FUN-damentals of Feeding in the NICU … · NICU and thefirst oral feeding being at the breast....
Transcript of FUN-damentals of Feeding in the NICU … · NICU and thefirst oral feeding being at the breast....
4/15/18
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FUN-damentals of Feeding in the
NICU Lynn S Wolf, MOT, OTR, IBCLC
Four Key Concepts
• Have a plan • The baby is boss? • You’ve got to able to breathe • Go with the (correct) flow
1. Have a plan
Dodrill, 2008 • Survey of NICUs in Queensland Australia
• 80% response rate
• None had formal written policies or procedures for transitioning from tube to oral feeding
• 14% had formal evaluation of readiness for oral feeding; few had guidelines for assessing tolerance with oral feeding
Failing to Plan is Planning to Fail
Alan Lakein
A Plan vs Standard Care Semi demand (McCain 2001)
Cue based (Puckett 2008)
Infant driven (Chrupcala 2015)
Criteria driven (Simpson 2002)
Hybrid (Kirk 2007) • All have clear criteria for when to offer feeding • Sometimes criteria for when to stop feeding • All provide some research support for shorter time
to full oral feeding or shorter time to d/c
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Other Components • Non-‐nutritive sucking: shorter LOS; faster transition to
full oral (Pimenta 2008, Foster 2016, Fields 1982)
• Oral motor/sensory intervention: decreased LOS, faster transition to full oral, better efficiency, improved wt gain (Fucille et al 2002, 2005, 2010, 2011, 2012, Lessen 2011, Rocha 2007)
• Skin to skin: milk supply, breastfeeding exclusivity and duration, self-‐regulation, LOS, weight gain (Hake-‐Brooks 2008, Hurst 1997, Jayaraman 2017, Ludington-‐Hoe 2011, Oras 2016, Conde-‐Agudelo 2011)
• Smell, oral care with EBM: improved sucking skills, feeding interest (Rodriguez 2010, Yildiz 2011)
Characteristics of a Plan to Progress to Oral Feeding
• Evidence based
• Developed to meet the needs of your NICU
• Development and implementation includes many stakeholders
• It looks at the continuum of factors that contribute to a positive oral feeding outcome
• Clear criteria to move along continuum
• It is family friendly, including strong support of breastfeeding; families are active participants
The Complete Plan for Oral Feeding Progression
• Pre-‐Oral: trophic feeds, progress toward full enteral, STS, NNS, Oral motor/sensory interventions, smell and oral care with EMB; building milk supply
• Early Oral: breast if possible; clear criteria to start this step; follow baby’s lead
• Skill Building: Gaining energy/endurance, wakefulness, strength and coordination; balance between breast and bottle; this is the longest stage and there can be tension between breast and bottle feeding
• Discharge Planning: transition to home; competent, confident care givers
Step Wise Plan
Kamitsuka et al, 2017
Step 1
• 23 – 30 weeks • Odor cloths, Non-‐nutritive suck; skin to skin; oral care with breastmilk; minimize noxious oral facial input
Step 2 • 30+ weeks; full enteral feeds; HFNC ≤3L; oral readiness eval • Oral sensory-‐motor activities; pacifier dips; nuzzling at breast
Step 3 • 31+ weeks; Successful at step 2 for 7 days; HFNC ≤2L • Swallow practice – binky trainer 5mL over 10 min; slowly increased to 10mL
Step 4
• 32+ weeks; completed Step 3; on bolus feeds; min resp support • Followed Kirk el al (2007) plan with oral advancement a combo of infant driven, but with step wise advancement
Alberta Oral Feeding Progression Plan
(Premji 2004 , Lasby 2011)
PRE-ORAL
Infant
Characteristics
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NUTRITIVE SUCKING
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NUTRITIVE SUCKING
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NEONATAL ORAL FEEDING REFERENCE POSTER
Lasby 2011
to the NICU per year. The project took place in the level II NICU where allhealthy premature infants born at ≥30 weeks’ gestation were included.
