POLICY/PROCEDURE TITLE:
Feeding Progression in the ISCC:
Individualized Enteral Advancement Table
(iEAT) & Infant Driven Feeding (IDF)
Women & Infant Services
RELATED TO:
[ ] Medical Center Policy (MCP)
[X] Nursing Practice Stds.
[ ] JCAHO
[X] Patient Care Stds.
[ ] QA
[ ] Other
[ ] ADMINISTRATIVE
[ X] CLINICAL
PAGE 1 OF 1
Effective date: 3/1/08
Reviewed date: 7/22/09
Revision date: 3/1/08
Unit/Department of Origin: ISCC
Other Approval:
[ ] Title 22
POLICY STATEMENT:
It is the policy of the ISCC to promote optimal oral feeding and nutrition of the preterm infant through
developmentally appropriate stages. The goal is to increase long-term breast milk provision,
breastfeeding, and reduce the risk of nipple and flow preferences for the bottle. Success with
supporting preterm breastfeeding requires an adequate maternal milk supply, and that staff
understand the skills associated with preterm maturation/readiness, recognition of cue-based feeding
signals, and knowledge of breastfeeding principles. At each step, the mother and staff have specific
roles. Lactation and Occupational Therapy will see each couplet at least once during each step.
RESPONSIBLE PARTY: Mothers and infants in the ISCC, Registered Nurses, Lactation Consultants,
Occupational Therapists, Registered Dietician, Physicians and NNPs.
PROCEDURE:
1. Admission orders to include initiation of Infant Driven Feeding Protocol including skin to skin (S2S)
care. If infant is unstable for S2S it will be ordered to hold S2S until infant is stable.
2. Infants when ready for enteral feedings will be started on the individualized Enteral Advancemet Table
(iEAT) based on their weight. This will include a gradual increase in feeding volume by following the
iEATs and gradual increase in caloric content by fortification of milk with Human Milk fortifier and
protein powder as tolerated by the infant.
3. Both Infant Driven Feeding Protocol and Enteral Advancement Table will go forward simultaneously
and independently at the pace set by the infant cues and tolerance. These two pathways will overlap
as the infant reaches full feeding volume and begins oral feedings.
REFERENCES:
See Attachments: Infant Driven Feeding Steps
Enteral Advancement Table example
See Related Policies: MOTHER’S MILK: COLLECTION, STORAGE & PREPARATION
Skin to Skin Care in the ISCC (S2S)
UCSD Medical Center
page 2
UCSD Medical Center individualized Enteral Advancement Table
(iEATs) for Neonates <1000 gm Birth Weight (example)
Patient Name:
Medical Record #:
Weight:
Date: 3/1/2008
grams
Date &
Time
mL/kg
(to be given Q3 hours)
Weight
(kg)
Volume (mL) of
each feeding
Caloric density of
milk or formula
1st day of feedings
1.5
0.000
0.0
20 kcal/oz
2nd day of feedings
1.5
0.000
0.0
20 kcal/oz
3rd day of feedings
1.5
0.000
0.0
20 kcal/oz
4th day of feedings
1.5
0.000
0.0
20 kcal/oz
5th day of feedings
1.5
0.000
0.0
20 kcal/oz
6th day of feedings
2
2.5
3
4
5
5.5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
20 kcal/oz
7th day of feedings
8th day of feedings
9th day of feedings
10th day of feedings
11th day of feedings
12th day of feedings
13th day of feedings
14th day of feedings
15th day of feedings
16th day of feedings
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Comments
20 kcal/oz
20 kcal/oz
20 kcal/oz
20 kcal/oz
22 kcal/oz
HMF
22 kcal/oz
24 kcal/oz
24 kcal/oz
HMF
25 kcal/oz
Protein
25 kcal/oz
Step 1
Goal:
Skin-To-Skin Time
(Est. GA: <31 weeks)
Team Member
a) Encouragement of Skin-to-Skin (S2S) care
b) Establishment of adequate maternal milk supply
Role
Baby
Mother
LC
OT
RT
RN
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RD
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Infant stable to initiate S2S care
Infant tolerates S2S care
Mother is to put infant S2S 1-2 times a day as per ISCC S2S Policy
If infant displays interest or feeding cues while S2S, mother may place infant at or near the
breast to smell, lick, suckle and latch as able
Enroll in SPIN program
Initiate SPIN parent education
Pump rental
Assess milk supply, flange fit and pump technique prior to maternal discharge
Assess need for OT intervention
Assist in teaching of S2S transfer technique
Assess airway adequacy & infant stability for transfer to S2S care
Assist in teaching parents transfer to S2S technique and assist in actual transfer of infant to
mother (or father) for S2S care
Monitor infant tolerance of S2S care
Encourage daily S2S care
Initiate Infant Driven Feeding Step 1 Crib Card
Assist in teaching parents transfer to S2S technique and assist in actual transfer of infant to
mother (or father) for S2S care
Encourage daily S2S and document in flow sheet
Daily assessment of hospital supply of mother’s milk and maternal milk supply, document in
flow sheet; contact mother by phone when there is less than a 3-day supply of milk in the
freezer to request delivery, inquire about pumping or supply problems
Request additional LC appointments if: decreased milk supply, pumping pain, signs of breast
infection, parental pumping fatigue or any other concerns that may effect milk production and
supply
Initial nutritional assessment and verify maternal nutritional assessment completed.
