NICUs Rely on Infant-Driven Feeding to Assess Oral Readiness for Feeding

In 2015, the three neonatal intensive care units in the Cleveland Clinic health system implemented Infant-Driven Feeding®, a program to help ensure that transition to oral feeding for pre-term babies is safe and nurturing. Data from pre- and post-intervention questionnaires indicate that the Infant-Driven Feeding (IDF) approach has led to a more positive feeding experience for infants, families and nursing staff at NICUs on Cleveland Clinic’s main campus, Fairview Hospital and Hillcrest Hospital.

“One of our nursing philosophies at Cleveland Clinic centers around relationship-based care,” says Tina DiFiore, MSN, APRN, NNP-BC, CNS. “IDF is relationship-based. It is truly about partnering with the patient, seeing what’s right for that particular patient, and providing the baby exactly what he or she needs.”

Turning to an evidence-based program

Cleveland Clinic began using IDF to provide “the gold standard of care,” says Carol Bennett, MSN, MBA, APRN, PCNS-BC. “Feeding practices had long been based on customs rather than evidence, and we needed to get away from that.”

Previously, nurses would begin oral feeding of infants at 34 weeks gestational age, the time when most babies develop the suck, swallow, breathe reflex. But simply using gestational age as a benchmark didn’t take into account the physical and neurological development of each individual baby. IDF provides consistent and relevant assessment tools and feeding techniques to support each infant’s needs, promote positive oral feeding experiences and, ultimately, decrease patient length of stay.

“The last challenge that babies in the NICU have to overcome is effective oral feeding,” says Bennett. “Utilizing IDF could lead to shorter hospital stays. And that’s the overall goal – to get babies home with their families.”

Surveying nurses on attitudes about infant feeding

Bennett, DiFiore and Shelagh Stoicoiu, MSN, RNC-NIC, spearheaded the IDF implementation project. They wrote a grant and obtained funding from Cleveland Clinic’s Stanley Shalom Zielony Institute for Nursing Excellence to educate the healthcare system’s 238 NICU nurses. All of the nurses completed an online four-hour module that covers infant development in utero and after birth, the science of feeding, assessment for oral feeding readiness, feeding interventions and other topics.

Bennett and Marybeth Sevastos, MSN, MBA, NE-BC, nurse manager of the NICU at main campus, created a 10-question survey to ascertain nurses’ feelings about oral feeding pre- and post-intervention. The questionnaire uses a Likert scale, asking if nurses strongly agree, agree, are neutral, disagree or strongly disagree to statements, including the following:

• I feel comfortable feeding a pre-term infant.
• I feel documentation of caregiver techniques to aid in feeding is appropriate.
• I feel communication with team and parents is optimal.
• I feel that current pre-term feeding regimens are safe for infants.
• I feel I have the knowledge to determine “what” a pre-term infant is telling us at each feeding.

Data supports the decision to use IDF

Nurses completed the anonymous survey in January 2015, prior to implementation of IDF. Between July and November of 2016, they then took the same survey. Results from all three NICUs demonstrate that the IDF program is a success:

• Main Campus – Overall, the majority of questions received a more favorable response after IDF implementation. In particular, nearly all of the respondents to the post-intervention survey strongly agreed or agreed that they felt comfortable feeding a pre-term infant, they felt confident managing a pre-term infant’s oral feeding needs, and they had the knowledge to determine what a pre-term infant was telling them at each feeding.
• Fairview Hospital – Results from the post-intervention survey showed an increase in parents’ confidence about their feeding ability of pre-term infants. Nurses also believed that the techniques used to make the feeding event safe were in place, and that there was an emergence in communication related to successful feeding in the NICU.
• Hillcrest Hospital – The top three areas of improvement from pre- to post-intervention related to nurses’ perceptions that feeding regimens were safe, nurses were comfortable managing a pre-term infant’s oral needs, and feedings were initiated at optimal times.

IDF has many benefits for patients, families and nurses, with the primary one being safety. “We have done remarkable work in improving feeding safety in our NICUs by using the IDF tools and assessing oral readiness of our babies,” says DiFiore. In addition, families are included in the education process and understand nurses’ decisions on oral feeding of their infants.

IDF also helps strengthen the mother-baby bond by encouraging skin-to-skin contact. Kangaroo care is often initiated before 34 weeks gestation age as an adjunct to IDF. “It helps mothers to nurture their babies even with the separation of an infant being in the ICU,” says Bennett.

Another advantage is that IDF is individualized and developmentally focused, adds Bennett. “It’s a safer and more functional way to feed babies,” she says. “Overall, it has been a positive initiative for all three of our NICUs.”