for bottle feeds Positioning of infant during feeds Techniques to promote intake Evaluation of feeding readiness (cues) Objectively rating the quality of feeding

An inter-professional “Chow Down Team” (nurse practitioner, nurses, clinical educator, occupational therapist, speech therapist, and physicians) initiated an evidence-based project to identify feeding methods, which would support the infant’s developmental needs, minimize negative oral stimulation, and decrease the number days to full oral feedings.

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What is the best evidence-based cue-based feeding model that supports the infant’s neurological development and is easily translatable to staff and parents?

Acknowledgements

Background

Recommendations

Practice Question

Evidence Education

Level Articles Summary Findings Quality

I

RCT

4

• Behavioral hunger cues can guide feedings progression without negative outcomes.• In the RCT, they initiated assessing cues at 32 weeks.• Using cues to guide feedings decreases the number of days to all nipple feeding.• One study noted a 50% reduction in the number of days to achieve all nipple feedings, which can potentially decrease length-of-stay & cost associated with hospitalization. • Two studies included infants with chronic lung disease (CLD) in their population. The authors recommended waiting to initiate nipple feeding until 34-35 weeks in the CLD group.

3 – A1 – B

II 0

III 1

• Delphi study validated the Infant-Driven Feeding Scales©, which identify and rates feeding readiness, the quality of nipple feeding attempts, standardizes feeding interventions, and documentation.

A

IV 4

• Recommends feedings are to be safe, pleasurable, developmentally appropriate, and allows the infant to drive the feeding.• Utilizes standardized tools or algorithm to assess feeding readiness, promotes consistency in practice, & teaches staff and parents about the method.

A

V 7• A breastfeeding quality tool can be used to rate breastfeeding attempts.• Recommends monitoring infant’s sucking bursts, behaviors, and signs for disengagement cues.

A

Thank you Mary Ann Dipetro for making the changes to the electronic medical record and Roy Hatch for your assistance with the literature search.

Initiate assessments for feeding cues at 33 weeks, 34 weeks for infants with CLD, & develop algorithm

Standardize the use of slow-flow nipplesUse side lying position, external pacing,

swaddling infantRemove infant from incubator for nipple and

gavage feedings to promote nurturingUse rating tools to score the quality of

breastfeeding and bottle feeding attempts⁴’ ⁹’ ¹⁶

Develop bedside tools to educate parents so they can assess their infant for feeding cues

Revise electronic documentation to reflect practice change

Perform a Pre & Post Survey of feeding practices Perform a prospective chart review to determine

infant outcomes before and after practice change to determine days to full oral feedings

References