Championing change: One feeding specialist’s advice for improving NICU feeding

Published by Ramya Kumar, M.S., CCC-SLP, BCS-S, CNT, IBCLC, NTMTC on Nov 27, 2023

By Ramya Kumar, NICU Developmental Coordinator at Abrazo Arrowhead Hospital; Speech-Language Pathologist at Arizona NICU Follow-Up Specialists

As a NICU feeding specialist, advocating for even a small change in practice can help decrease long-term feeding challenges for babies with a NICU stay. How feeding and breathing tubes are positioned and taped, supporting breastfeeding and the kind of pacifiers and bottles babies used all can impact NICU babies’ future feeding.

Simply put, priming NICU babies appropriately leads to more feeding success upon discharge. But any feeding specialist who’s worked in a NICU can relate to the roadblocks to improving feeding practices.

Consider the following scenario. Research shows that using a slow and consistent bottle nipple flow rate supports a baby’s feeding quality and eventual intake quantity. However, many well-meaning NICU staff members use a faster flow because they assume slower flows tire a baby out or make them work harder. This often creates a more stressful feeding experience for the baby and it can lead to inconsistency in practice.

In addition, many NICUs stock disposable nipples that come from formula companies. The flow tends to be inconsistent, and they’re not a product that families can access once babies are discharged.

While staying up to date with the latest clinical research is important and a crucial step in change management, simply citing that information to colleagues isn’t likely to help you make changes. What I found in my time working in NICUs and mentoring NICU teams is that creating a culture change takes time. It needs to be implemented in small steps that are systematic and strategic.

For example, with nipple flow practices in the NICU, here is what I’ve found works:

  1. If you are in a NICU that stocks disposable nipples, try choosing one brand based on flow rate. While we know that there is still inconsistency between each disposable nipple used, there is some predictability when choosing one brand instead of multiple options.

  2. Choose a small focus group of patients to test a research-based product. For example, try a new nipple and bottle system with the more vulnerable babies in the NICU, typically those who are born under 30 weeks. If you can show feeding improvement with this demographic, you may get more buy-in to gradually expand the process to other NICU babies and medical diagnoses.

Many logistical challenges make it hard for feeding therapists to change how feeding has always been done in some NICUs. Staffing is a common problem in every area of healthcare, including the NICU. And parents of babies who spend early weeks or even months in the NICU cannot always be present to assist with feeding as discharge nears.

The following are two challenges parents and NICU teams have to work together to overcome.

  1. Increase parent confidence and competence with feeding at discharge. Most parents spend a lot of time in the NICU with their newborn in the beginning when the baby is in an acute stage. As time passes, they have to go back to work or to care for other kids. However, these later stages of the NICU stay are crucial moments of learning and skill development –– for the baby and for the parents. Building parental confidence and competence in the early days and toward discharge should be an integral step in the process of transitioning from hospital to home.

  2. Focus on quality together with quantity. NICU staff are understandably focused on how much food a baby eats and how well they are growing. There is a big emphasis on numbers and percentages of intake rather than how engaged the baby is during feeding. Focusing more on quality by letting the baby guide the feeding pace more, even when it means a temporary drop in quantity, can improve feeding in the long run.

baby in an incubator with a nurse taking notes on a clipboard beside him or her

Planning and implementing changes in your NICU

Over the years, I’ve mentored many new clinicians motivated to implement all the research and practices they learn into their NICU. They’re disappointed to find that the existing culture can be hard to change. The key is to focus on slow growth and not to take resistance personally.

Following are eight tips to slowly implement changes that can improve care for NICU babies and their families.

  1. Learn the lay of the land and build trust. No one wants a new boss or employee to make changes immediately. Take your time and learn the culture you’re entering. Get to know your coworkers and make sure they know and trust you before you suggest changes. Enter from a space of learning and collaborating to optimize outcomes.

  2. Know your why. Many changes that would improve the experience for NICU babies take more effort and time – like slower or more frequent feeding. Knowing why these changes matter are necessary for explaining your position. Do your homework and bring research to support any recommendations you make.

  3. Identify NICU feeding champions. Find three clinicians open to helping you improve the NICU: a neonatologist, a neonatal nurse practitioner and someone from the nursing staff. This way, you have a team to support your goals, as well as perspectives from all the stakeholders. Always make sure you have representation from the night shift and day shift.

  4. Start small. Slowly pick low-hanging fruit when deciding how to make changes in your NICU. You can build on that initial success later.

  5. Pay attention to logistics. Anytime you introduce a new system, you’re changing and often adding workflow steps for the bedside staff. Find ways to help alleviate that work so that it doesn’t become the focus of negativity.

