Fed When Hungry, Premature Babies Go Home Sooner

Release Date: February 16, 2010 | By Christe Bruderlin-Nelson, Contributing Editor
Research Source:

Although many parents and health care providers attempt to schedule a preterm newborn’s feeding pattern, a new review of studies reveals that feeding in response to the infant’s own hunger cues might result in earlier discharge from the hospital.

As preterm infants mature to about 34 weeks old — approaching what would have been full term — it might make be time to ease away from rigid schedules, suggested review co-author William McGuire: “Maybe we should be more holistic and baby responsive, especially in regard to feeding. Maybe the babies know what they want and need better than we do.”

McGuire is a professor of child health at the Centre for Reviews and Dissemination at Hull York Medical School, in England.

The researchers performed a search of the Cochrane Neonatal Review Group to find eight pertinent studies, which included between 13 and 150 preterm infants. Six studies took place in the United States and two took place in Canada.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

The authors focused on randomized controlled trials that compared demand or semi-demand feeding with scheduled feeding in preterm infants who were transitioning from tube feeding to oral feeding.

Demand feeding means feeding the infant in response to their hunger cues (crying) and satiation cues, such as releasing the breast or bottle and refusing it when they are full. In semi-demand feeding, caregivers assess the infant for at regular intervals and feed the infant if hunger cues are present. If the infant is sleeping soundly, the infant will receive a tube feeding when scheduled.

Of the eight studies, three found that demand or semi-demand feeding allowed for earlier discharge by about two to four days. However, the studies were small and had methodological weaknesses that made it difficult to draw solid conclusions.

The current standard of practice for premature babies is scheduled interval feeding, but that doesn’t mean it’s the ideal.

“Feeding preterm infants in response to their hunger and satiation cues rather than at scheduled intervals might help in the establishment of independent oral feeding, increase nutrient intake and growth rates and allow earlier hospital discharge,” the reviewers say.

Moreover, McGuire said, “if babies do establish feeding and get discharged sooner” there would also be less overcrowding on hospital units and fewer transfers, which are bad for both babies and families.

“This review very clearly highlights the paucity of truly good feeding studies in which mothers and infants were allowed or encouraged to establish breastfeeding ‘rhythm’ early in life,” said Jay Gordon, M.D., attending pediatrician at Cedars Sinai Medical Center and associate clinical professor of pediatrics at UCLA Medical School.

“My personal experience is that even the most caring and skilled neonatologists exhibit extreme tunnel vision about feeding and illness outcomes later in a baby’s life,” Gordon said. “I’m certain that they care; they just exhibit a strong bias towards short-term rather than long-term outcomes.”

Gordon would like future such studies to specify whether infants are receiving breast milk or formula. “Excellent studies have established that not breastfeeding increases the number of ear infections, hospitalizations and even first year deaths,” he said. “Studies have also shown that hospital physicians and nurses can increase the incidence and success of breastfeeding by their behavior.”

Lead review author Felicia McCormick said she would like to see more research into transitional care wards, “where mothers and their babies who are not ready for home but don’t (any longer) need to be in intensive care can stay together.”

Transitional care wards have staff with neonatal expertise and around-the-clock staffing by midwives and nurses “who can support mothers to enjoy their babies and become knowledgeable and confident in caring for and feeding them,” said McCormick, at the mother and infant research unit in the Department of Health Sciences at the University of York.

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Reach the Health Behavior News Service, part of the Center for Advancing Health, at (202) 387-2829 or hbns-editor@cfah.org.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

McCormick FM, Tosh K, McGuire W. Ad libitum or demand/semi-demand feeding versus scheduled interval feeding for preterm infants. Cochrane Database of Systematic Reviews 2010, Issue 2.

Tags for this article:
Pregnancy/Childbirth/Breastfeeding   Medical/Hospital Practice   Promote your Health  

Comments on this article
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Jenny says
February 17, 2010 at 11:58 AM

I have one point to make; crying is the last feeding cue, arm mouthing/tongue-poking, arm waving, kicking/stretching/bicycling legs and grunting are all feeding cues, and will be exhibited before crying. Waiting for a baby to cry before you feed it means you've missed the initial feeding cues, and can lead to poor latch (in breastfed infants) and gulping/air swallowing. For a preemie crying for feeds is a waste of calories, as well as raising cortisol levels in such a vulnerable and rapidly developing brain.

Kathy says
February 17, 2010 at 7:30 PM

I wonder if a better approach than scheduled or demand feeding would be to mimic how the child would be fed in the womb -- continuously (or nearly so).

LLL Leader says
February 18, 2010 at 10:18 PM

Agreeing with Jenny

Neonatologist/IBCLC says
February 19, 2010 at 11:02 AM

agreeing with Jenny too... and glad to see research evidence for what makes sense.

charla says
February 19, 2010 at 11:52 AM

agreeing with Jenny as well, we have a long way to go!

ann says
February 19, 2010 at 1:46 PM

Agree with Jenny on defining feeding cues. However, we cannot determine if crying was the only demand cue utilized here but rather an example of what a cue might be.

Tracy says
February 20, 2010 at 8:31 AM

My only concern would be if the neonate was getting enough calories. Scheduled feeds are based on calorie needs/day/kg. Would this approach possibly result in the neonate becoming calorie deficient? I totally agree with Jenny, we then have neonates using energy, which could result in weight loss, or temperature instability. But interesting research to continue to follow.

Derek / Neonatologist says
February 23, 2010 at 1:54 PM

We have attempted

Karen S. Geertsen says
March 2, 2010 at 2:33 PM

My background is NICU. I have seen for myself the avoidance behavior premies exhibit when forced to feed beyond their hunger levels. We followed a schedule at our hospital and sometimes the babies would cry, vomit a feed, or just go limp for lack of energy.
I now work outpatient with infants. The Pediatricians and I are all for demand feedings and not for scheduled feeds. Our job entails how to get parents to notice feeding cues and how to feed babies when they ask for it.
I was happy to see this article. We need advocates for these helpless, precious newborns.

sudarshan kumari. india says
March 8, 2010 at 10:46 AM

In nicu to make it convenient for nurses, scheduled feeds are ordered ,as nurses need time for other procedures in nicu. It is not uncommon that premies gain less weight when in hospital, we always tell mothers that once babies will be at home weight gain will be faster, this is true in our set up where grandmother rules the schedule , insisting feeding when ever demanded by baby,every 2-3hrs . Shortage of nurses prevents demand feeding in many nicus, the lesson is let the baby decide for feeds himself. of course this applies to neonates who have no problem other than weight gain at disachrge.
It is not uncommon to discharge babies before they attain birth weight, but gestation shouldbe at le

jennifer says
April 15, 2010 at 1:38 AM

As the mom of two ex 32-week preemies and now a 2 1/2 month old full-termer, as well as being a baby nurse for 10+ years, I have always hated the idea of scheduled/forced feedings, ESPECIALLY bottle-fed babies. If a breast-fed neonate can be allowed to nurse once within a 5-6 hour period, even if just for 10 minutes, why must a formula-fed baby be forced to consume 1+ ounce every 4 hours? I am always getting