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Cue-Based Feeding for Late Preterm Infants: 5 Facts You May Not Know

Research has shown that cue-based feeding for late preterm infants offers benefits, and it can be easy to read the cues if you're observant.

For over two decades, we’ve had good evidence that cue-based feedings are best for breastfed infants born at term. Until recently, the evidence for cue-based feeding for late preterm infants has been less convincing. Anyone listening to my interview with Dr. Tena Fry will gain some great insights that they might not have already known. But here are a few facts stand out in my mind.

Early and “mid” hunger cues are subtle

Tena emphasized that the earliest hunger cues are very subtle. These early cues include:

  • Stirring; making very small movements
  • Mouth-opening
  • Turning the head from side to side
  • Rooting towards an object

Mid hunger cues include:

  • Stretching
  • More movement of the arms and legs
  • Bringing hands to mouth (or even just trying to)

Late cues:

  • Agitated movements
  • Crying (with or without tears)
  • Turning bright red

Tena told us what we all know – babies can’t put their needs into words! But they do give us messages. If healthcare personnel and parents know what to look for, and focus on the cues, they can easily read these cues. I loved Tena’s simple advice to parents, “If a [breastfed newborn’s] eyes are open, offer him food!” I wholeheartedly agree.

Terminology is important

You already know how much I believe in the need to know terminology. So we talked about some pertinent terms.

The term “demand feeding” is not usually used these days because it implies that the baby is crying or “demanding” to be fed. Waiting until such “demanding” occurs is not helpful at all. Cue-based feeding means reading the cues listed above.

The term “provider-driven feeding” means that the physician (or possibly the nurse or the hospital policy) determines when and how much the baby eats. (I mentioned feeding “quotas” as they reflect volume-driven feedings, which, of course, are determined by the professional.) The term “infant-driven feeding” is more or less equivalent to cue-based feeding. If we promote cue-based feedings for late preterm infants, we more or less allow the baby to determine when and how much he eats. But that brings me to my next point.

Cues alone cannot determine when preterm infants are fed

As Tena pointed out, late preterm infants are “the great pretenders.” Never mind the fact that we often miss the cues. Sometimes, these babies simply don’t cue at all! They just sleep. But that doesn’t mean they don’t need food. Cue-based feedings for late preterm infants should be encouraged, but we cannot rely solely on the cues. However, we do need to observe for them.

Cue-based feedings provide many benefits

We all know that consumption of the mother’s milk nourishes and protects the baby. But Tena’s research study showed a number of other benefits. The most prominent benefits of cue-based feedings for late preterm infants included earlier discharge from the hospital (a cost-savings, of course) and that full oral feedings were accomplished sooner (so the baby could get rid of his IV sooner).

Late preterm infants have issues that impact feeding

As I’m fond of saying, late preterm infants are, by definition, born before term. That means that although we “house” them on the same unit with term babies, they do not have the same capabilities. As Tena reminded us, they are sleepier, have decreased respiratory function, have difficulty maintaining their temperature and glucose levels, and they are at higher risk for jaundice.

All of these factors impact the breastfeeding experience and the feeding plan in general. Very frequently, late preterm infants are readmitted to the hospital for dehydration and hyperbilirunemia, which, by the way, frequently go hand-in-hand.

Tena also pointed out that late preterm infants can have developmental delays. That’s a fact we sometimes forget about with late preterm infants.

The main takeaway here is that we need to encourage cue-based feeding for late preterm infants. Research has shown that this approach offers many benefits, and it’s fairly easy to learn the cues. But we must also remember that these babies have a number of difficulties, so sometimes feeding cues are absent. Therefore, we need to make sure we feed the baby even if cues are not present.

What kinds of cues do you look for in your baby?

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  1. Dee

    Can you please clarify in weeks what a late preterm infant? Some resources say 34.7-36.7 weeks. I was taught up to 38.5 weeks? If not, is a 38 -40 weeker considered term ?
    If so, is a 38.5 weeker the “same” as a 39-40 weeker? Again i was taight no, but the literature is confusing.

    • Marie Biancuzzo

      Dee, good question! And don’t feel silly for asking. Just recently, while revising my Lactation Exam Review course, I looked it up because I wanted course participants straight on it, once and for all. The confusion comes because there are different definitions. We all know that “preterm” infants are those who are born before term. But…

      Different organizations define “preterm” a bit differently. The World Health Organization has these definitions:
      • moderate to late preterm (32 to 37 weeks)
      • very preterm (28 to 32 weeks)
      • extremely preterm (less than 28 weeks)

      So if you’re taking the IBLCE exam, that’s what you want to know. However, if you’re in the United States, just doing your day-to-day job, you want to know something a little different!

      The American Academy of Pediatrics defines “late-preterm infants as those born at 34 0/7 weeks through 36 6⁄7 weeks’ gestation.”

      Hope that helps! Thank you for giving me the opportunity to clarify!

  2. Pingback:Breastfeeding babies born at 36 or 37 weeks – Kathryn Stagg IBCLC

  3. Pingback:Breastfeeding babies of 36 or 37 weeks gestation | Breastfeeding Twins and Triplets

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