Overall Framework
A quality improvement model was developed to translate IDF modelof care into nursing practice in our NICU. The IDF task force was formedand included representatives from nursing, physicians, occupationaltherapists, and lactation specialists. Task force members met regularlyonce or twice a month for the duration of the project and ultimately be-came IDF champions. As task force members, they were responsible fordeveloping the IDF guideline for the unit, educational materials fornurses and parents, a tool for auditing charts, and were responsible forconducting parental and nursing surveys. Teammembers performed lit-erature searches and group interviews with physicians, nurses, and par-ents to identify facilitators and barriers for developing and implementingIDF policies in premature infants. The project was divided into before-and after intervention phases, each lasted about 6months. The transitioninterval lasted about 3 months with a pilot study-taking place duringthat period. The after-intervention phase was measured after the IDFmedical guideline and nursing education campaign were completed.
Intervention and Implementation
All nurses working in the level II NICU were required to complete afive hour continuing education program which included a literature re-view, neurodevelopmental approach to oral feeding, principles of IDF,breastfeeding in the NICU, and a nipple feeding workshop. Numerousquestion and answer sessions with the nursing staff were conducted to
educate staff regarding specific implementations strategies for our NICU.The project was also discussed with the physicians in a division meetingto elicit their acceptance and incorporate their suggestions.
On the bases of the literature review, expert opinions and numerousunit discussions, an algorithm was developed to determine when aninfant was ready to start the IDF pathway and how the oral feedingscould be advanced (Fig. 1). Oral feeding progress was monitored forachievement of first and all oral feedings, weight gain, and necessity forfeeding therapist involvement. Feeding performance was not onlyevaluated by the amount of volume transferred during a feeding andtime of feeding, but also by readiness (behavior) behavior and qualitativefeeding assessments, used with permission from the IDFS© created andvalidated by Ludwig, S. & Waitzman, K.A. (2007; 2014) (Table 1).4,5 Spe-cial attentionwas given to the breast fed infants since direct breastfeedingis often overlooked in the NICU and evidence has shown that duration ofbreast milk feeding is positively associated with breast feedings in theNICU and the first oral feeding being at the breast.9 Exclusive breastfeedingfor at least 3 days before initiating any bottle feedings was offered tothe infants whose mothers were interested in breastfeeding. Details areaddressed in the algorithm for infant driven breastfeeding (Fig. 2). Educa-tion related to infant driven feeding was offered to all parents. A parentaleducational booklet containing language appropriate information on IDFwas given to every family participated in the project; neonatal nursesreviewed the material with parents before initiating feeding protocol.
Methods of Evaluation
A chart audit tool was developed to monitor infants’ feeding prog-ress. It was created to collect information on the PCAs at birth, at
Fig. 1. Algorithm for Infant Driven Feeding.
65P. Gelfer et al. / Newborn & Infant Nursing Reviews 15 (2015) 64–67
Decision Making Algorithms Gelfer et al, 2015
Algorithm for Infant Driven Feeding
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2. The Baby is Boss!
Or is he/she?
Feeder Controls Feeding
Infant Controls Feeding
Co-‐regulated Feeding
“Just Right Challenge”
Who is the BOSS of the Feeding? Why Co-‐regulated Feeding?
• At one end: stress, physiologic compromise
• At the other end: lack of progress
• Feeding is about learning: best learning is when there is the highest level of success (the “just right challenge”) in a non-‐stressful environment. • None of us learn well in a stressful environment
Feeder Controls Feeding
Infant Controls Feeding
Co-‐regulated Feeding
“Just Right Challenge”
Impact of Feeding on Brain Development
• Rapid brain growth in NICU
• Baby is “building their brain” during NICU stay
• Experience impacts brain development
• Current research supports the concept that early stress changes the way the brain develops in potentially negative ways
Pain Lack of satiation with drip feeds
NG tubes
Suction ET tube
Impact on brain development
Poor resilience to stress
More easily stressed by small things
Anxiety/depression/ hypervigilence
Food = stress Food selectivity and/or refusal
Maternal separation Gagging
Physiologic stress with feeding
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Long term impacts of stress around feeding
• Emotional problems from anxiety to phobias to PTSD have roots in fear, trauma and stress
• Preschoolers with very selective eating are more likely to be anxious or depressed and have hypersensitivity to taste and texture (Zucker et al, 2015)
Co-‐regulated Feeding: Choosing a Feeding Time
Feeder’s Role:
• Knows the window when feeding is expected
• Watches for signs baby is becoming more wakeful
• At that time helps baby come to most full arousal; slow and gentle
Baby’s Role:
• Has periods of greater wakefulness
• Show’s feeder if he/she is ready to wake fully or not when provided with appropriate help with arousal.
