SOFFI An Evidence-Based Method For Quality Bottle-Feedings of Preterm

NIH Public Access
Author Manuscript
J Perinat Neonatal Nurs. Author manuscript; available in PMC 2014 January 20.
Published in final edited form as:
NIH-PA Author Manuscript
J Perinat Neonatal Nurs. 2011 ; 25(4): 349–359. doi:10.1097/JPN.0b013e318234ac7a.
SOFFI: An evidence-based method for quality bottle-feedings of

preterm, ill, and fragile infants
Erin Sundseth Ross, PhD, CCC-SLP and
Assistant Clinical Professor, University of Colorado Denver, School of Medicine, Department of
Pediatrics, JFK Partners, Denver, Colorado
Honorary Research Fellow, Children’s Nutrition Research Centre, University of Queensland,
Brisbane, Australia
M. Kathleen Philbin, RN, PhD
Associate Professor, The College of New Jersey Ewing, New Jersey
Adjunct Associate Professor, University of Pennsylvania School of Nursing, Philadelphia,
Pennsylvania
Abstract
Successful oral feeding of preterm and other ill and fragile infants is an interactive process that
requires (1) sensitive, ongoing assessment of an infant’s physiology and behavior, (2)
knowledgeable decisions that support immediate and long-term enjoyment of food, and (3)
competent skill in feeding. Caregivers can support feeding success by using the infant’s biological
and behavioral channels of communication to inform their feeding decisions and actions. The
Supporting Oral Feeding in Fragile Infants (SOFFI) Method is described here with text,
algorithms and reference guides. Two of the algorithms and the reference guides are published
separately as Philbin, Ross. SOFFI Reference Guides: Text, Algorithms, and Appendices, (in
review). The information in all of these materials is drawn from sound research findings and,
rarely, when such findings are not available, from expert, commonly accepted clinical practice. If
the quality of a feeding takes priority over the quantity ingested, feeding skill develops pleasurably
and at the infant’s own pace. Once physiologic organization and behavioral skills are established,
an affinity for feeding and the ingestion of sufficient quantity occur naturally, often rapidly, and at
approximately the same post-menstrual age as volume-focused feedings. Nurses, therapists, and
parents alike can use the SOFFI Method to increase the likelihood of feeding success in the
population of infants at risk for feeding problems that emerge in infancy and extend into the pre-
school years.
Keywords
NICU; preterm infant; bottle; feeding; behavior; algorithm; manual; guide; quality; nursing care
Infant feeding, by its nature, is an interactive, developmental task.1 Current research in

preterm infant feeding shows that the infant’s ability to feed well is closely related to the
caregiver’s ability to understand and sensitively respond to his physiology and behavioral
communications.1, 2 While breastfeeding is by far the superior means of feeding, the great
majority of infants in American Newborn Intensive Care Units (NICUs) are fed by bottle 3.
This article describes a method that is primarily concerned with the quality of a feeding
Corresponding Author Contact Information M. Kathleen Philbin, RN, PhD, School of Nursing, The College of New Jersey, P.O. Box
7718, Ewing, NJ 08628-0718, Office: 609-771-348, Fax: 609-637-5159, Cell: 856-912-3197 (preferred).
Ross and Philbin Page 2
rather than its quantity. As it is used here, a quality feeding is defined as a complex event in
which the infant is safe, physiologically stable, actively participating, behaviorally organized
generally and in oro-motor activity, and comfortable. The infant’s nutritional status and
caloric intake are understood as baseline conditions. The quality of a feeding relies on the
assessments, decisions, and actions of a caregiver who is knowledgeable about feeding the
infant at hand, sensitive to the infant’s behavioral and physiologic communications, and who
has competent feeding skills. Further, this caregiver is oriented toward positively reinforcing
an association between feeding and pleasurable human contact and toward supporting the
infant’s individual manner and pace of acquiring feeding abilities. Such a caregiver may be
either an accomplished feeder or an active learner with the supervision or coaching of an
accomplished feeder. The SOFFI Method prioritizes the quality of the experience before the
quantity ingested because many studies show that most infants who develop feeding
problems are averse to food and feeding. Their consequent refusal to feed is a source of
anxiety and self-doubt for their parents and long term developmental difficulties for
themselves.4
Parents come to the NICU with a wide range of understanding and capability for feeding an
immature or ill infant. Knowing this, nurses and therapists can build parents’ competence
and confidence by modeling and coaching high quality feeding interactions. Many studies
show that parents place a high value on their infant’s feeding and growth and judge their
parenting competence by these metrics.5, 6 When the unique behavior of an infant is
understood as a communicative attempt and parents know how to respond to it effectively,

