The maturation and coordination of sucking, swallowing, and respiration in preterm infants

Exploring factors related to oral feeding progression in premature infants

PURPOSE

To identify infant and maternal characteristics associated with the pace of progression from the first oral feeding to complete oral feeding.

SUBJECTS

One hundred forty-two stable premature infants who were fully or partially gavage feeding immediately after birth (29 to 34 weeks gestational age at birth).

DESIGN

Exploratory secondary analysis.

METHODS

Data are from an ongoing randomized clinical trial of a developmental maternally administered intervention (Hospital to Home Transition-Optimizing Premature Infant's Environment) for mother-infant dyads at high social-environmental risk.

MAIN OUTCOME MEASURES

Oral feeding progression (transition time from the first attempt to complete oral feeding).

SAMPLE CHARACTERISTICS

The convenience sample of preterm infants consisted of 48.6% male infants; the mean gestational age at birth was 32.4 weeks and mean birth weight 1787 g; and African American mothers (47.9%; n = 80) and Latina mothers (52.1%; n = 83).

PRINCIPLE RESULTS

Multivariable linear regression results showed that, on average, the number of days for infants of Latina mothers to achieve complete oral feeding was 2.43 days more than for infants of African American mothers. In addition, lower birth weight and lower postmenstrual age at first oral feeding were associated with longer feeding progression. Higher infant morbidity was correlated with longer feeding progression.

CONCLUSION

Infants with Latina mothers, lower birth weight, lower postmenstrual age at first oral feeding, and higher morbidity scores had a longer transition from first to complete oral feeding. Identification of infants at risk for delayed transition from first to complete oral feeding may allow for the development and testing of appropriate interventions that support the transition from gavage to complete oral feeding.

Longitudinal changes in suck-swallow-breathe, oxygen saturation, and heart rate patterns in term breastfeeding infants

BACKGROUND

Despite the differences in breastfeeding and bottle-feeding, our understanding of how suck-swallow-breathe (SSwB), oxygenation, and heart rate patterns change as the infant ages is based predominantly on bottle-feeding studies. Therefore, this study aimed to measure how SSwB, oxygenation, and heart rate patterns changed during the first 4 months of lactation in term breastfeeding infants.

METHODS

Infants less than 1 month postpartum (n = 15) were monitored early in lactation and again later in lactation (2-4 months postpartum). Simultaneous recordings of vacuum, tongue movement, respiration, swallowing, oxygen saturation, and heart rate were made during both nutritive sucking and non-nutritive sucking during breastfeeding.

RESULTS

Infants transferred a similar amount of milk (P = .15) over a shorter duration later in lactation (P = .04). Compared to early lactation, suck bursts became longer (P < .001), pauses became shorter (P < .001), vacuum levels decreased (all P < .05), oxygen saturation increased (P < .001), and heart rate decreased (P < .001) later in lactation.

CONCLUSION

This study confirmed that term infants become more efficient at breastfeeding as they age, primarily by extending their suck bursts and pausing less. Although infants demonstrated satisfactory SSwB coordination during early lactation, they showed a level of adaption or conditioning at later lactation by applying weaker vacuum levels and demonstrating improved cardiorespiratory responses.

Oral-motor function and feeding intervention

This article presents the elements of the Oral Motor Intervention section of the Infant Care Path for Physical Therapy in the Neonatal Intensive Care Unit (NICU). The types of physical therapy interventions presented in this path are evidence based as well as infant driven and family focused. In the context of anticipated maturation of suck-swallow-breathe coordination, the timing and methods for initiation of oral feedings and transition from gavage to full breast or bottle-feedings are presented with supporting evidence.

The effect of oral training on vital signs of premature infants

AIMS AND OBJECTIVES

This study aimed to develop an applicable oral training protocol and test its effects on vital sign stabilisation in premature infants.

BACKGROUND

Oral training improves the feeding behaviour of premature infants. However, the inconsistencies of oral training procedures in previous studies obscure the interventional effect of oral training on vital sign stabilisation in premature infants.

DESIGN

True experimental design.

METHODS

Sixty premature infants with a gestational age <33 weeks were recruited and randomly assigned to the oral training or control group.

RESULTS

Heart rate, respiratory rate and oxygen saturation tended to improve in the oral training group compared to those in the control group. However, the intergroup differences with respect to vital signs before and after feeding were not statistically significant.