Co-‐regulated Feeding: Starting the Feeding -‐ bottle
Feeder’s Role:
• Makes sure baby is interested in sucking (pacifier)
• Proper position (adequate postural support)
• Chooses appropriate nipple flow rate
• Starts with empty nipple
• Always uses pacing at the beginning of feeding to assess baby’s initial response to feeding
Baby’s Role:
• Shows interest in sucking
• Able to initiate sucking on empty bottle nipple
• Physiologic stability as feeding starts
Co-‐regulated Feeding: During the Feeding
Feeder’s Role:
• Monitors baby’s moment to moment response to feeding (physiologic, behavioral) watch/feel/listen for very subtle cues
• Adjusts feeding as needed through pacing
• Recognizes importance of baby’s sucking pauses
• May provide some gentle encouragement as sucking pauses are longer
Baby’s Role:
• Coordinates suck/swallow/breathe to the best of their ability
• Provides cues to feeder as to how feeding is working
• As little drama as possible
During the Feeding: Subtle Stress Cues
WATCH -‐ especially the face
• Eye brows raised
• Eyes closed tight
• Eye blink
• Gaze aversion
• Brow furrow
• Color change
FEEL -‐ the babies body
• Changes in tone
• Head pulls back or turns slightly
LISTEN – to breathing and swallowing
• Tachypnea, apnea, stridor, rattle, obstruction
• Time between breathing pauses
• Swallow sounds
• SSB timing
Co-‐regulated Feeding: Ending the Feeding
Feeder’s Role:
• Notices baby slowing down and adjusts techniques
• More pacing?
• Depending on age and behavior may stop feeding to burp and re-‐wake
• Does not keep pushing baby when they get sleepy
• Does not use techniques to make baby suck “a little bit more” (cheek/chin support)
Baby’s Role:
• Sucking slows way down and probably stops
• Baby will probably get sleepy
• Gentle ending; no drama
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3. You’ve got to be able to Breathe!!
Sucking
Swallowing Breathing
Foundations of Infant Feeding
Medical Stability
State and Behavior
Parent Knowledge and Skill
Normal S/S/B Coordination
• Precisely coordinated timing
• Sucking is organized in bursts and pauses
• During the burst: SSB
• During the pause: breathing only
Swallowing Suppresses Breathing
• Swallowing and breathing do not occur simultaneously
• Breathing must stop for every swallow
• TRY IT!! Suck -‐ Stop breathe -‐ Swallow -‐ Start breathe -‐-‐-‐ Repeat
The Anatomic Challenge to Breathing During Feeding
Factors That Can Impact Breathing During Feeding
• Feeding induced apnea
• Ventilatory reductions during feeding
• Respiratory insufficiency • Structural • Disease related
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Feeding Induced Apnea (Deglutition Apnea)
Term -‐ bottle Preterm -‐ bottle Selley et al 1986
Cascade of Events in Feeding Induced Apnea
• Most frequently at the beginning and end of feeding; only noticed with very close observation
• This is a maturational issue; common to preemies, but not term infants
Mathew, 1988
Ventilatory Reductions During Feeding (Bottle)
Young preterm infants do not recover as well from the ventilatory reductions associated with bottle feeding.
Baseline Continuous Sucking
Intermittent Sucking
Recovery
Respiratory Rate
TcO2
36-38 weeks
34-35 weeks Shivpuri et al, 1983
Pulmonary and Cardiorespiratory Changes
• Respiratory Distress Syndrome
• Bronchopulmonary Dysplasia
• Congenital Heart Disease
Impact of IRDS/BDP on Feeding
• Reduced sucking rate and length of sucking bursts at term corrected age
0
10
20
30
40
50
60
70
80
No BPD Mild BPD Severe BPD
Sucks/Minute
Sucks/Burst
0
2
4
6
8
10
12
No BPD Mild BPD Severe BPD
Sucks/Burst
Mizuno et al, 2007
Impact of IRDS/BDP on Feeding
• Lower O2 saturations with feeding, at term corrected age
82
84
86
88
90
92
94
96
98
100
Non BPD Mild BPD Severe BPD
Oxyg
en
Satu
rati
on
Baseline
During feed
Mizuno et al 2007
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Impact of IRDS/BDP on Feeding
Feeding is very inefficient
ml/minute
0
1
2
3
4
5
6
7
8
9
10
Non BPD Mild BPD Severe BPD
Feed
ing
Eff
icie
ncy (
ml/
min
ute
)
ml/minute
Mizuno et al 2007
Other Respiratory Conditions that Impact Oral Feeding
• Congenital anomalies • diaphragmatic hernia • Congenital adenomatoid malformation (CAM) • Pulmonary hypoplasia • Paralyzed diaphragm
• Respiratory obstructions • Choanal stenosis • Malacia (laryngo, broncho, tracheo) • Glossoptosis
Parting Words on Breathing
(Let them take your breath away!!)
