Cue-Based Feeding: Who is Driving the Feed?

Kim Flanagan, MSN, CRNP / April 2017

Let’s face it: Back in the day, a NICU nurse who could encourage an infant to take the entire feed (every time) was considered a rock star. And, although I am ashamed to say it, I was a rock star. I considered my ability to get the last 5 or 7 mL into my patient to be a “skill”.

But that was the 1990’s… and we just didn’t know any better.

Parents desperately wanted their babies to go home. The last task on the requirements list was the ability to take full oral feeds in preparation for discharge. I certainly was not going to get in the way of that process. I wanted to care for my patient as best I could. If the physician ordered 30 mL q 3 hours, then I knew what I needed to do.

Thankfully times have changed, and today we DO know better. Yet knowing better does not always equate to a practice change for all. So the question is, who is driving the feeding when you feed a baby?

NICU Feeding: Volume/time based model

Traditional models of infant feeding are based on volume and time. Looking to primarily base feeding advance on weight gain, the focus tends to regard the feeding amount ordered as the goal. While physiologic instability is a clear indication to slow or stop a feeding, this may not always be understood or appreciated by the caregiver. The message the infant is sending (“feeding time is too much for me” or “this feed needs to be over”) may be lost in translation.

The consequences of not paying attention or clearly understanding these signs can have deleterious effects. It has been established in the literature that more than 50% of NICU parents report problematic feeding issues at 18-24 months post discharge, and the overall incidence of feeding issues in the preterm infant ranges from 18-90%.[1][2][3]  A volume-driven feeding would include the following strategies:[4]

  • Increasing flow rate/prodding
  • Providing chin/cheek support
  • Putting infant’s head/neck back
  • Continuing to feed despite signs of mild physiologic instability
  • Feeding unswaddled

NICU Feeding: Cue Based Feeding

By contrast, a cue-based feeding model would involve the following strategies:[5][6][7]

  • Providing a more controllable flow rate to protect the immature preterm infant’s airway and aspiration risk
  • Providing an elevated side-lying position with supportive swaddling
  • Providing co-regulated pacing, thus providing opportunity to coordinate the suck-swallow breath
  • Providing support for state regulation through re-alerting or calming
  • Using a developmentally supportive system understood by nursing and families
  • Avoiding prodding, twisting, or moving nipple inside infant’s mouth

Cue based feeding involves a paradigm shift in the way we interpret feeding success. It is based on the infant’s signs of readiness and tolerance of the feed, versus the amount ingested. In other words, it is quality verses quantity.

When reviewing the literature, one can see that cue-based feeding can lead to earlier achievement of full oral feeding. However, change takes time and education to universalize and standardize practice. Can you offer any insight as to how you work to implement cue based feeding in your unit? Let us know in the comments section below!



  1. Hawdon JM, Beauregard N, Slattery J, Kennedy G. Identification of neonates at risk of developing feeding problems in infancy. Dev Med Child Neurol. 2000; 42(4):235-239.
  1. Cerro N, Zeunert S, Simmer KN, Daniels LA. Eating behavior of children 1.5-3.5 years born preterm: parents’ perceptions. J Paediatr Child Health. 2002; 38(1):72-78.
  1. Mathisen B, Worrall L, O’Callaghan MO, Wall C, Shepherd RW. Feeding problems and dysphagia in six-month old extremely low birth weight infants. Adv Speech Lang Pathol. 2000; 2:9-17.
  1. Shaker CS. Feed me only when I’m cueing: moving away from a volume driven culture in the NICU. Neonatal Intens Care. 2012;25:27-32.
  1. Shaker CS. Cue-based co-regulated feeding in the NICU: Supporting parents in learning to feed their preterm infant. Newborn Infant Nurs Rev. 2013;13:51-55.
  1. Shaker CS. Nipple feeding premature infants: a different perspective. Neonatal Netw. 1990; 8(5):9-17.
  1. Cue-Based Feeding in the NICU: Using the Infant’s Communication as a Guide. Shaker, Catherine. Neonatal Network, 2013-11-01T00:00:00, vol. 32, no. 6, pp. 404-408(5). Springer Publishing Company

About the Author

Kim Flanagan, MSN, CRNP, has worked as a NICU nurse and Neonatal Nurse Practitioner for 20 years. She currently serves as the Clinical NICU Specialist for Medela, Inc. In this role, she works with NICUs across the country to maximize their use of human milk in the neonatal population to improve patient outcomes, patient safety and best practices.