Risks of Volume-Driven Feeding Methods

Kim Flanagan, MSN, CRNP / June 2017


Did I accurately draw up the Epi in that code? Did I hear a murmur when I auscultated that baby’s chest? Does that baby’s abdomen look more distended?

Out of all the critical management decisions nurses make in the NICU, how we manage feeding a “feeder grower” is probably not high on the list of priorities. But it should be. Here’s why: How we feed our infant patients can have a critical effect on them, both now and later in life.

The traditional method of volume-driven feeds was once the best way we knew how to feed. Today there is a new paradigm in infant feeding, and it focuses on quality over quantity. This method offers nurses a better way to care for their patients by reducing risk of transitioning to oral feeds too early, and by setting them up for success (both in the NICU and beyond).

Traditional models of volume-driven infant feeding miss important cues

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 ordered feeding amount as the definitive goal. And while physiologic instability is a clear indication to slow or stop a feeding, this may not always be appreciated by the caregiver. The messages that the infant is sending, such as “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 such signs can have deleterious effects. There is evidence in the literature that feeding issues that are initiated in the early stages of childhood are likely to persist later in life. These can impact other aspects of the health and behavior of the child.

Oral aversion risks

Although many feeding problems can resolve over time, they have the potential to result in tremendous anxiety for parents, and may cause challenges within the parent–child relationship.[1] 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%.[2],[3],[4]  This can result in compromising the development of healthy eating habits for the child later in life. Thus it is clear that preterm infants in particular are at heightened risk for experiencing problematic feeding behaviors post-discharge.

Negative physiological impacts

In addition to impacting feeding issues both in the short-term and long-term, initiating feeds prior to infant readiness can potentially result in actual physiologic harm to the infant, inducing episode of apnea, bradycardia, and cyanosis. Moreover, it may place that child at risk of silent or overt aspiration and pneumonia.

Infant feeding guidance

It is important to be aware of these risks, and then ask ourselves: what kind of example do we want to set for our families? Parents learn not only from our words, but also from what we do as care providers.

Ideally, we want to set the example of quality of the feed over quantity. Having a clear focus on how the infant is managing and responding during a feed, instead of completion of a timely task, sets the infant up for success when parents will take on the challenging task of feeding their baby at home.

Infant feeding: Quality over quantity

How do you focus on quality over quantity feeds to protect the babies in your NICU? Let us know in the comments below!

Looking for more on this subject? Read Avoiding Oral Aversion in the NICU


  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.
  2. 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.
  3. 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.
  4. 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.


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, LLC. 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.