feeding generally becomes successful. In this context, the attachment relationship tends to
strengthen and parents’ anxiety tends to diminish.6 A knowledgeable and skilled nurse or
therapist observing and coaching a parent during a feedings can measurably benefit this
process.7 Indeed, collaboration between a nurse or therapist and parent in understanding and
responding to an infant’s behavior can benefit infant development and parent-infant
interaction in many ways and over long periods of time.1, 6-12
The literature offers various approaches to acquiring bottle feeding skill. Clinical pathways,
such as the one by Kirk et al., base the progression of feeding on the volume ingested with
little said about feeding skill.13 Scales, such as the one developed by Ludwig and Waitzman,
use holistic assessments to determine the infant’s readiness or skill but do not address the
conduct of the feeding itself.14 Recently, Kirk, Alder, et al. published a decision pathway for
feeding progression based in part on infant behavior but also on the infant’s age and the
quantity ingested without addressing individual variation and skill development.13 At
present, there are no published methods that address both feeding readiness and real-time
feeding management with quality as the primary objective. SOFFI fills the gap.
Basis of the SOFFI Method in Theory and Research

Synactive theory 16 provides the primary theoretical basis for the SOFFI Method because it
is a construct with ample explanatory power consistent with the known physiology and
behavior of preterm and other fragile infants. Additionally, it is the most widely accepted
model for understanding and using preterm infant behavior to guide care.16 As such, NICU
staff are likely to be familiar with SOFFI concepts and terminology.
Synactive theory posits that infants are biologically striving, throughout development,
toward the self-regulation of increasingly complex abilities. Caregivers can support this
emerging competence by attentively and knowledgeably responding to each, individual
infant’s autonomic neurophysiology, behavioral state, and motor (or movement) behavior so
that the infant remains functionally organized and self-regulated. 10-12 The SOFFI Method
assumes the synactive stance and applies it to the achievement of safe, functional bottle
feeding in the context of pleasurable behavioral-social reciprocity. The theory places a high
value on the parent as the ideal caregiver both physically and socially. 9,11,16 Clinicians are
seen as sources of skillful support for the infant’s development and the expanding parent-
child relationship.10,11,12 The nurse, who typically provides the majority of feedings, uses
the SOFFI Method herself and coaches the parent in understanding and adopting it.
The details of the SOFFI Method are based on a review of the current and classic literature
in the field. The databases OVID-CINAHL, PubMed, and the Cochran Database were used
to identify literature concerning 1) synactive theory, 2) the use of synactive theory in
providing care to support infant development, 3) feeding development in the preterm infant,
and 4) models for preterm infant feeding. The search was generally limited to the period of
2002 to 2010, but without limits for synactive theory and models of feeding preterm, ill, or
infants. Subsequently, the reference lists of entire articles were examined for potentially
relevant material including editorials, commentaries, and case reports. All material was then
reviewed for inclusion in the SOFFI Reference Guides.17
The literature review revealed a diverse body of research, commentary, and clinical practice.
The major foci of these writings are the neuromotor and physiologic mechanisms of bottle
feeding,18 the immediate bottle feeding experience,19, 20 and the long term cumulative
learning acquired during repeated feeding experiences.2, 19 There are also models of bottle
feeding readiness 2, 21 and bottle feeding outcomes 22, methods of enhancing bottle feeding
efficiency 23, and descriptions of suck-swallow-breathe coordination.22
The SOFFI Method, Algorithms, and Reference Guides have been modified over time based
on recommendations of nurse, therapist, and parent trainees, practicing clinicians, and by
some of the experts whose studies are cited here.
The SOFFI Bottle Feeding Algorithm

