You may not realize it, but each time you take a squirt of water from a sports bottle or sip a milkshake through a straw, your body is performing a series of coordinated actions known as suck, swallow and breathe (SSB).

In most people—even most newborn babies—this process is managed without much conscious control. However, many babies who are born prematurely—particularly those under 33 weeks gestational age—have not yet developed the neurological controls needed to perform this process. These infants need to receive nutrition through a feeding tube.

Up until recently, deciding when a baby was ready to transition from tube feedings to bottle feedings posed a challenge for nurses and physicians at the Neonatal Intensive Care Unit (NICU) at the Mass General for Children (MGfC). Thanks to recent research, the team now has a streamlined and objective process that improves care for babies born prematurely.

Bottle Feeding Challenges

Up until a few years ago in the MGfC NICU, the decision-making process was primarily a subjective one, explains Peggy Doyle Settle, MS, RNC, the NICU Nurse Director.

Babies were fed every three or four hours depending on how well they tolerated their feedings, and if a baby was awake, alert and showing rooting behavior, he or she would be offered a bottle regardless of gestational age.

This approach created some challenges, however.

“We looked at our practice and realized we were not very consistent with the way we initiated feedings or decided whether the baby wanted to feed,” Settle explains. “There was also disagreement between nurses and physicians when it came to assessing a baby’s readiness to feed.”

The team had also taken note of research suggesting that starting premature infants on oral feeding too soon was contributing to the development of oral aversions—a reluctance or fear related to eating, drinking or having anything near the mouth—later in childhood.

Implementing the Infant-Driven Feeding Scale®

In 2012, the NICU convened a multidisciplinary team of nurses and physicians to develop a new system for oral feeding based on a set of scoring tools known as the Infant-Driven Feeding Scale®. The scale was developed in 2007 by Ohio-based neonatal specialists Kara Ann Waitzman and Sue Ludwig.

As a first step, the team agreed they would not attempt to start oral feedings on premature infants until they were at least 33 weeks gestational age.

The team would then start to assess the infant’s “readiness to feed” using a five-point scale. A score of one on the scale meant that the infant was alert and fussy prior to care and showed rooting or hands-to-mouth behavior. A score of two indicated that the infant became alert once handled and showed some rooting behavior or took a pacifier.

At the opposite end of the spectrum, a score of 5 meant that the infant experienced unsafe changes in heart or respiratory rate during handling and thus was not ready to attempt oral feeding.

Oral feeding attempts would only begin after the infant scored a 1 or 2 on the assessment scale at least 50% of the time over a period of 24 hours.

After feedings began, two additional assessment scales were used to track the quality of the feeding (how much of each feeding was taken orally each session), as well as the amount of positioning support that caregivers had to provide during feeding.

Assessing the Changes

To test the effectiveness of this system, the team compared data from 82 infants who went through the new protocol to 95 infants in a historical control group.

Their analysis showed no significantly statistical difference between the age of the first oral feeding or in the number of days that it took the infants to transition to full oral feeding. They also found that it did not significantly increase the length of stay in the NICU, or the length of time between full oral feeding and discharge.

These results were encouraging as previous studies of the infant-driven feeding method had suggested the system increased length of stay in the NICU.

The infant-driven feeding system has been the standard of care in the NICU since July 2013. Settle says that the new process has helped to streamline care in the NICU and has given the team a common language to use when making assessments. It has also helped them to more rapidly identify infants in need of an early neurological evaluation.

“Sometimes you have a baby that shows he or she is ready to feed, but is unable to coordinate their suck, swallow and breathe response. We can now call neurology or get a feeding team consult so we can teach them to eat in a skillful way, rather than just waiting to see if they will figure it out themselves.”