Generate Individualized Enteral Advancement Table (iEAT) when infant ready to start enteral
feeding
UCSD Medical Center
page 4
MD or NNP
***Advance to Step 2***
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
Admission Orders to Include: Initiate Infant Driven Feeding starting at Step 1, initiation of iEAT
and Daily S2S care
 MD/NNP order to suspend for unstable infants only
When baby is 31 weeks adjusted gestational age
UCSD Medical Center
page 5
Step 2
Goal:
Going To The Breast
(Est. GA:31-33 weeks)
Team Member
a) To initiate non-nutritive breastfeeding (NNBF)
b) To encourage continued S2S care
Role
Mother
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LC
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Baby
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OT
RN
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Infant receives and tolerates daily S2S care
Infant begins rooting, licking and suckling at the breast (NNBF)
Infant begins to show readiness to take milk flow at breast by suckling for longer intervals
with an active alert state
Mother will pump to empty her breast prior to NNBF
Mother will receive instruction, assistance and monitoring to correctly position infant at breast
Infant will be placed at the breast and allowed to smell, lick, suckle and latch as able
If infant is too sleepy revert to S2S
While S2S, if infant displays interest or feeding cues, mother may place infant at or near the
breast to smell, lick, suckle and latch as able
Consult to assess pumping, milk production, proper flange fitting and assess for need of nipple
shield
Assist in initiating NNBF, provide instruction, assistance, and monitoring of correct position at
breast
Assess need for OT intervention
Assist in initiating NNBF, provide instruction, assistance, and monitor correct position at breast
Initiate Infant Driven Feeding Step 2 Crib Card
Continue to encourage daily S2S and document in flow sheet
Daily assessment of hospital supply of mother’s milk and maternal milk supply, document in
flow sheet; contact mother by phone when there is less than a 3-day supply of milk in the
freezer to request delivery, inquire about pumping or supply problems
Assist in initiating NNBF, give instructions, assistance, and monitor correct position at breast
NNBF session should be limited to 10-20 minutes, and may occur when the infant is alert
without regard to NG feeding schedule. If infant is awake/alert encourage NNBF while gavage
feeding
Request additional LC appointments if: decreased milk supply, pumping pain, signs of breast
infection, pumping fatigue or concerns that may effect milk production and supply
UCSD Medical Center
page 6
RD
 Monitor infant growth and nutritional status
MD or NNP
 Monitor infant tolerance of feeds and fluid status
***Advance to Step 3*** When infant is ready for milk flow at the breast, active, alert and sucking throughout NNBF
and is able to tolerate S2S contact, transition to an alert state, have a respiratory rate less
than 70, and no longer requiring positive airway pressure
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UCSD Medical Center
page 7
Step 3
Goal:
Learning To
Breastfeed
(Est. GA: 32-34 weeks)
Team Member
a) To initiate nutritive breastfeeding
b) To encourage continued S2S care
Role
Baby
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Infant continues to tolerate S2S care
Infant begins to transfer milk at the breast
Mother
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Monitor let down, rate of flow, amount of milk transfer and tolerance during breastfeeding
Coordinate pumping with feedings, based on how baby tolerates breast fullness and to
maintain normal pumping schedule
Learn to recognize and respond to bradycardia and desaturations in baby during feedings and
handling
Allow baby to nurse for 10-20 minutes from one breast; use the other breast during the next
session
Pump after breastfeeding as indicated in Step 2
Sign up for discharge teaching class
Consult for pumping, milk production, preparation for breastfeeding, positioning, latch, and
assessment of milk transfer
Fitting and teaching use of breast shield
Assess need for OT intervention
Fitting and teaching use of breast shield
Frequent consult during the learning phase of early breastfeeding
Delay initiation of bottle feeding for 1-2 weeks during this phase for infants less than 34 weeks
Initiate Infant Driven Feeding Step 3 Crib Card
Continue to encourage daily S2S and document on flow sheet.