The SOFFI Bottle Feeding algorithm displays a sequence of assessments, questions with
“yes” or “no” answers, and decisions that lead to consequent actions. These actions affect
the feeding and lead to the next set of assessments, decisions, and actions. In each case, the
options for action are: (1) proceed along the algorithm to continue the feeding as is, (2)
make a change to support stability or otherwise improve the feeding experience, (3) defer
the feeding to a later time and gavage the remaining milk/formula, or (4) stop this bottle
feeding and omit other closely following bottle feedings. The SOFFI Reference Guides with
Appendices and the remaining two algorithms (The SOFFI Flow Rate Algorithm and the
SOFFI Pacing Algorithm) provide the details for assessments, decisions, and actions
referenced by letter in the SOFFI Bottle Feeding Algorithm.17
A Caveat Regarding the Use of the Algorithm

The SOFFI algorithm is meant to be learned away from the bedside. A caregiver or parent
who is just acquiring skill in using them may want a quick visual check during a feeding but
this must be accomplished without moving the hands or significantly changing the direction
of gaze. The caregiver should maintain a virtually exclusive attention on the infant
throughout the feeding. Such attention would preclude conversations with others, looking
away from the infant, and stopping/re-starting a feeding to do tasks.
Decisions to Start a Feeding (See “Start” on the SOFFI Bottle Feeding

Algorithm)
Physiologic Stability
The algorithm begins at “Start” with an assessment of the infant’s physiologic stability in
bed during routine care or handling.24 Tenuous physiologic stability is likely to be revealed
during common handling (e.g., a typical pre-feeding routine: unwrapping, diaper change,
axillary temperature measurement, rewrapping). Physiologic stability for feeding is
influenced by medical morbidity, demands on the synactive systems by medical or nursing
tasks prior to the feeding, pre-feeding arousal level, oro-motor maturity, and previous
feeding experience. Keep in mind that an infant crying from hunger or other distress for a
period of time before a feeding has spent precious reserves and may be unable to sustain a
physiologically stable, behaviorally organized, and pleasant feeding experience afterward.
Physiologic stability is the primary requirement for bottle feeding in the SOFFI Method for
two reasons. First, feeding entails its own physiologic demands making it likely that an
infant who is unstable before feeding would become even more unstable during a feeding
and, therefore, less safe. Secondly, all other aspects of feeding are dependent on the infant’s
physiologic stability. An infant might be able to ingest food while physiologically unstable
but is unlikely to do so with self-regulation and comfort. Not surprisingly, physiologic
stability during feeding is also shown to affect the long term development of feeding
skill.22, 25
To be clear, physiologic stability is not defined here as recovery from critical illness. Rather,
it is defined as stable vital signs, good color, and good muscle tone when the infant is alone
in bed or during simple handling 24, 26. Stable vital signs are defined as a respiratory rate
between 40 and 60 breaths per minute (or another range specified for that particular infant),
a heart rate within 20% of recent resting levels (or a range specified for that particular
infant), and blood oxygen saturation levels within the range specified by unit guidelines (or
orders for that infant). The infant who is breathing outside of the acceptable respiratory rate
is working very hard to maintain oxygenation. Good color is defined as pink in face and
body with minimal to no paleness, mottled color, or localized duskiness/cyanosis, and good
tone is defined as moderate flexion across shoulders, neck, trunk, and hips. These stability
parameters are drawn from well-established information in the feeding physiology literature
and are consistent with synactive theory.9, 27
Postponing or omitting a bottle feeding on the basis of physiologic instability, as defined

here, spares the infant several likely, deleterious outcomes: (1) worsened physiologic
instability during the feeding, (2) practice in using disorganized behaviors to manage the
feeding, (3) an increased likelihood of solidifying disorganized behaviors in the repertoire,