  6. Roll up your sleeves and help. Don’t be afraid to win over team trust by jumping in and helping with areas other than feeding. Changing diapers or holding a baby are some of the best times to talk about feeding. You’re sharing knowledge and supporting the baby and overall team in ways that set you up for a culture of collaboration.

  7. Track qualitative and quantitative improvement. NICU teams track the volume of feedings and some are also tracking readiness and quality of feeding sessions. Compare new data to the old data to see if the changes you implement are effective. I always recommended looking at 24-48 hours of data, rather than just a few feedings.

  8. Set babies up for success at home. Involving the parents, especially near discharge, can ensure continuity at home. For example, if a baby’s parents want to use a particular feeding system at home, have them bring it to the NICU to try it out.

Implementing changes in the NICU takes time, patience and resilience. Leading change in an environment that has long-standing practices is not simple, but the ability to impact long-term care and developmental outcomes is worthwhile. NICU feeding specialists have the power to shape children’s future, one mealtime at a time.

Ramya Kumar, M.S., CCC-SLP, BCS-S, CNT, IBCLC, NTMTC, specializes in infant and pediatric feeding development. She works with clinicians across the country and internationally through workshops and direct mentorship to improve NICU care practices.

Supporting a smoother transition to home for NICU babies

Published by Feeding Matters on Oct 02, 2023

New guidelines for NICU discharge can lead to radical improvements…as long as staff have the means to implement them  

man in a blue button-down shirt smiling

In his years as a neonatologist, Vincent C. Smith, MD, MPH, has found anecdotally and in his research that the clinician managing a family’s discharge from neonatal intensive care units (NICU) disproportionately impacts patient outcomes.

Smith, the division chief of newborn medicine at Boston Medical Center, led a study examining how families are prepared for discharge and found significant variability in outcomes. Families with a primary nurse invested in their transition home after NICU discharge fared better. “It wasn’t about gestational age, length of stay or medical complexity. That discharge clinician sets the course,” he says.

Smith wasn’t alone in his findings.

Clinicians across disciplines working with NICU families, as well as parents, find that whether families are ready for the dramatic adjustment of going from a team of clinical support to being on their own is usually left to chance.

Erika Goyer, parent liaison and communications director of National Perinatal Association (NPA), says, “Medical care is siloed. You have a high-risk pregnancy with one team. Once your baby is born and needs intensive care, they’re transferred to the NICU, and you move on to another team. As your baby progresses, you’re supposed to move on to a team at home. What that team comes down to at home is usually just you.”

An estimated 9-13% of newborns in the U.S. require neonatal intensive care for complex medical needs, a number that’s increasing.

To support these families, a cohort of multidisciplinary clinical leaders – including Feeding Matters – and parents came together to standardize NICU discharge. Their hope with the NICU guidelines is to improve families’ experience, reduce stress and help NICU babies access the follow-up care they need to thrive.

two parents, in the hospital, looking at their newborn in their bassinet

Why NICU families need more support

If you speak to NICU families after their first night home, says Smith, what’s true for all of them is that none slept comfortably. Even in the best circumstances, there tends to be a lack of continuity for families. “A lot of families feel abandoned by the NICU. They get their papers and their baby, and they’re joyous. Then they go from bells, whistles and lights, with 50 people around to just them and a baby. And they just had to make do.”

Kristy Love, executive director of NPA and NICU patient advocate, knows firsthand what it’s like to have a child in the NICU. Both of her children were NICU babies. She spent as long as three months in the hospital with one of her kids. What she’s found in her years supporting other parents is that not much has changed since she struggled to transition home with her preemie over 20 years ago. Parents still contact her as much as a year after leaving the NICU to share their struggles. “We have all this support in the NICU during our journey, and then once we go home we’re flying solo,” she says.

She shared her concerns with Smith at a board meeting for the National Perinatal Association, and from there, the NICU discharge guidelines were born.

NICU discharge guidelines explained

The National Perinatal Association spent a year looking at NICU discharge factors like research, protocols, insurance benefits and parents’ experience. The National Perinatal Association looked at NICU discharge factors like research, protocols, insurance benefits and parents’ experience. They worked together with a group of multidisciplinary experts, including Cuyler Romeo MOT, OTR/L, SCFES, IBCLC, director of strategic initiatives at Feeding Matters. Together the content experts finalized the NICU guidelines and submitted them to the Journal of Parentology for peer review.

