Cue-Based Feeding: How to Facilitate Positive Opportunities for Breast and Bottle Feeding

Cue-based feeding is a broad term to describe a process by which parents and medical providers can successfully attend to developmental cues to promote optimal feeding opportunities. It is also referred to as infant-led or demand feeding. This approach may be used to heighten the quality of a baby’s feed through use of a developmentally supportive model to improve the caregiver-infant relationship during the transition to full oral feeds. When the focus of a feed is led by volume expectations, negative consequences may ensue—such as disinterest, oral aversion and reduced quality of feed—that may compromise safety of swallow.

Infants born premature or with a multitude of underlying diagnoses (respiratory, gastrointestinal, neurological, etc.) are at an elevated risk for negative feeding experiences. Despite the potential challenges experienced by infants with immature oral feeding skills, communication associated with feeding readiness often remains intact.

What does my baby communicate?

Readiness to eat (identifiable behaviors and reflexes) – Turn toward the breast or bottle (rooting), sucking, bringing hands to mouth, lip smacking and crying out. A “hunger cry” is considered a late attempt to communicate hunger. Attention to other ways your baby communicates hunger prior to crying out is encouraged.

Desire to stop feeding – Release from nipple, disengagement (loss of eye contact, turning head away), and fussiness.

Positive oral feeding experiences

Physiologic stability – No significant changes in heart rate, breathing or oxygen saturation levels. Signs of increased work breathing include movement of the nostrils or chest, color change and audible breath sounds.

State modulation - No unpredictable rapid transitions indicating poor regulation. For example, your baby may appear engaged one minute and fall asleep the next. This would indicate reduced state control.

Lack of stress signs – If you notice finger splaying, changes in facial expression (e.g., grimacing), saluting, hiccups, sneezing, yawning and gaze aversion, your baby may be communicating displeasure.

Engagement – Joint attention, smile and eye contact during feed.

Two techniques to promote cue-based feeding

1. Skin-to-skin (STS) or kangaroo care

• Place your baby on your chest for sustained, direct skin-to-skin contact.
• This will provide an optimal setting for your baby to communicate oral feeding readiness.
• STS allows a baby to become in sync with the rhythm of the heart and respiratory rate of the mother or father, regulates body temperature, creates less stress, and promotes biologic flexion (arms and legs toward chest with midline orientation).
• These experiences enable a baby’s brain to organize and focus on interaction and eating.
• Rooting toward the breast and placing hands to mouth during STS are cues that the baby is ready to feed.
• Crying out may be misinterpreted as a feeding cue; however, this is not always the case, as babies cry for a variety of reasons.

2. Attention and timely reactions to your baby’s oral feeding readiness cues

• According to a recent systematic review, “weight gain, time to full oral feedings, and hospital length of stay may be improved with use of cue-based feeding.”
• Your baby’s attempts to communicate may be misinterpreted or overlooked if not understood correctly.
• Be assured that as you begin to attend to the subtle efforts your baby makes to signal desire to feed, you will build competence and confidence to attend and react in a timely manner.

As always, if you are experience feeding issues with your baby, please contact your physician to request a feeding and swallowing assessment to be completed by a speech-language pathologist or an occupational therapist.