and (4) a feeding-associated aversive experience. Repeated experiences, whether organizing
or disorganizing, create readily available behavior repertoires because they develop well
defined neuronal connections. The Theory of Neuronal Grouping Selection suggests that
neural maps in the cortex of the brain are established through repetitive experiences and
behaviors in the present as well as the past 28.
If the infant is judged to be physiologically unstable (a “no” answer), the consequent action
is to omit the bottle feeding (“stop”) and intervene to improve stability. The caregiver is
referred to specific lettered Reference Guides for the means of accomplishing
stabilization.17 The feeding is then completed with a slow gavage.
Readiness to Feed
If the infant is stable enough to engage in bottle-feeding generally, the next assessment on
the algorithm is the infant’s readiness to feed at that moment. Clinical opinion and research
indicate that an infant will feed most competently when showing signs of hunger and
readiness to feed. These readiness signs include moving extremities and head, moving hands
onto face or mouth, moving the face against bed linens or hands, mouthing or sucking
movements, and behavior state arousal.25, 29-31 In young preterm infants just learning to
feed, these readiness behaviors may occur at short, irregular intervals and be subtle and
fleeting32. Therefore, the nurse or parent must be watchful for them lest the arousal
opportunity passes by and the infant returns to sleep. Should these readiness indicators be
absent, the caregiver is directed to defer the bottle feeding until they are present and to
accomplish the feeding by slow gavage.
If signs of readiness are judged to be present (a “yes” decision), the assessment continues
with the infant held in arms and offered an opportunity to suck nonnutritively. McCain and
colleagues (2001) showed that infants acquired full oral feedings sooner when the basis for
offering a feeding was the infant’s ability to maintain an alert behavioral state while sucking
nonnutritively prior to all nutritive feedings.33
If the infant cannot maintain physiologic stability and a drowsy or alert state with non-
nutritive sucking while held in arms (a “no” decision), the feeding is deferred because it is
unlikely that comfort and physiologic stability will follow given requirements of the feeding
itself. In this case, the action is to stabilize the infant and accomplish the feeding by slow
gavage possibly with a positive oral experience such as tasting or smelling milk.
If the infant is judged able and ready to feed at this point (a “yes” decision) the consequent
action is to offer the bottle.
Decisions during the Feeding

Supporting Physiologic Stability and Self-Regulation
The caregiver continues to assess physiologic stability throughout the feeding noting
particularly a major desaturation, vital signs outside the infant’s parameters for more than a
moment or repeatedly, or multiple coughs or choking. Particular care in observation and
decision is required for infants with respiratory distress syndrome as they are more likely to
have atypical feeding skills including apneic swallows (≥ 3 swallows without a breath).34 If
these or equivalent signs of significant physiologic instability or compromise are present at
any time (a “yes” answer) the caregiver is directed to stop the feeding, re-stabilize the infant,
and give the remaining milk/formula by slow gavage. Physiologic events that do not indicate
significant instability (a ‘no” answer) lead the caregiver to support self-regulation