The guidelines address topics like:

  • Basic information
  • Anticipatory guidance
  • Family and home needs assessment
  • Transfer and coordination of care
  • Other important considerations

Smith says there are around 300 guidelines, and no one expects NICUs to adopt all of them at the same time. The hope is that hospital neonatal teams will identify a few of the guidelines particular to their organization and population and then build from there. Over time, they can gradually implement all of the guidelines. nurse holding a baby

“Many people get overwhelmed when they see the challenges before them because they don’t necessarily have the team, resources or funding. I find everybody can make small changes leading to bigger changes,” says Smith.

Having peer-reviewed guidelines is an important step to improve all families’ experiences. Organizations like the American Academy of Pediatrics and others recommend that hospitals have a transition plan, but it was never formalized until now. “Everybody said you needed to have a plan in place to execute, but they weren’t given any guidance on it,” says Goyer.

Pilot program to put NICU guidelines into practice

Having NICU discharge guidelines is an important first step. Putting it into practice in the field is essential. When the team who wrote the guidelines looked for a NICU as a pilot program for implementing them, they chose Banner-University Medical Center Tucson.

Romeo, who served on the guidelines committee, is a clinician there. Plus, a local community partner, Smooth Way Home, helps families transition home from the NICU.

In January 2022, Romeo says they launched the pilot program by identifying barriers to a smooth transition home. Through crowdsourcing in the unit and close collaboration with the developmental RNs, Nancy Gates and Ashley Lee, they chose three areas of focus:

  • Processes: Discharge processes and coordination
  • Providers: Community provider readiness to accept infants into community-based care
  • Parents: Parent and caregiver education and advocacy to support optimal care and development at home

The team found that families may not receive developmental care support once they were discharged home. It was unclear if families referred to the Arizona Early Intervention Program (AzIEP) were receiving care. Not all children discharged from the NICU qualify for early intervention services despite their difficult beginnings. If they did qualify, getting that first appointment proved challenging. “Before piloting the guidelines, our NICU team would refer families to AzIEP and then have no way to know if they received care,” says Romeo.

A long standing barrier to accessing services after discharge was knowledge sharing. Nancy and Ashley reported that early intervention agencies often were unable to access the infants’ medical records. Without this information it was difficult for families to qualify for service.

To address these issues, says Romeo, the developmental RNs are leading the way in investigating process improvements for information transition while working closely with Smooth Way Home as a liaison for a warm handoff into the EI system.

It’s a multi-year pilot program that we hope will grow into a larger program if we are able to secure funding. Our families deserve to be well prepared so they can finally enjoy their baby at home.

Romeo says the guidelines lead to better outcomes, but funding remains the most significant barrier. “This work is done while the clinicians continue to fulfill their typical job demands. Nancy and Ashley do not have time allocated for this project, but they feel it is vital to the infant’s health and development so the work continues.” stethoscope, medical mask, and hearts on a blue backdrop Everyone involved says improving the continuum of care for NICU babies and their families requires tremendous work. But every level of improvement matters to the families who benefit from it. As Goyer says, “This is all about making sure families aren’t alone and have the support and skills they need from the clinicians and community around them.”

Visit NICU to Home for more information about the NICU guidelines.   Feeding Matters has been a strategic partner in creating and implementing the guidelines, together with NPA. For more information about how we help families of children with pediatric feeding disorder, click here.

Breastfeeding for babies in the NICU and beyond

Published by Joy Browne, PhD, PCNS, IMH-E on Sep 13, 2023

A comprehensive guide for navigating baby feeding for infants in the NICU By Joy Browne, PhD, PCNS, IMH-E Clinical Professor of Pediatrics at the University of Colorado School of Medicine Most expecting parents have the best intentions to breastfeed new babies. The science is clear that breast milk has the most benefits for a baby’s health even beyond the infant years. Mothers, too, reap emotional, mental and physical benefits from breastfeeding. But breastfeeding can be harder than it seems. The challenges are even greater for parents with babies in the neonatal intensive care unit (NICU) for any number of reasons, such as medical complications, a mother’s delayed milk production or a mother’s lack of access to the baby. That’s not to say breastfeeding babies in the NICU is impossible. With support, it certainly can be possible. And even those babies who can’t breastfeed immediately benefit from colostrum expressed at birth and skin-to-skin contact that lays a foundation for breastfeeding.

Can I breastfeed if my baby is in the NICU?

The journey of nurturing your newborn is more complex when your baby requires specialized care. One common concern is whether you can breastfeed a baby in the NICU. The answer is a resounding yes. Breastfeeding has many benefits, especially for premature or medically fragile infants. NICUs will often actively encourage and support breastfeeding, recognizing its vital role in promoting bonding, immune system development and overall growth. While it might require extra patience and support from both you and the NICU staff, remember that you are an essential part of your baby’s care team. Your commitment to breastfeeding can provide comfort, nourishment and a sense of familiarity to your baby during this critical time.

