The Differences Between Cue Based and Infant-Driven Feeding®

For the past decade or two, NICUs have been moving away from traditional volume-driven oral feeding practices toward quality and safety oriented practices which are driven by the infant, rather than professionals or the clock. And rightfully so. This transition is supported by evidence and an understanding of neurodevelopment, feeding, and swallowing.

During this evolution, cue-based feeding and Infant-Driven Feeding® (IDF) have often been used synonymously. We’d like to provide insight into how and why they are different.

The confusion around cue-based feeding became apparent to us while consulting in NICUs and speaking nationally about IDF. We asked NICU professionals if their units had a defined model for oral feeding practice. Many said, “Yes, we do cue-based feeding.”

“Great,” we replied, “so what does that entail? How do you know you’re doing cue-based feeding?”


“Well, we pay attention to cues before feeding and we stop when the baby disengages.”

“How does everyone make decisions related to the cues? Is everyone on the same page about which cues are related to feeding readiness? Do you orally feed the first time you ever see an infant cue? How is quality defined (other than volume), documented and communicated in your cue-based model? How do you know what techniques the previous caregiver provided to support the infant’s oral feeding? How do you demonstrate and communicate a consistent approach to the parents?”

More pausing.

To be fair, some NICUs had developed effective cue-based feeding practice models for their units. This is fabulous.

However, the challenge is this: each of those units said they were ‘doing cue based feeding’ and yet each model was different from the other, sometimes vastly different, even within the same unit or between shifts. Therefore, we still couldn’t put our finger on exactly what it meant to ‘do cue-based feeding’.

Cue-based feeding is a phrase that captures the ever-growing list of literature that supports the wise premise that babies progress with oral feeding more safely and effectively when we (as caregivers) allow the baby’s cues (and stability) to lead us, rather than feeding them via a prescribed frequency regardless of cues. The literature also supports the concept that feeding infants beyond the point of active engagement is unsafe and unfounded.

So how does this differ from IDF?

While IDF encompasses the cue based feeding literature, it also provides an identified process to consistently implement this complex and multi-faceted practice at the bedside from admission through discharge. IDF includes a neurodevelopmental foundation that is inclusive of families, breastfeeding, bottle-feeding and an in-depth understanding of the impact of feeding readiness, quality, and caregiver techniques on long-term oral feeding success. IDF also includes the use of a validated assessment and documentation tool, the Infant-Driven Feeding Scalesã (IDFS).

Truly practicing the IDF Model of Practice and using the IDFS requires unit-wide completion of a comprehensive online education program created by the IDF authors, so that every single bedside professional learns the same depth and breadth of information from the same presenters (and is tested on it) – even if you were just hired yesterday and the unit completed the original education last year. In short, IDF can be replicated between caregivers and between NICUs because implementation of the practice can be accomplished through specific online education.

(Note to hospitals: Asking bedside professionals to reinvent the wheel and attempt to condense this comprehensive education into a one-hour PPT for current or future staff is ineffective. This mindset perpetuates the idea that oral feeding and swallowing in this fragile population requires education akin to hand washing. Premature and sick infants deserve well-informed caregivers that understand the complexity of oral feeding and are able to set the stage for safe and successful feeding for life, not just their NICU stay.)

Before we can assume we know anything for sure about how babies feed in the NICU, we must first ‘control for the caregiver’. Babies and parents cannot be exposed to different ‘techniques’, concepts, and equipment every shift of every day and be expected to make true and reliable progress.

As a neonatal community, neither can we.