throughout the feeding as described in the SOFFI Reference Guides.17 Measures supporting
self-regulation may include holding in an upright or side-lying position to improve suck,
swallow, and breathe coordination or pausing for a rest break.
Engagement / Participation
If the infant is physiologically stable while feeding the algorithm next indicates assessing
engagement or participation. Is the infant actively trying to nipple? If the answer is “no”,
(e.g., low tone, sleeping, not sucking spontaneously, or trying to escape) the feeding
terminates in the central “stop” oval. Active participation is necessary for learning
coordinated, well-regulated feeding behavior. The studies of Thoyre et al. (2004) conclude
that infant engagement and contingent caregiver responses are the best measure of feeding
success.1 Similarly, McCain, et al. show a more rapid acquisition of feeding skills when the
infant’s alertness and participation, rather than the volume ingested, determine the
continuation of a feeding.29, 33 Of course infants can be made to suck by moving the nipple
around in the mouth to stimulate the suck reflex. However stimulating involuntary sucking
has deleterious consequences including protecting the airway with poorly coordinated and
defensive feeding behavior, and, not surprisingly, an association between feeding and
aversive experience.
Feeding Efficiency – Nipple Unit Flow Rate (See Flow Rate Algorithm and Appendix A in
the SOFFI Reference Guides.17)
While the infant remains physiologically stable and engaged, the caregiver maintains an
ongoing assessment of feeding efficiency; that is the amount taken from the bottle compared
to the amount swallowed and the effort expended. The amount taken from the bottle with
one suck, the bolus, is determined by the infant’s suck strength and coordination AND the
rate of flow through the nipple with each suck. Feeding is not efficient if the nipple flow rate
is too fast (delivers too large a bolus with one suck) or too slow (little or no flow despite
coordinated feeding efforts). Feeding efficiency has been addressed in a number of studies.
The SOFFI Flow Rate Algorithm, Appendix A 17 walks the caregiver through the process of
determining the nipple with the most efficient flow rate for an individual infant and includes
relevant references.
Drooling out some of the milk/formula may indicate that the nipple flow rate is too fast for
that baby35. For example Chang et al., (2007) showed improved efficiency (greater ingested
volume in a shorter period of time) when infants used a slower flow, single-hole nipple
rather than a faster flow, cross-cut nipple.19 Similarly, Amaizu, et al., found that a nipple
flow rate appropriate to the infant’s physiologic stability and oral-motor skill improved
feeding safety, efficiency, and self-regulation.23 Gewolb, et al. showed that a slower flow
nipple and rest breaks improved efficiency for infants with respiratory distress.34, 36 Slowing
the rate of flow often improves suck-swallow-breathe coordination and reduces fluid
loss.19, 23, 37-39 The first strategy for slowing the flow rate is using a slower flow nipple
because pacing, another strategy, requires more diligence and education to implement
correctly. A single slower-flowing nipple unit provides consistency across caregivers and a
common element for oro-motor practice.
Infants with chronic lung disease or conditions causing oromotor weakness may suck with a
well-developed pattern of short suck-swallow bursts and pauses and yet have inefficient
feeding because they do not have the suction strength to pull the milk/formula out of the
bottle. They may appear to be feeding efficiently, but take little in. For these infants a nipple
that is faster flowing (e.g., the standard flow nipple) than the usually-preferred or baseline
slow-flow nipple may improve efficiency while delivering a flow rate that the infant can
control with his typically weak suction strength. However, the effects of the faster-flowing
nipple must be observed carefully. If it delivers more volume per suck than the infant can
swallow between breaths, the interruption of regular breathing may result in apnea and
oxygen desaturation, aspiration, or choking. To reiterate, a faster flowing nipple is seldom
indicated and care must be taken with its use. The SOFFI Reference Guide Appendix A 17
guides the assessment of safety, efficiency, and comfort related to nipple flow.
External Pacing (See Flow Rate Algorithm and Appendix B in the Reference Guides)17
If the infant is feeding efficiently, whether with the original nipple or an alternative as
selected above, the answer to the question regarding the presence of spillage, gulping, etc.
would be “no”. That is to say, none of those behaviors is observed. The algorithm arrow
then directs the caregiver to bypass other algorithm components to arrive at the long vertical
rectangle. This component directs the caregiver to continue, throughout the feeding, to
assess, decide, and act with respect to physiologic stability, engagement, efficiency, and
coordinated suck-swallow-breathe sequences.
If the caregiver has tried to solve the efficiency problem by changing the characteristics of
the nipple but must still answer “yes” to the algorithm question about spillage, gulping, etc.,
the algorithm leads to the action “add support”. The caregiver then externally paces suck-
swallow-breathe coordination using the SOFFI Pacing Algorithm and the SOFFI Reference
Guides Appendix B.17
Pacing is a set of maneuvers that entrains sucking bursts to a pattern that allows sufficient
opportunity and time to breathe. In pacing, the caregiver counts the number of sucks before
a breath and interrupts flow after 3 to 5 sucks with no breath. The number of allowable suck-
swallow combinations without a breath (between one and five) is determined for each infant
based on the limits of respiratory effort necessary to maintain physiologic stability. For
example, some infants who have more than three consecutive suck-swallows without a
breath will maintain physiologic stability initially but gradually desaturate. They will benefit
from external pacing to interrupt sucking after three suck-swallow combinations without a
breath. The goal of the interruption is to maintain physiologic stability (e.g., oxygenation),
rather than respond to distress after desaturation or an untoward event (e.g., choking) has
occurred.
The integration of suck-swallow-breathe is usually well developed in newborn term infants

