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.
Keywords: CO-PRODUCTION; CONSENSUS; CUE-BASED FEEDING; CUES; ENTERAL NUTRITION, QUALITATIVE RESEARCH; FEASIBILITY STUDIES; INFANT NUTRITIONAL PHYSIOLOGICAL PHENOMENA; INFANT, PREMATURE; NEONATAL INTENSIVE CARE; NEONATAL UNITS; NEONATE; PARENTS; PRETERM INFANT; RESPONSIVE FEEDING; WEIGHT GAIN.
Preterm babies who are ready to progress from tube feeding to oral feeding are usually fed according to a fixed schedule. Scheduled feeding protocols set a minimum corrected gestational age at which oral feeding may commence, and specify the rate of change from tube to oral feeding. Scheduled feeding also sets the volume and timing of each feed. A few small studies show that feeding babies according to their cues might have benefits for them and their parents; for example, babies may be discharged from hospital sooner. Cue-based feeding may help parents to understand the needs of their baby and be more involved in their care. Examples of hunger cues are mouthing movements, bringing hands to mouth and sucking. Examples of stop cues are falling asleep and stopping sucking. We developed a cue-based feeding intervention and tested it in three neonatal units to see if a large trial could be done and if parents and staff liked the intervention. We reviewed previous research, visited three hospitals that use cue-based feeding and interviewed parents and staff about their experiences of feeding preterm babies. We developed the intervention with parents and staff. The intervention included a feeding protocol, training for parents and staff, and a feeding record. Parents and staff liked most parts of the intervention. The training did not reach all staff, and staff and parents found it time-consuming to record every feed. Many parents and staff thought that cue-based feeding was better for babies, and parents thought that neonatal units should change to cue-based feeding. We discussed our findings with parents, staff and research experts. Based on their ideas, we recommend that the intervention is developed into an app (application) and that all neonatal units in the UK are surveyed to find out if they use cue-based feeding and if they would agree to be part of a large trial.