Daily assessment of hospital supply of mother’s milk and maternal milk supply, document in
flow sheet; contact mother by phone when there is less than a 3-day supply of milk in the
freezer to request delivery, inquire about pumping or supply problems


LC
OT
RN
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UCSD Medical Center
page 8
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RD
MD or NNP
***Advance to Step 4***
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Initiate breast feeding when infant shows signs/cues of interest, this may be 1x or 2x daily
When a breastfeeding occurs is determined by the infant (awake, alert prior to feeding), not the
nurse or parent. If the infant sleeps through a planned breastfeeding, try later in the shift.
 Infants are breastfed as much (or as little) as they want each feeding by readiness cues 1x or
2x daily
 To determine the need for gavage supplementation: assess the amount of milk taken either by
doing a test weight, or if infant actively sucks less than 5 minutes; give full gavage feeding, for
5-15 minutes; give 1/2 of feeding, for > 15 minutes; give no supplement
 If infant displays interest in feeding after being taken off breast during this phase, have mother
put baby back on breast during gavage feeding
 If mother pumps less than 40 ml at a pump session, baby may tolerate feeding from a full
breast
 If mother’s supply is >40 ml she may use one of several techniques to reduce the amount of
flow and supply to the early breastfeeding infant which include:
o Pumping 1/2 of her milk out just prior to positioning baby at breast. If this technique is
used, mother will need to pump remainder of milk out within 15 minutes of the
breastfeeding session
o Schedule pumping to be 1-2 hours prior to positioning baby at breast. If this technique is
used, mother will need to pump at her regular 3-hour interval
o If milk supply is ample and mother is never empty, baby may go to breast directly after
mother has pumped and she can continue her regular pumping schedule
 Fitting and teaching use of breast shield
 As baby’s suck and stamina improve, teach mother to assess the amount consumed by test
weight.
 Alert LC to problems with volume and/or supply.
 Help mother to sign up for discharge teaching class
 Monitor infant growth and nutritional status
 Monitor infant tolerance of feeds and fluid status
When ready to begin infant driven feeding protocol, be fed routinely 1x a shift, and be offered
a bottle feeding
UCSD Medical Center
page 9
Step 4
Drinking Milk At The
Breast & Learning
To Bottle
(Est. GA: 33-35 weeks)
Team Member
Baby
Mother
Goal:
a) To gain proficiency at nutritive breastfeeding
b) To initiate bottle feeding
c) To encourage continued S2S care
Role
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LC
OT
D:\533567565.doc
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Infant tolerates S2S care
Infant begins to transfer more milk at breast
Infant begins bottle feeding and learns to transfer milk
Infant will start with oral feeding 1x/shift, progressing to 2x/shift and demand feeding (NG in)
as intake increases and weight gain is maintained
Infant will initiate oral feedings by demonstrating hunger cues
Infant will be gavage fed when not showing signs of feeding readiness
Breastfeeding as outlined in Step 3, infant may now stay at the breast for 20-30 minutes if
actively participating
Mother may need to adjust the amount of milk in her breast as outlined in Step 3
If infant is to gavage the remainder of the feeding, start the gavage at least 5 minutes after
baby has latched and demonstrated a nutritive suck.
Mother will pump after breastfeeding or as indicated in Step 3
Mother can BF whenever infant is active and shows cues s/he is ready to orally feed
Mother will learn technique for bottle feeding infant
Consult for pumping and milk production
Teaching use of shield if not yet introduced
Assessment of breastfeeding progress
Begin teaching for discharge preparation; explain triple feeds, weaning use of shield, etc
Assess need for OT intervention
Discuss Infant Driven Feeding Progression with family
Teach bottle feeding technique to parents
UCSD Medical Center
page 10
RN
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Ongoing feeding assessment and intervention as needed
Monitor feeding progression
Initiate Infant Driven Feeding Step 4 Crib Card
Refer to flow chart for Infant Driven Feeding Progression details (to be done)
Advance infant to 1x/shift feeding
For breastfeeding infants, assess the amount of milk taken either by doing a test weight, or if
infant actively sucks less than 5 minutes; give full gavage feeding, for 5-15 minutes; give 1/2 of
feeding, for > 15 minutes; give no supplement
If the mother cannot come in for every PO feeding, ask permission to bottle feed mother’s milk
and continue to advance. However, do not introduce bottle feedings before 34 weeks nor
before the infant is taking at least one full breastfeeding a day
Infants continue to be fed q3 hours and receive any volume not taken po by gavage until
advanced to Demand Feeding (NG in) stage
Advance infant to 2x/shift feeding when PO volume is > 75% of feed in 30 minutes 1x/shift for
2 days and has gained appropriate wt (10-15 gm/Kg/day)
If infant has progressed to 2x/shift feeding, mother may breastfeed any 2 feedings during one
shift as long as the infant is awake and alert prior to the feedings (i.e. infant may breastfeed 2
feedings in a row)
Advance to demand feeding (NG in) when PO volume is > 75% of feed in 30 minutes 2x/shift
for 2 days and has gained appropriate wt (10-15 gm/Kg/day)
Infants on demand feeding (NG in) are fed PO as much or as little as they want and as often
as they demand a feeding by readiness cues every 2-4 hours. If the infant does not wake up
by 4 hours, gavage a 4 hour feeding volume. If the infant does wake but takes only a small
amount, do not push the feeding beyond 30 minutes or gavage any additional volume.