and appears as a seamless whole (inhale, suck, swallow, exhale) with each segment running
into the next and breathing barely apparent. However, medically compromised term infants
(e.g., infants with a cardiac defect, or with neurologic impairment) often lack a mature or
well integrated suck-swallow-breathe sequence. Preterm and other fragile infants may have
a sucking reflex that excludes breathing because it is very strong and difficult or impossible
to interrupt, particularly when hungry. A series of more than three to five suck-swallow
combinations without a breath constitutes feeding apnea and has a variety of deleterious
consequences. For example, air hunger may force the infant to breathe while continuing to
suck and consequently inhale or aspirate milk/formula. Alternatively, the infant may suck
more than can be swallowed and reflexively protect the airway by adducting the false vocal
focal fold; that is to say, the infant may choke. Lack of breathing while feeding, or feeding
apnea, can lower blood oxygen concentration beyond limits set for that child. It can also
induce the “diving response” in which a lowering respiratory rate triggers the fetal response
of slowing the heart rate (i.e., becoming bradycardic) thus causing hypoxia. For some infants
this apnea and bradycardia can become self-sustaining and require intervention to re-instate
breathing. The diving response is physiologically functional for the fetus, who does not need
to breathe, but it is not functional for an extra-uterine fetus (i.e., a preterm infant). With
pacing, however, physiologic stability can be maintained and sucking efficiency

improved.37 External pacing can also provide the neurobehavioral “practice” that facilitates
development of mature suck-swallow-breathe coordination. Law-Morstatt and colleagues
(2003) found a decrease in bradycardic episodes and improved sucking efficiency when the
infant was externally paced to maintain physiologic stability.37
Decisions to End a Feeding

At some point the infant either will have taken the prescribed amount of milk/formula or
qualified for a decision to “stop”. Decisions to end or “stop” a feeding are indicated
throughout the SOFFI Feeding Algorithm. Decisions to “stop” are based on physiologic
instability, lack of engagement in feeding, inefficient effort, and/or difficulty integrating
suck-swallow-breathe combinations despite caregiver efforts. These bases for stopping are
well supported in the literature.1, 21, 29, 30, 33, 41 For example, McCain’s feeding protocol
calls for stopping if the infant shows instability such as gasping or fatigue.29, 33 Thoyre,
Shaker and Pridham (2005) recommend stopping if the infant has motoric changes such as
flaccidity in the face (particularly the lower face) or limbs, or if the infant tries to escape the
bottle by extending arms and legs or arching the trunk or neck.20 With the exception of
obvious physiologic compromise (e.g. choking, bradycardia), ending a feeding based on the
volume ingested appears to be a common criterion despite the literature cited here showing
the validity of other “stop” criteria.38
Philbin, et al. conducted meticulous real time observations of 118 bottle feedings of 20
preterm infants in a prominent academic NICU.38 These feedings were not noticeably
different than those observed by any of the investigators over many years in many different
hospitals. During the feeding the nurse was asked to tell the observer the reason for each
pause or stop in feeding as it occurred. If the nurse did not, the observer inquired in a neutral
manner and otherwise refrained from interaction. The data show that quantity of intake
rather than quality of feeding dominated decisions and actions. For example, the top four
reasons for pausing/stopping a feeding concerned inefficient feeding even though 3 out of 4
unstable physiologic conditions were observed more frequently. Multiple swallows without
breathing (i.e., feeding apneas) were observed 10 times more often than cited as a reason to
pause/stop. Overall, physiologic and behavioral indicators of distress were observed 3 to 10
times more frequently than cited as reasons to pause/stop and increased after the first pause
(e.g., to burp). A smaller study by Verno, et al. (n = 56) in a large suburban NICU compared
the outcomes of infants fed as usual with outcomes of infants fed using a SOFFI-based
method to guide decisions to stop a feeding.40 The infants fed by the SOFFI-based method
started bottle feeding 5 days post-menstrual age (PMA) older than the infants fed as usual
but were completely bottle-feeding at the same age, 37 weeks PMA. Further, they were less
likely to be transferred to a specialty hospital for feeding problems (p = 0.03) and less likely
to be referred to a feeding clinic by three months corrected age (p = 0.04).44
Documenting Infant Progression and Staff Feeding Activity Using the