• Feeding is the most energy expending work of infants
• If you can’t breathe, you can’t feed
• So understanding respiratory issues for each baby is key to determining appropriate expectations
4. Go with the (Correct) Flow
If you don’t have the correct flow there are many dangers……
Impact of Flow on Feeding
• The higher the flow, the more challenge to the SSB mechanism
• High flow: 1 suck per swallow
• Low flow: 4-‐5 sucks per swallow
• Low flow allows much more time for breathing • Does the baby get less? • Think of the sprinter vs the distance runner
High Flow
• More likelihood of feeding induced apnea
• More likelihood of physiologic compromise which leads to increased fatigue
• More stress with feeding (trying to drink from a fast flowing hose)
• In general higher fatigue and less intake • Think of the sprinter and distance runner • High flow makes babies sprinters
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How do we manage flow?
At the breast:
• Depends on mom milk supply and baby’s ability to transfer milk
• High flow: pre-‐pump some or all of milk; nipple shield? pacing?
• Low flow: add supplemental flow system; wait for maturation
How do we manage flow?
With a bottle:
• Choose the right nipple
• Choose the right position
• Pacing during feeding
Nipple Flow Rates
0 5 10 15 20 25
Enfamil Preemie
Enfamil Standard
Enfamil Slow Flow
Similac Premature (red)
Similac Orthodontic
Dr. Brown's #1
Similac Slow Flow
Dr. Brown's Preemie
Simlac Standard
Dr. Brown's Ultra Preemie
0 0.05 0.1 0.15 0.2 0.25 0.3
Similac
Enfamil
Dr. Brown's
mL per min Coefficient of Variation (CV)
Comparative Flow Rates for Specific Nipples
Variability of Flow Rate Between Same Type Nipples
Pados et al 2015
Extra Slow Fl0w
For training of: • SSB timing and coordination • Swallowing
Binky Trainer Bionix Ultra Preemie
Feeding Position Horizontal Bottle Position
NO – Gravity increases flow rate
YES – Gravity effect is minimal
Feeding In Sidelying Support for Baby
• There are several choices for a horizontal bottle position in sidelying or very upright
• Amount of support needed depends on head control, maturation, and general medical condition • To optimize feeding, want to give as much postural
support as possible. • Less postural support may help keep baby awake,
but carefully weigh cost and benefit
• Younger babies will do best in a fully supported sidelying position
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Pacing • Stop flow by:
• Tipping baby up, bottle down (no milk in nipple) • Breaking suction • Removing bottle
• For feeding induced apnea • Stop flow after 2-‐3 sucks
• For insufficient ventilatory support • Stop flow after 5-‐10 sucks
• Has to be done before baby gets in trouble • Must be completely tuned in to baby to do it well
In Summary… • Your NICU should have a clear plan for oral feeding
that is multi-‐dimensional
• You are in charge of co-‐regulating every feeding you do with a baby to provide the “just right” challenge
• Always consider the impact of breathing on feeding
• Lean toward slower flow, rather than faster flow; volume will come when the baby has matured, gotten healthier and felt successful
References
Chrupcala, K.A., Edwards, T.M., and Spatz, D.L. (2015). A Continuous Quality Improvement Project to
Implement Infant-‐Driven Feeding as a Standard of Practice in the Newborn/Infant Intensive Care Unit. J Obstet Gynecol Neonatal Nurs 44, 654-‐664.
Conde-‐Agudelo, A., Belizán, J.M., and Diaz-‐Rossello, J. (2011). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev , CD002771.