However, if the infant takes < 75% of the volume for the shift, the RN on the next shift should
return to the former milestone (PO 2x/shift) then may try demand feedings again when ready
to advance
Infant advances to full PO feeds, and the NG tube is removed when: PO volume is > 75% of
daily volume for 2 days and has gained appropriate wt (10-15 gm/Kg/day)
Continue to encourage daily S2S and document on flow sheet
Daily assessment of hospital supply of mother’s milk and maternal milk supply, document in
flow sheet; contact mother by phone when there is less than a 3-day supply of milk in the
freezer to request delivery, inquire about pumping or supply problems
If mother has low milk supply or is not able to let down use a 10 ml syringe with a 5f feeding
tube placed behind the breast shield or in the baby’s mouth to facilitate milk transfer.
UCSD Medical Center
page 11

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RD
MD or NNP
***Advance to Step 5***
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Bottles may be introduced during this phase, preferably with the mother present
Alert LC to problems with volume and/or supply
 Monitor infant growth and nutritional status
 Assess infant tolerance of feeding progression
 Monitor infant growth and nutritional status
When infant is taking full feeding on demand and getting ready for discharge
UCSD Medical Center
page 12
Step 5
Goal:
Getting Ready For
Home (Est. GA: >35
weeks)
a) To develop a discharge feeding plan
b) To instruct mother about ongoing pumping needs
c) To prepare family for feeding progression post-discharge
d) To transfer lactation follow-up to community provider
Role
Team Member
Baby

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Infant taking all feedings orally
Infant meeting medical discharge criteria by the end of this step
Mother
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LC
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OT
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Attend DC class (if not previously done)
Demonstrate competence in breast and bottle feeding
Demonstrate understanding of feeding plan
Demonstrate competence in preparing and completing feedings per discharge feeding plan
(mixing fortifier, latching baby, using nipple shield, supplementing via bottle, etc.)
Final LC for assessment of feeding and discharge transition of feeding plan
Collaborate with RD to formulate nutrition and transition of feeding discharge plan
Mother will be instructed on:
o How to assess adequate milk transfer
o Supplementation with the bottle after breastfeeding
o When and how to increase breastfeeding sessions
o When to use both breasts at a feeding
o When to wean breast shield
o Written handouts will be given to mother to reinforce the plan
o Community resources for lactation including UCSD support group
o When to return the pump
Discharge assessment
D:\533567565.doc
UCSD Medical Center
page 13
RN
RD
MD or NNP
Discharge Coordinator
****Final Step****
D:\533567565.doc
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Teach bottle feeding techniques
Reinforce feeding plan
Make sure mother and family are signed up for and attend a discharge class
DC teaching per ISCC protocol
Support mother and family in following discharge feeding plan in hospital for last week before
discharge with family doing as many feedings as possible
 Collaborate with LC to formulate nutrition and transition of feeding discharge plan
 Teach mother mixing of fortified milk
 Provide handouts on mixing instructions
 Individualize Primary Care Provider discharge instructions
 Consult with RD about DC nutrition plan
 Consult LC for transition from bottle to breast plan for discharge
 Prepare discharge feeding plan
 Dictate discharge feeding plan into discharge summary
 Arrange discharge follow-up
 In conjunction with social work plan DC conference for family
 Fax DC plan to LC
 Assist family in obtaining transitional formula for fortification
 Arrange discharge follow-up appointment
 Arrange home health follow-up appointment
 Provide (2) copies of discharge summary/feeding plan, one for family and the other for PCP
Baby discharged to home.
Make sure parents understand discharge feeding plan and that follow-up is in place.
UCSD Medical Center
page 14
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