SOFFI Bottle Feeding Algorithm
An infant’s progression in feeding competence can be documented by circling the “stop”
point on successive algorithm pages.
Such documentation can also assist in tracking staff consistency in using the SOFFI Method
indicating a need for further guided practice in its use. More precise documentation of infant
progression and staff consistency can be achieved with a modified version of the algorithm
available from the authors.
Decisions to Increase Feeding Frequency and/or Volume

There is little evidence for strategies to “advance feedings” (i.e., offering additional feeds
within a certain period of time). The authors’ clinical experience, research, and consultations
in the United States and internationally is that most nurseries add feedings based on a
measure of the volume previously ingested with a secondary regard for the quality of the
feeding behavior.38 For example, Simpson et al. (2002) demonstrated more rapid
progression when feedings were advanced by one feeding a day only when the current
number of oral feedings were fully completed.40 Many NICUs use this strategy which
appears to be based on the idea that stamina rather than skill is the key factor in feeding
development. Other NICUs give several bottle-plus-gavage feedings within a 24-hour
period, increasing the amount taken by bottle over time. McCain, et al., (2001) shortened
time to full bottle feedings by 5 days using this protocol.33 This approach could provide
more beneficial practice opportunities if the feedings were done with attention to quality. On
the other hand, it could provide more non-functional practice (defensive, uncoordinated
feeding behaviors) if the feeding is focused on quantity. Decisions about the number of
bottle feedings are also influenced by the method of gavage supplementation. NICUs that
use intermittently placed oro-gastric or naso-gastric tubes for feeding frequently require the
infant to complete a full feed before attempting a second because of the stress of placing the
tube after a partial feeding. In contrast, NICUs that use flexible, indwelling feeding tubes
tend to attempt bottle feedings more frequently in a 24-hour period. The SOFFI Feeding
Algorithms and Reference Guides remain applicable whatever the means of advancement
because they involve continuous assessment, decision, and action based on the infant’s
behavior.
The SOFFI Method in Practice