Dodrill, P., McMahon, S., Donovan, T., and Cleghorn, G. (2008). Current management of transitional feeding issues in preterm neonates born in Queensland, Australia. Early Hum Dev 84, 637-‐643.
Field, T., Ignatoff, E., Stringer, S., Brennan, J., Greenberg, R., Widmayer, S., and Anderson, G.C. (1982). Nonnutritive sucking during tube feedings: effects on preterm neonates in an intensive care unit. Pediatrics 70, 381-‐84.
Foster, J.P., Psaila, K., and Patterson, T. (2016). Non-‐nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev 10, CD001071.
Fucile, S., and Gisel, E.G. (2010). Sensorimotor interventions improve growth and motor function in preterm infants. Neonatal Netw 29, 359-‐366.
Fucile, S., Gisel, E.G., McFarland, D.H., and Lau, C. (2011). Oral and non-‐oral sensorimotor interventions enhance oral feeding performance in preterm infants. Dev Med Child Neurol 53, 829-‐835.
Fucile, S., Gisel, G., and Lau, C. (2005). Effect of an oral stimulation program on sucking skill maturation of preterm infants. Dev Med Child Neurol 47, 158-‐162.
Fucile, S., McFarland, D.H., Gisel, E.G., and Lau, C. (2012). Oral and nonoral sensorimotor interventions facilitate suck-‐swallow-‐respiration functions and their coordination in preterm infants. Early Hum Dev 88, 345-‐350.
Gelfer, P., McCarthy, A., and Spruill, C.T. (2015). Infant Driven Feeding for Preterm Infants: Learning Through Experience. Newborn and Infant Nursing Reviews 15, 64-‐67.
Hake-‐Brooks, S.J., and Anderson, G.C. (2008). Kangaroo care and breastfeeding of mother-‐preterm infant dyads 0-‐18 months: a randomized, controlled trial. Neonatal Netw 27, 151-‐59.
Hurst, N.M., Valentine, C.J., Renfro, L., Burns, P., and Ferlic, L. (1997). Skin-‐to-‐skin holding in the neonatal intensive care unit influences maternal milk volume. J Perinatol 17, 213-‐17.
Jayaraman, D., Mukhopadhyay, K., Bhalla, A.K., and Dhaliwal, L.K. (2017). Randomized Controlled Trial on Effect of Intermittent Early Versus Late Kangaroo Mother Care on Human Milk Feeding in Low-‐Birth-‐Weight Neonates. J Hum Lact 33, 533-‐39.
Kamitsuka, M.D., Nervik, P.A., Nielsen, S.L., and Clark, R.H. (2017). Incidence of Nasogastric and Gastrostomy Tube at Discharge Is Reduced after Implementing an Oral Feeding Protocol in Premature (< 30 weeks) Infants. Am J Perinatol 34, 606-‐613.
Kirk, A.T., Alder, S.C., and King, J.D. (2007). Cue-‐based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. J Perinatol 27, 572-‐78.
Lasby, K., and Dressler-‐Mund, D. (2011). Making the literature palatable at the bedside: Reference poster promotes oral feeding best practice. Adv Neonatal Care 11, 17-‐24.
Lessen, B.S. (2011). Effect of the premature infant oral motor intervention on feeding progression and length of stay in preterm infants. Adv Neonatal Care 11, 129-‐139.
Ludington-‐Hoe, S.M. (2011). Thirty years of Kangaroo Care science and practice. Neonatal Netw 30, 357-‐362.
McCain, G.C., Gartside, P.S., Greenberg, J.M., and Lott, J.W. (2001). A feeding protocol for healthy preterm infants that shortens time to oral feeding. J Pediatr 139, 374-‐79.
Mizuno, K., Nishida, Y., Taki, M., Hibino, S., Murase, M., Sakurai, M., and Itabashi, K. (2007). Infants with bronchopulmonary dysplasia suckle with weak pressures to maintain breathing during feeding. Pediatrics 120, e1035-‐042.
Oras, P., Thernström Blomqvist, Y., Hedberg Nyqvist, K., Gradin, M., Rubertsson, C., Hellström-‐Westas, L., and Funkquist, E.L. (2016). Skin-‐to-‐skin contact is associated with earlier breastfeeding attainment in preterm infants. Acta Paediatr 105, 783-‐89.
