According to the World Health Organization (WHO), infants born before the 37th week of gestational age are considered premature [
1]. At present, in the United States, approximately 12% [
2] of infants and in Iran 10% [
3] of infants are born prematurely. The number of premature infants and their survival rates are increasing worldwide [
4]. Preterm infants are at risk for life-threatening illnesses. (e.g.; diseases that affect the gastrointestinal, respiratory, neurological and cardiovascular systems) [
5]. In addition, poor muscle tone, immature oromotor control and coordination of sucking, swallowing, and breathing often lead to difficulties in achieving timely independent oral feedings [
6]. Browne et al. [
7] found that premature infants had problems with successful feeding and weight gain not only during their NICU (Neonatal Intensive Care Unit) stays but also after discharge. Respiratory status, oxygen saturation and heart rate are sensitive indicators of premature infants’ ability to manage feeding successfully [
8]. In order to support preterm infants in feeding competence, typically, feeding volumes required for growth are provided through gavage tube feedings, either naso- or oro-gastric, until infants are competent in independent oral feedings [
9]. Oral feeding present
s a complex accomplishment for most preterm infants [
10]. Achieving independent oral feeding is one of the American Academy of Pediatrics’ recommended criteria for infant discharge [
11]. Infant feeding protocols, thus, should be evaluated with the goal to assist premature infants in safely acquiring independent oral feeding skills before discharge [
12]. Some interventions such as non-nutritive sucking and individualized developmental care have shown to be efficacious in supporting the shift from gavage to independent oral feeding, which in turn likely will reduce the duration of hospital stays [
10]. Today, increasing emphasis is placed on the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) in NICUs. This individualized approach to care is based on reading each preterm infant’s behavioral cues, and on formulating a plan of care based there upon. This approach enhances and builds upon the infant’s strengths, and supports the infant in areas of sensitivity and vulnerability [
13]. Given the specificity of each preterm infant’s behavioral cues for self-regulation during feeding, [
12] a shift from gestational age-based guidelines for initiating oral feedings or volume-based feedings [
14] to an approach based on infants’ behavioral cues likely should occur. Behavioral cue-based feeding (BCBF) based on close observation of the infant’s behavioral signals [
15] is a method in which caregivers determine how and when an infant expects to be fed. Each infant is considered an individual with meaningful behaviors. A gestational age and volume-driven approach to feeding therefore is shifted towards an infant-driven approach [
16]. Crick et al. (2007) found that cue-based feeding was effective in the successful achievement of premature infants’ competence in earlier independent oral feeding [
17]. Behavioral cue-based feeding requires coordinated breathing, sucking, and swallowing for behavioral regulation and physiological stability, and as with all behavior, is influenced by the environment and the caregiver [
18]. Results of a study in New York that compared infant-driven feeding protocols and routine feedings based on physicians’ prescription orders showed that the infant-driven approach was associated with faster achievement of oral feeding skills, and thereby earlier hospital discharge [
19]. NICU nurses are in an excellent position to identify cue-based infant feeding behaviors since they care for infants for extended time periods; this avails them of ample opportunity to observe closely and get to know the infants in their care. With a primary care nursing team, nurses tend to develop close relationships with infants and their families, which in turn enhance their understanding and observation of preferences, strengths, and vulnerabilities of the infant, as well as of subtle and/or unexpected behavioral changes possibly signaling impending setbacks or illness [
20]. Despite the growing evidence of the success and importance of this type of feeding, its implementation continues to meet resistance in NICUs, likely because embracing change is often fraught with anxiety of failure; it requires letting go of the security of well-established, routinized infant age and volume-based protocols [
17]. Abdul-Aziz et al. [
21] in Egypt found that educating mothers in reading their infants’ cues and using these cues in feeding their preterm infants increased gains in weight, and head circumference, and shortened the time to full nipple feeding. Evidence of the effectiveness of cue-based infant-driven feeding in Iran so far is lacking. Many NICUs in Iran begin oral feedings based on postconceptional age and feeding volume, with resultant frequent feeding problems that delay discharge. Therefore, the current study was designed to determine the effects of behavioral cue-based feeding on preterm infants’ short-term health outcomes.