SOFFI concepts and decision parameters have been disseminated to NICU clinicians
through many consultations and training conferences (e.g., the Rocky Mountain Fragile
Infant Feeding Institute.)42, 43 The SOFFI Method is established clinical practice in a
relatively small number of NICUs across the US and internationally with a thorough
adoption of more than 10 years in the first author’s practice site.44 In randomized, controlled
trials a similar approach to overall caregiving (including feeding) showed that sensitive
responding to feeding behaviors resulted in earlier acquisition of competent feeding skills
and full feedings by bottle.9, 11, 12, 44 Refinements to the SOFFI Feeding Algorithm have
been suggested by practicing clinicians and by some of the experts whose studies are cited
here.
In a systematic, on line evaluation completed two months after SOFFI training45, ninety
percent of respondents judged the SOFFI Method as “easy to understand”, and 100% judged
that it “helps to think aloud about the decisions made during a feeding.” Ninety-four percent
thought the SOFFI Method was helpful in making decisions about supportive interventions,
and 82% thought it was useful in explaining why a feeding was stopped to family members.
During training, some participants thought the SOFFI Bottle Feeding Algorithm was
“intimidating” when they first saw it. However, this appraisal was nearly always eliminated
with explanation of the algorithm and use in practice. Identified benefits of the SOFFI
Method for clinicians and parents include: 1) a common language for communication about
feeding between staff and with parents, 2) a systematic, theory-based means of evaluating
feeding development, 3) a means of providing anticipatory guidance to parents, and 4) a
means of assessing staff performance.
Conclusion
The SOFFI Method for bottle feeding preterm and other fragile infants is based on
established, tested theory with details drawn almost exclusively from the research literature.
It integrates readily with staff education and clinical practice programs that are based on
synactive theory because both use the same vocabulary and indicators of physiologic and
behavioral organization. As a whole it provides a common language and concrete feeding
plan (the algorithm) orienting feeding to the quality of the infant’s experience and long term
feeding success. The shared SOFFI orientation supports staff-staff and staff-parent
collaboration in successful feeding development. By building common goals for feeding, a
common knowledge base and feeding path, and a common skill set for nurses, therapists,
and parents, the SOFFI Method supports the infant’s physical growth, expands the infant’s
behavioral repertoire, establishes feeding as a pleasurable activity, and strengthens mutually
beneficial infant-parent interaction and attachment.
Acknowledgments
We gratefully acknowledge our colleagues and mentors in the global NIDCAP community and the many nurses,
occupational therapists, speech-language pathologists, researchers, infants, and parents who have helped to develop
our thinking over the years. Sharon Sables-Baus helped with early versions of the algorithms. Manuscript
preparation was supported by: (ESR) NIH #5 T32 DK 07658-17, (MKP) The Children’s Hospital of Philadelphia
and The College of New Jersey.
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Biographies
Erin Ross, PhD, CCC-SLP has provided feeding and developmental consultation in Level II
and III NICUs for 20 years. She evaluates and treats children in an outpatient feeding clinic
and lectures nationally and internationally.
M. Kathleen Philbin, RN, PhD has specialized in adapting Level II and III NICU practices
for optimal preterm infant development for 20 years. She teaches, does trainings in preterm
infant handling and feeding, and consults widely regarding evidence-based care to support
preterm infant development.
Figure 1. SOFFI Method Algorithm for Bottle-Feeding

Beginning at START, the SOFFI Bottle Feeding Algorithm guides the caregiver through a
sequence of assessments, decisions, and actions to realize a safe, high quality feeding that
builds competent feeding behaviors and enjoyment of food and feeding. Letters in the
algorithm indicate identically lettered sections in The SOFFI Reference Guides: Text,
Algorithms, and Appendices: A Manualized Method for Quality Bottle Feedings. (Philbin &
Ross, in review). The SOFFI Reference Guides provide details of assessment observations,
decision explanations, and clinical action options. The algorithm is more easily followed in
an enlarged format and printed in color. Contact the authors for a color copy. “No” decisions
are shown in red and “yes” decisions in green. “STOP” indicates ending or pausing a
feeding to stabilize the infant. The algorithm should be learned away from the bedside.
Newly trained clinicians and parents may want to use the algorithm for a quick reference
glance while feeding, but attention should be focused primarily on the infant and on the
caregiver’s own behavior. The figure is used here with permission of the authors.

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J Perinat Neonatal Nurs. 2011 ; 25(4): 349–359. doi:10.1097/JPN.0b013e318234ac7a.

SOFFI: An evidence-based method for quality bottle-feedings of

Infant feeding, by its nature, is an interactive, developmental task.1 Current research in

understood as a communicative attempt and parents know how to respond to it effectively,

Basis of the SOFFI Method in Theory and Research

efficiency 23, and descriptions of suck-swallow-breathe coordination.22

The SOFFI Bottle Feeding Algorithm

A Caveat Regarding the Use of the Algorithm

Decisions to Start a Feeding (See “Start” on the SOFFI Bottle Feeding

Postponing or omitting a bottle feeding on the basis of physiologic instability, as defined

feeding, (3) an increased likelihood of solidifying disorganized behaviors in the repertoire,

Decisions during the Feeding

significant instability (a ‘no” answer) lead the caregiver to support self-regulation

The integration of suck-swallow-breathe is usually well developed in newborn term infants

pacing, however, physiologic stability can be maintained and sucking efficiency

Decisions to End a Feeding

Documenting Infant Progression and Staff Feeding Activity Using the

Decisions to Increase Feeding Frequency and/or Volume

The SOFFI Method in Practice

Figure 1. SOFFI Method Algorithm for Bottle-Feeding

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