The how and when to begin oral feedings with high-risk preterm infants have long been debated in neonatal research and clinical settings. Without a doubt, breast milk is the ideal nutrition for human infants.1 Yet, mother's own milk is not always available to all infants and many preterm infants are not physiologically or behaviorally ready to go to breast even if gastric feedings are well established. Banked breast milk can be used for gavage or bottle-feedings; however, it seldom meets the unique caloric needs of high-risk infants. Most would argue through that, while perhaps not optimal, it is better than formula. Ideally, all preterm infants should be receiving breast milk as soon as gastric feedings are established, and as soon as they are developmentally able to begin oral feedings, the preferred method for all oral feedings is direct breast-feeding.2,3

The notion of providing the first oral feeding directly at breast is potentially a new concept for many neonatal intensive care unit (NICU) care providers, even those arguing for coregulatory or cue-based feedings. Recently, the National Association of Neonatal Nurses published a new guideline supporting best practices for provision of infant-directed feeding, and providing the first oral feeding directly at the breast or at least by a family member is outlined within these recommendations.4 The developmental frame work for cue-based feedings is grounded in using the infant's demonstrated readiness (physiologic and behavioral cue stability) as a marker for beginning and continuing oral feedings. Thus, the question becomes: "What if the infant demonstrates readiness cues and the mother is unavailable to provide the feeding directly at breast?" Considering whether it is in the best interest of the high-risk infant "to wait" can be the basis of highly debated discussions between care providers and families. I would argue that waiting or working together with the mother to be nearby as her infant nears oral feeding readiness is more important than having a bedside caregiver provide that first oral feeding according to cues and self-regulatory behaviors regardless of the mother's availability to breast-feed. Those who have worked to establish cue-based feeding protocols as the standard of care in the NICU may feel like this is contradictory to earlier recommendations for the oral feeding to be solely "cue-based," but I would argue that historically caregivers have routinely made these types of feeding choices and may be continuing to do so. Bedside caregivers might choose to ignore infant self-regulatory cues when their schedules do not permit orally feeding the preterm infant (there are 3 babies ready to feed at the same time), or when their schedules indicate that this is the best time for them as caregivers to provide an ordered feeding assessment, or the degree of support for nipple-feeding necessitates choosing to orally feed the infant when there is ample time available to meet the needs of the infant.

We need to make the same arguments in support of mother's provision of direct breast-feeding. Helping each mother to know and support her infant during direct breast-feeding might even call for a higher priority. Mothers will need more support to make this first oral feeding a positive and successful feeding experience, but the rewards far outweigh the costs, especially when it is feeding directly at the breast. In addition, the fact that this feeding experience has the potential to not only help the mother to better establish her milk supply but also increase the duration of provision of breast milk feedings for the infant is a justifiable motivator for healthcare professionals.5,6 Education for mothers during these early experiences needs to focus on providing support through properly positioning the infant, facilitating infant latch, and teaching mothers about practical assessment that they can make of true milk transfer. Helping mothers to understand all of these concepts will increase their confidence and motivation for other breast-feeding activities (ie, pumping, care of breasts, and milk storage) and overall long-term breast-feeding success.

Pineda7 found that preterm infants who had their first oral feeding experience directly at the breast with their mother had longer and more sustained durations of breast milk feedings while in the NICU (milk supply remained intact over the course of the stay). In addition, the first oral feeding, as a direct breast-feeding experience, was found to be associated with a higher likelihood of infants receiving breast milk at discharge than for infants who receive breast milk in a bottle yet never experience direct breast-feeding.7 Although this is only one retrospective cohort study, the findings highlight the practice changes that need to occur. Initiating breast pumping earlier and continuously with electronic pumps is a start but is not enough to support high-risk mothers in successful provision of breast milk feedings at NICU discharge. Mothers must be supported to put their infants to the breast earlier and more often.

