What are best practices for beginning oral feedings for high-risk infants?

T he 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. 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. 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. 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