Pados, B.F., Park, J., Thoyre, S.M., Estrem, H., and Nix, W.B. (2015). Milk Flow Rates From Bottle Nipples Used for Feeding Infants Who Are Hospitalized. Am J Speech Lang Pathol 24, 671-‐79.
Philbin, M.K., and Ross, E.S. (2011). The SOFFI Reference Guide: text, algorithms, and appendices: a manualized method for quality bottle-‐feedings. J Perinat Neonatal Nurs 25, 360-‐380.
Philbin, M.K., and Ross, E.S. (2011). The SOFFI Reference Guide: text, algorithms, and appendices: a manualized method for quality bottle-‐feedings. J Perinat Neonatal Nurs 25, 360-‐380.
Pimenta, H.P., Moreira, M.E.L., Rocha, A.D., Junior, S.C.G., Pinto, L.W., and Lucena, S.L. (2008). Effects of non-‐nutritive sucking and oral stimulation on breastfeeding rates for preterm, low birth weight infants: a randomized clinical trial. J Pediatr (Rio J) 84, 423-‐27.
Premji, S.S., McNeil, D.A., and Scotland, J. (2004). Regional neonatal oral feeding protocol: changing the ethos of feeding preterm infants. J Perinat Neonatal Nurs 18, 371-‐384.
Puckett, B., Grover, V.K., Holt, T., and Sankaran, K. (2008). Cue-‐based feeding for preterm infants: a prospective trial. Am J Perinatol 25, 623-‐28.
Rocha, A.D., Moreira, M.E., Pimenta, H.P., Ramos, J.R., and Lucena, S.L. (2007). A randomized study of the efficacy of sensory-‐motor-‐oral stimulation and non-‐nutritive sucking in very low birthweight infant. Early Hum Dev 83, 385-‐88.
Rodriguez, N.A., Meier, P.P., Groer, M.W., Zeller, J.M., Engstrom, J.L., and Fogg, L. (2010). A pilot study to determine the safety and feasibility of oropharyngeal administration of own mother's colostrum to extremely low-‐birth-‐weight infants. Adv Neonatal Care 10, 206-‐212.
Ross, E.S., and Philbin, M.K. (2011). Supporting oral feeding in fragile infants: an evidence-‐based method for quality bottle-‐feedings of preterm, ill, and fragile infants. J Perinat Neonatal Nurs 25, 349-‐57; quiz 358-‐9.
Shaker, C. (2017). Infant-‐Guided, Co-‐Regulated Feeding in the Neonatal Intensive Care Unit. Part I: Theoretical Underpinnings for Neuroprotection and Safety. Semin Speech Lang 38, 096-‐105.
Shaker, C. (2017). Infant-‐Guided, Co-‐Regulated Feeding in the Neonatal Intensive Care Unit. Part II: Interventions to Promote Neuroprotection and Safety. Semin Speech Lang 38, 106-‐115.
Shaker, C.S. (2013). Cue-‐based Co-‐regulated Feeding in the Neonatal Intensive Care Unit: Supporting Parents in Learning to Feed Their Preterm Infant. Newborn and Infant Nursing Reviews 13, 51-‐55.
Shaker, C.S. (2013). Cue-‐based feeding in the NICU: using the infant's communication as a guide. Neonatal Netw 32, 404-‐08.
Shaker, C.S. (2013). Reading the Feeding. The ASHA Leader -‐ American Speech-‐Language-‐Hearing Association , 42-‐47.
Simpson, C., Schanler, R.J., and Lau, C. (2002). Early introduction of oral feeding in preterm infants. Pediatrics 110, 517-‐522.
Thoyre, S.M., Holditch-‐Davis, D., Schwartz, T.A., Melendez Roman, C.R., and Nix, W. (2012). Coregulated Approach to Feeding Preterm Infants With Lung Disease: Effects During Feeding. Nurs Res
Thoyre, S.M., Hubbard, C., Park, J., Pridham, K., and McKechnie, A. (2016). Implementing Co-‐Regulated Feeding with Mothers of Preterm Infants. MCN Am J Matern Child Nurs 41, 204-‐211.
Yildiz, A., Arikan, D., Gözüm, S., Taştekın, A., and Budancamanak, I. (2011). The effect of the odor of breast milk on the time needed for transition from gavage to total oral feeding in preterm infants. J Nurs Scholarsh 43, 265-‐273.