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Am J Perinatol
DOI: 10.1055/a-2796-1524
Original Article

Cue-Based and Volume-Based Oral Feeding Progression Strategies and Outcomes in Extremely Premature Infants

Authors

  • Mariana Diaz

    1   Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, Florida, United States

  • Padma Nandula

    2   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, Florida, United States

  • Vasantha H.S. Kumar

    2   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, Florida, United States

  • Shiva Gautam

    3   Department of Biostatistics, University of Florida College of Medicine—Jacksonville, Jacksonville, Florida, United States

  • Mark L. Hudak

    2   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, Florida, United States

  • Sanket D. Shah 

    2   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, Florida, United States
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Abstract

Objective

This study aimed to compare the feeding outcomes of extremely premature infants (EPI, <28 weeks' gestational age) cared for by the same neonatology group at two tertiary neonatal intensive care units that employed two different oral feeding strategies (cue-based oral feeding progression [CB-OFP] and volume-based oral feeding progression [VB-OFP]).

Study Design

We conducted a retrospective cohort study of EPI (July 1, 2022, and April 12, 2024) patients discharged on full oral feedings. The primary outcome was postmenstrual age (PMA) when full oral feeding was achieved. Secondary outcomes included time to full oral feeds, PMA and weight at initiation and discharge, growth velocity, and length of hospital stay.

Results

Baseline characteristics were similar among 119 EPIs (CB-OFP: n = 61; VB-OFP: n = 58) except for maternal magnesium sulfate exposure and postnatal steroid use. CB-OFP infants achieved full oral feeding at an earlier PMA (median: 37.6 vs. 40.1 weeks; p < 0.001) and in fewer median days (20 vs. 27 days; p = 0.03). CB-OFP was also associated with earlier discharge (median PMA at discharge: 38.6 vs. 41.3 weeks; p < 0.001) and shorter length of stay (93 vs. 111.5 days; p < 0.001). Growth velocity and discharge weight z-scores did not differ significantly between groups.

Conclusion

Our experience suggests that a CB-OFP strategy may be associated with earlier attainment of full oral feeds and a shorter length of stay compared with VB-OFP. Future randomized controlled trials are warranted to validate these findings and to assess potential long-term neurodevelopmental outcomes with different feeding strategies.

Key Points

  • There is no consensus on the optimal oral feeding progression strategy for EPIs.

  • A CB-OFP strategy was associated with earlier achievement of full oral feeding and a shorter length of stay.

  • Oral motor interventions, including stimulation exercises, may play a role in improving oral feeding abilities in EPIs.

Keywords

extremely premature infants - oral feeding progression - cue-based feeding - volume-based feeding - length of stay

Data Availability Statement

After deidentification individual participant data that underlie the results reported in this article will be available to researchers who provide a methodologically sound proposal. To gain access, data requestors will need to sign a data access agreement.


Contributors' Statement

S.D.S. conceptualized and designed the study, critically reviewed and revised the manuscript. M.D. collected the data, drafted the initial manuscript, and critically reviewed and revised the manuscript. P.N. supervised data collection and critically reviewed and revised the manuscript for important intellectual content. S.G. performed statistical analyses and critically reviewed and revised the manuscript. M.L.H. and V.H.S.K. critically reviewed the analysis and revised the manuscript for important intellectual content.




Publication History

Received: 27 October 2025

Accepted: 23 January 2026

Article published online:
05 February 2026

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