Developing a complex intervention to assess the feasibility of cue-based feeding for preterm infants in neonatal units (CuBS)

Cue-based feeding is a co-regulated approach to feeding preterm infants transitioning from tube to oral feeding (Crossan & Pickler, 2004) that aims to respond to infant feeding and satiation cues. The infant, therefore, determines the timing, duration, and volume of oral intake. Proposed benefits of cue-based feeding are that it improves infant sleep and the earlier establishment of full oral feeding resulting in shorter hospital stays for preterm infants. However, a recent Cochrane review (Watson & McGuire, 2016) concluded that there was low quality evidence that cue-based feeding leads to earlier transition to full oral feeding. The overall aim of our study is to assess in three UK clinical site: a) whether a cue-based feeding intervention is acceptable to parents, babies and neonatal unit staff; and b) whether it would be feasible to conduct a clinical and cost-effectiveness study. This 21-month feasibility study, informed by the Medical Research Council guidance on evaluating complex interventions (Craigie et al 2008) has four phases. Phase one, reported here, Cue-based feeding is a co-regulated approach to feeding preterm infants transitioning from tube to oral feeding (Crossan & Pickler, 2004) that aims to respond to infant feeding and satiation cues. The infant, therefore, determines the timing, duration, and volume of oral intake. Proposed benefits of cue-based feeding are that it improves infant sleep and the earlier establishment of full oral feeding resulting in shorter hospital stays for preterm infants. However, a recent Cochrane review (Watson & McGuire, 2016) concluded that there was low quality evidence that cue-based feeding leads to earlier transition to full oral feeding. The overall aim of our study is to assess in three UK clinical site: a) whether a cue-based feeding intervention is acceptable to parents, babies and neonatal unit staff; and b) whether it would be feasible to conduct a clinical and cost-effectiveness study. This 21-month feasibility study, informed by the Medical Research Council guidance on evaluating complex interventions (Craigie et al 2008) has four phases. Phase one, reported here, Cue-based feeding is a co-regulated approach to feeding preterm infants transitioning from tube to oral feeding (Crossan & Pickler, 2004) that aims to respond to infant feeding and satiation cues. The infant, therefore, determines the timing, duration, and volume of oral intake. Proposed benefits of cue-based feeding are that it improves infant sleep and the earlier establishment of full oral feeding resulting in shorter hospital stays for preterm infants. However, a recent Cochrane review (Watson & McGuire, 2016) concluded that there was low quality evidence that cue-based feeding leads to earlier transition to full oral feeding. The overall aim of our study is to assess in three UK clinical site: a) whether a cue-based feeding intervention is acceptable to parents, babies and neonatal unit staff; and b) whether it would be feasible to conduct a clinical and cost-effectiveness study. This 21-month feasibility study, informed by the Medical Research Council guidance on evaluating complex interventions (Craigie et al 2008) has four phases. Phase one, reported here, involved building the evidence base that will underpin development of the intervention. It comprised a systematic review of the components, characteristics, theoretical basis and associated behaviour change techniques (BCTs) of cue-based feeding interventions; three case studies of neonatal units (NNUs) with embedded cue-based feeding; a telephone survey of 18 NNUs across the UK; and qualitative research involving parents and staff in three sites. In total, 25 studies were included in the review. Only one new trial of cue-based feeding versus scheduled feeding has been published since the Cochrane review (Watson & McGuire, 2016). Interventions tested do not appear to have a theoretical basis, although various models of infant feeding have been used. Education- based BCTs were cited most frequently by included studies. The 18 NNUs from across the UK were surveyed and classified according to the level of integration of cue based feeding into the transition from tube to oral feedings; not at all embedded, considering changes, and making changes. The key driver for implementation of cue-based feeding was a move towards family integrated care and UNICEF Baby Friendly Initiative accreditation. The approach varied greatly across NNUs, regardless of their level of integration. The case studies of three sites (Glasgow UK, and Uppsala and Falun in Sweden), were selected on the basis of different approaches in terms of the population of infants eligible, how the cues are assessed, and the practicalities of implementation. The research across the three primary sites for the study included 32 staff from a range of disciplines, and 15 parents. Staff demonstrated a good understanding of, and were largely positive towards cue-based feeding, albeit with some safety concerns. Start cues were mentioned more often than stop cues, and staff felt that training for nursing staff as well as parents would be needed. Parents felt that feeding was an important step in establishing their identity as a parent, with oral feeding seen as the last hurdle before going home. Parents said they pay close attention to their baby’s cues and noted the potential usefulness of visual images of feeding cues. Parents’ experiences of using cue-based feeding were not always congruent with staff’s perspectives. These findings highlighted the need for a theory driven intervention. The inconsistencies in cue-based feeding practices across neonatal units coupled with staff’s safety concerns suggest a need for a feeding protocol. To support its implementation in practice interventions should focus on motivational, volitional and educational strategies. Acknowledgement This study is funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (project reference16/ 144/05). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.