Acknowledging Your NICU Culture: The First Step Toward Meaningful Change
Any meaningful practice change begins with acknowledging your starting point. Bringing prefeeding practice into a NICU is no different.
Before implementing new tools, protocols, or education, it’s essential to pause and take an honest look at your unit’s existing culture. Culture shapes how care is delivered, how decisions are made, and how new ideas are received. Without understanding that context, even well-designed initiatives can struggle to take hold.
When thinking about developing a robust prefeeding program, I recommend starting by examining your NICU through the lens of the three Prefeeding Pathways. Each pathway requires a different level of reflection, and implementation strategy. The most effective place to begin is often the Foundation Pathway.
Starting With the Foundation Pathway
The primary objective of the Foundation Pathway is to establish positive associations with the oral-sensory and motor aspects of feeding. This includes early feeding-related sensory experiences such as smell, taste, facial and oral touch, pressure, and the motor actions of licking, rooting, and sucking.
The Foundation Pathway is often the easiest place to begin because many of its practices already exist—at least in some form—within most NICU cultures. Kangaroo care, colostrum care, and early sensory exposure are familiar concepts. Often, what’s needed is not a complete overhaul, but a shift in focus and intentionality—recognizing these practices as foundational prefeeding experiences rather than isolated tasks.
This pathway also lends itself well to a multidisciplinary approach, as nurses, therapists, lactation consultants, and families are often already involved in these moments of care.
Examining Current Practice
As you begin analyzing how your unit supports the Foundation Pathway, start by identifying what is already happening. Ask yourself:
What practices in our NICU support positive oral-sensory and motor experiences related to feeding?
Who is currently involved in these practices?
How consistently are they applied?
List these practices and identify the key players involved. Then, rate each practice on a scale from 1 to 5, with 5 representing a well-established, consistent practice and 1 indicating something that occurs infrequently or without shared understanding. From there, create a specific goal for how each practice could be strengthened to better support positive oral and facial sensory-motor experiences. Expand on your key players to create more oversight and collaboration. Therapists, parents and nurses can work together to ensure shared practices are as consistent as possible.
Education plays a critical role here. Creating opportunities for staff to understand why these practices matter—and how their role contributes to early prefeeding development—is essential for meaningful culture change. Stay true to the Foundation Pathway's intention: supportive, positive experiences of oral sensory and motor experiences without challenge or demand. Remains clear and consistent, and ensures all team members understand how to support these experiences in a way that is developmentally appropriate and well-received by the infant.
Therapist-Focused Interventions
The same evaluative process used to examine unit culture can be applied to identify therapist-focused Foundation-level interventions you want to intentionally incorporate into departments’ NICU therapy practices. This begins with clearly defining which intervention you are introducing and why it supports Foundation Pathway objectives. For example, therapist-guided milk tasting or milk drop experiences, teams should first align on the purpose of the intervention—supporting positive oral-sensory exposure and associative learning, not advancing volume or feeding performance. From there, guidelines can be developed around appropriate candidates, timing, positioning, sensory supports, and clinical cues for continuation or pause. Establishing shared expectations through targeted education allows therapists and interdisciplinary team members to understand both the intent and the boundaries of the practice, reducing variability and promoting consistency. Thoughtful education and discussion around these interventions are essential for building confidence, supporting clinical reasoning, and embedding new practices into the culture of care.
Make sure to keep all documents you create to help guide this process. These will become part of your quality improvement projects, serve as justification for practice changes, and provide supporting evidence for what can eventually become a robust prefeeding habilitation guideline for your unit.
Don’t Forget the Parents
Finally, it’s important not to overlook the role of parents. The Foundation Pathway represents the earliest stage of prefeeding habilitation, often occurring during some of the most overwhelming days of a baby’s NICU stay. Parents may feel exhausted, uncertain, and unsure how they can help.
This is an opportunity.
By educating families on the purpose of Foundation-level work and empowering them with concrete ways to support their baby’s sensory and feeding development, clinicians can help restore a sense of agency. These early moments of guidance can strengthen trust between families and care teams, while also supporting bonding and confidence at a critical time.
