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.

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.