In a second study published that same year, Pineda8 found that older white mothers were more likely to be providing breast milk and direct breast-feedings at discharge from the NICU than other mothers of high-risk infants. These findings tell us that more and/or different strategies are needed to target and support the most at-risk infants, those of younger, underrepresented minority mothers. In a replication study of Pineda's earlier work, Casavant and McGrath9 not only demonstrated similar results but also found even stronger (significant) relationships between provision of direct breast-feeding at first oral feeding and provision of breast milk at discharge as well as increased numbers of direct breast-feedings during the NICU compared with mothers who were providing breast milk but were unable to provide the first oral feeding directly at the breast.9

The importance of establishing routine caregiving practices in the NICU that are truly supportive of exclusive breast-feeding mothers is imperative. Mothers often view breast-feeding as an important aspect of care they can uniquely provide for their high-risk infants. Caregivers who empower mothers in breast-feeding activities at NICU admission and throughout the NICU stay facilitate continued breast-feeding success after discharge. It has been demonstrated that if breast-feeding is not well established in the NICU, it is unlikely that it will be well-established after discharge.8,10,11

To facilitate the transition from gavage feedings to oral feedings, all parents, and especially mothers of breast milk-fed preterm infants, need to be encouraged to participate in kangaroo (skin-to-skin) care as soon as infant stability is achieved and as often as possible. Infant stability has even been found to be best facilitated with skin-to-skin care. Skin-to-skin care is well documented to promote breast milk production12 and maintenance of the breast-feeding duration.13 Education must be regularly provided to all families on the benefit of early and frequent skin-to-skin contact and at breast experiences. Parents also need to understand the philosophy underpinning infant-directed, cue-based feedings so that alternative feedings methods can be implemented and viewed as helpful tools when mothers are unavailable to breast-feed. Finally, parents need to understand that the journey to breast-feeding a preterm infant begins in the NICU but most often continues beyond discharge. By using appropriate strategies and providing parents the anticipatory guidance, clinicians provide families the best chance possible at the breast-feeding experience they so greatly desire and deserve.

Research clearly indicates that a cue-based approach to feeding preterm infants results in the most optimal oral feeding outcomes.4-6 While evidence is mounting regarding the benefit of providing breast milk and breast-feedings during the NICU hospitalization, clinicians must recognize the barriers families face when trying to participate in all their infant's oral feeding opportunities. Thus, our role must be to facilitate them and making sure not to add potential professional barriers for parents to overcome. Family and work responsibilities make it difficult for most mothers to be present for multiple feedings each day. Thus, it is vitally important that all members of the healthcare team communicate with families in a consistent, positive manner regarding the path to successful, direct breast-feeding. Caregivers need to formulate a partnership with families and put together a plan that ensures meeting the feeding goals of the family while meeting infant needs. The question then becomes what is the best method for provision of oral feedings to a preterm infant whose mother's ultimate goal is to breast-feed but cannot be present for all oral feedings? Formulating such a plan requires ongoing honest discussions with mothers about not only their personal breast-feeding goals but also how their ongoing breast- and bottle-feeding experiences affect their future goals, as well as their expectations for delivery of oral feedings when the mother cannot be present for direct breast-feedings. A realistic plan, detailing how the breast milk-fed infant will move to all direct breast-feeding, needs to be discussed and put into place with achievable goals as the infant transitions to the home environment.

Finally, helping mothers to celebrate successfully meeting direct breast-feeding goals is important to motivating them to continue breast pumping and milk storage activities. These activities are hard work, and the mother's commitment must be acknowledged as her efforts are supporting best outcomes for her infant. Celebrations can document the first direct breast-feeding as well as the completing a whole feeding at breast and other events that document the mother's commitment to this process. Empowering the family makes the most sense, and although infants live in the NICU for weeks and even months, they live with families for the rest of their lives.

It is fitting that this is my last neonatal expert column for the Journal of Perinatal & Neonatal Nursing. Family-centered oral feeding of high-risk infants has been a focus of my neonatal practice and research trajectory; I am excited to see how our practices will continue to support families and change in the future. I am honored to have written this column for the past 8 years. I have learned much in this role and am thankful to both Dr Susan Blackburn and Dr Susan Bakewell-Sachs for their editorial guidance and support. I also want to thank my editorial board colleagues as well as the readers for their feedback and encouragement over the years. I am saddened to not be continuing in this role but excited about moving into my new role as Co-Editor of Advances in Neonatal Care. Thanks for listening and keep up the great work caring for high-risk infants and families!!

-Jacqueline M. McGrath, PhD, RN, FNAP, FAAN

Associate Dean for Research and Scholarship; Professor

School of Nursing, University of Connecticut

Storrs, Connecticut

Director, Nursing Research

Connecticut Children's Medical Center

Hartford, Connecticut

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