Oral Feeding Practices in NICU Infants on CPAP or HFNC: A U.S. Cross-Sectional Survey

Abstract

Objective

Coordination of sucking–swallowing–breathing matures at 32 to 34 weeks' gestation; early oral feeds risk aspiration, while delays may increase oral aversion and length of stay. Safety of feeding on high-flow nasal cannula (HFNC) or continuous positive airway pressure (CPAP) is uncertain, and practice variations are common. This study describes the U.S. neonatal intensive care unit (NICU) practices for oral feeding during HFNC/CPAP and decision criteria.

Study Design

National cross-sectional telephone survey (July 2024–February 2025) of key informants from level III and IV NICUs.

Results

Of 159 NICUs, 83.0% routinely permitted oral feeding on HFNC, 10.7% sometimes, and 6.3% never. Only 9.4% routinely allowed CPAP feeding, 7.5% sometimes, and 83.0% never. Units allowing CPAP feeding used stricter readiness criteria, continuous monitoring, and involved speech-language pathology/occupational therapy.

Conclusion

Oral feeding on HFNC is common; CPAP feeding is rare and criteria-bound, with regional variation. Heterogeneity underscores the need for consensus guidance and trials evaluating CPAP feeding effects on feeding outcomes, length of stay, and neurodevelopment.

Key Points

• Oral feeding during noninvasive support is widespread for HFNC but far more selective on CPAP.

• Units that permit CPAP feeding use strict criteria and multidisciplinary evaluation.

• Considerable variability across units and regions highlights the need for standardized guidance.

Keywords

oral feeding difficulty - CPAP - HFNC - preterm infants - NICU

Contributors' Statement

M.K.: drafted the initial manuscript, administered the phone surveys, collected data, carried out the initial analyses, and critically reviewed and revised the manuscript; S.S.: administered phone surveys and collected data, and reviewed the manuscript; S.V.: conceptualized and designed the study, carried out the initial analyses, and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Publication History

Received: 29 September 2025

Accepted: 09 November 2025

Article published online:
24 November 2025

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