Benefits of breastfeeding in the NICU

A mother’s breastmilk is specially designed to meet their baby’s unique nutritional needs, whether they begin their lives in the NICU or typically develop and are born at term. Babies in the NICU, especially, benefit from breastmilk for their health and development. A study in shows, “…early human milk feeding is associated with a decrease in mortality and morbidity in the Neonatal Intensive Care Unit (NICU), decreased rates of illness and rehospitalization in the first year of life and improved neurodevelopmental outcomes.” We also know that a mother’s colostrum is a powerful protector. Many nurseries will ask mothers to express colostrum to be used for oral care and first tastes while in the NICU. Besides breastmilk’s nutritional benefits, breastfeeding also may facilitate bonding between mother and baby, reduce a mother’s stress levels, and decrease the risk of postpartum depression.

Is bottle feeding easier than breastfeeding?

It’s commonly misunderstood that breastfeeding is harder for babies than bottle feeding. Instead, studies show in many instances that breastfeeding is easier than bottles.
  • With bottle feeding, babies may work hard to extract milk from the nipple, expending extra effort to consume their required nourishment.
  • With breastfeeding, babies can grasp, latch and regulate milk flow according to their comfort and pace. They control how much they consume and how to coordinate their sucking with breathing.
Unlike some instances of hurried bottle feeding that might involve manipulating the nipple to facilitate milk intake, breastfeeding respects the baby’s innate rhythm of sucking, breathing and swallowing.

Why skin-to-skin contact matters for babies and new moms

One of the most important benefits of early breastfeeding is skin-to-skin contact. It’s an intimate and powerful connection a mother will have with a baby. Skin-to-skin contact creates physiologic organization of both the baby’s and the mother’s bodies. Following are some ways new babies and mothers benefit from skin-to-skin contact:
  • The mother’s body supports the baby’s temperature regulation. Once the fetus leaves its temperature-controlled environment of the uterus, the mother’s physiology heats up to ensure the baby is warm enough.
  • The mother’s breathing helps to regulate the baby’s breathing.
  • The mother secretes oxytocin, also called “the love hormone,” when the baby is nearby, supporting attachment as well as social and emotional development.
Even babies who aren’t breastfeeding can benefit from skin-to-skin interaction. In the NICU, younger and more critically ill babies are often transferred to their mother’s bodies so that the baby benefits from the mother’s ability to regulate their physiology. Skin-to-skin contact is now becoming a more standardized procedure for those babies who are stable enough to be off their mechanical support systems.

Continuing your breastfeeding journey beyond the NICU

Just because you know the benefits of breastfeeding doesn’t mean it’s easy. Having a baby in intensive care is extremely stressful – often coming after a stressful pregnancy, labor or delivery. The stress of these circumstances could interfere with successful breastfeeding, so mothers who can’t breastfeed should never feel guilty. Even with the best intentions, there are variables new mothers have to manage to be successful at breastfeeding. All mothers – especially those with babies in the NICU – need more support for breastfeeding from policies, NICU resources and community support. Following are some breastfeeding resources available:
  • Hospitals usually have lactation consultants on staff for in-patient support and outpatient appointments
  • LaLeche League operates in most communities.
  • The Affordable Care Act in 2011 made coverage of lactation consulting a federal requirement for mothers from the prenatal period through weaning. This includes the cost of breast pumps. If your health plan fails to provide coverage, the National Women’s Law Center has a script to use when calling a health plan.
  • SimpliFed provides a virtual baby feeding and breastfeeding support service, fully covered by health plans in all 50 states.

Continuing breastfeeding at home after discharge from the NICU

Babies in the NICU typically eat well at discharge but may have eating difficulties around two to four months. This is a period where babies’ brains are reorganizing, which leads to a change in the way they eat. It’s essential that babies get the most positive feeding experiences at this stage. Researchers have found that by three months, babies’ brains are about 65 percent the size they’ll be in adulthood, making the period around and right after a time of huge brain growth and organization of neurons. Any unused neurons are shed. This is why early experiences impact brain organization, and lay the foundation for all behavior – including eating. Professionals who support families after NICU discharge need more information about attending to the eating needs of these babies and their development. Educational programs about the science behind supporting babies’ transitions into their homes are essential for early intervention providers. By understanding the benefits of breastfeeding in the NICU and beyond, parents can make informed choices that support their baby’s health journey. It’s up to everyone who supports families with new babies to make caring for them easier.
Joy Browne, PhD teaches multi-disciplines in areas of development from newborn to very young infancy, especially for babies who start their lives in intensive care. Her research has helped to develop standards of evidence-based care for infant and family centered developmental care.