Problem-Solving: Initiating PO Feeding in the NICU


My colleagues and I have been discussing the age at which to start bottle feedings. I realize it will depend on the child’s development, their history, their stress level, and rooting behavior. But in writing a policy for the NICU for cue Based Feeding I was hoping for a starting age. We’ve said 33 weeks or greater. I have a NICU manager who is pushing for 32 weeks, and a neonatologist who wants to stay away from a defining age. Currently we have “CBF to begin 33 weeks or later. Any infant younger than 33 weeks to be assessed by speech therapist first.” But that last statement has yet to be approved. And I was hoping to have literature to back the age. Any feedback is much appreciated.


The question about when NICU infants initiate PO feeding is of course multi-factorial, so PMA (post-menstrual age) is just one factor. Unfortunately, while it puts us in “the ballpark”, it has little value in and of itself. The PMA has significance, I like to say, in the context of the infant’s co-morbidities and history. Considering only PMA without regard for co-morbidities and history can lead to first PO feedings that are physiologically stressful, adversely affect neuroprotection and set the stage for feeding early onset refusals as a result, as you know. Some infants at a particular age, for example, 37 weeks PMA may not be ready/appropriate to PO, often due to the sequalae from their co-morbidities and history.

As I teach across the US regarding NICU feeding/swallowing practice, the earliest I have heard PO feeding being initiated is 31 weeks PMA. This has typically been a healthy preterm stable on unassisted RA and with a clean history; but even then, readiness of requisite subsystems, such as postural/head/neck control and state modulation, may not be available for that infant, and the suck-swallow-breathe interface is likely quite precarious. Asking the infant to feed 9 weeks prior to his due date would be worrisome. The push to “get infants out” and the desire to “get infants home” has created undue pressure on the infants, staff and in-turn on families to “get it in”.

Perhaps that is why the neonatologist is suggesting avoiding a defining age and is looking instead, hopefully, at a more global assessment of the infant. Alternatively, he/she may be leaving the door open to push harder unfortunately . Carrie Anne’s reference should be helpful but unfortunately Dr. Pickler often has a focus on “practicing” PO as a benefit and the pathway to good outcomes. While some in the NICU think “practice makes perfect” when it comes to feeding, unfortunately, when feeding attempts are ill-timed or are not truly supportive, then “practice”  only makes “permanent”   the emotional overlay and activation of the HP axis/cortisol release associated with physiologic stress in preterms, that likely co-occurs with trying to feed and struggle. Contrast that with an infant-guided feeding approach , truly cue-based PO feeding, that focuses on the experience and neuroprotection, versus intake.

Individualized readiness using multiple factors, one of those factors being PMA, is ideal an most supportive of neuroprotection. I am not aware of any research that has specifically determined “the age” to start, as so many variables indeed must be taken into account as I referenced above. That would be a hard study to do and do well. My thought is that 33-34 weeks PMA is likely most typical across the US based on feedback I solicit in every city I teach. If you can help to build criteria that encompass not only age (PMA), but a more comprehensive look at the infant, then perhaps there will be room purposefully built in to individualize and assess that unique infant’s readiness in the setting of his co-morbidities and history.

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