Feeding preterm infants in response to hunger and satiation cues may allow earlier hospital discharge

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.