CONCLUSIONS

Further studies comparing protocols with different measurement points and durations are suggested.

Health profile of young adults born preterm: negative effects of rapid weight gain in early life

INTRODUCTION

Early postnatal weight gain is associated with determinants of cardiovascular disease (CVD) and type 2 diabetes mellitus (DM2) in adults born term. We aimed to investigate the association of weight gain during different periods, and weight trajectories in early life after preterm birth, with determinants of CVD and DM2 in early adulthood.

METHODS

Associations of first-year growth and tempo of weight gain with determinants of CVD and DM2 in 162 young adults (18-24 yr) born preterm (gestational age <36 wk) were determined and compared with data of young adults born term (n = 217).

RESULTS

Gain in weight for length in the period from preterm birth up to term age, and in the first 3 months after term age, was positively associated with body fat percentage and waist circumference at 21 yr. Gain in weight for length in the first 3 months after term age was also positively associated with total cholesterol and low-density lipoprotein cholesterol levels in early adulthood. Subjects with the highest gain in weight from birth to term age (highest quartile) had significantly higher body fat percentage, waist circumference, acute insulin response, and disposition index in early adulthood than the subgroups with moderate and low gain in weight. Rapid catch-up in weight during the first 3 months after term age resulted in a higher fat percentage, waist circumference, and serum triglycerides level than slower catch-up in weight.

CONCLUSION

Accelerated neonatal gain in weight relative to length after preterm birth (immediately after birth and during the first 3 months after term age) is associated with determinants of CVD in early adulthood and should therefore be avoided.

Oral feeding readiness in the neonatal intensive care unit

Oral feeding is a complex sensorimotor process that is influenced by many variables, making the introduction and management of oral feeding a challenge for many health care providers. Feeding practice guided by tradition or a trial-and-error approach may be inconsistent and has the potential to delay the progression of oral feeding skills. Oral feeding initiation and management should be based on careful, individualized assessment of the NICU infant and requires an understanding of neonatal physiology and neurodevelopment. The purpose of this article is to help the health care provider with this complex process by (a) defining oral feeding readiness, (b) describing the importance of oral feeding in the NICU and the physiology of feeding, and (c) providing a review of the literature regarding the transition from gavage to oral feeding in the NICU.

Prenatal Mouth Movements: Can We Identify Co-Ordinated Fetal Mouth and LIP Actions Necessary for Feeding?

Observations of prenatal movement patterns of mouth and lips essential for feeding could have the potential for an assessment of the readiness to feed after birth. Although there is some research on sucking per se, we know very little about prenatal preparatory movements for sucking, namely, the ability to co-ordinate opening the mouth widely and then pursing the lips as if around a teat or nipple in utero. The purpose of the present study was to test two hypotheses using an adapted version of the Facial Action Coding Scheme: first that mouth stretch (AU 27) will be followed by lip pucker (AU 18), and second that these coordinated movement patterns will increase as a function of gestational age. Fifteen healthy fetuses were scanned four times between 24 and 36 weeks gestation using 4D ultrasound visualization. Results showed a decreased number of mouth stretches with increasing fetal age. Contrary to our expectations, we did not find an increase in movement patterns of mouth stretch followed by lip pucker in preparation for feeding ex utero. The results are discussed in terms of sensory triggers in utero required to elicit preparatory movements for feeding ex utero.

Neonatal management and safe discharge of late and moderate preterm infants

Late and moderate preterm infants form the majority of admissions for prematurity to special care neonatal nurseries. Although at risk for acute disorders of prematurity, they do not suffer the serious long term risks and chronic illnesses of the extremely premature. The special challenges addressed here are of transition and of thermal adaptation, nutritional compensation for postnatal growth restriction, the establishment of early feeding, and the avoidance of post-discharge jaundice or apnea. These 'healthy' premature infants provide challenges for discharge planning, in that opportunities may be available for discharge well before the expected date of delivery, which should be pursued. Barriers to early discharge are rigid conservative protocols and unwarranted investigations; facilitators of discharge are individualized care by nurses expert in cue-based feeding, early management of the thermal environment, support of family preferences and encouragement of mother-baby interactions. Safe discharge depends on recognizing these opportunities and applying strategies to address them.

Oral and nonoral sensorimotor interventions facilitate suck-swallow-respiration functions and their coordination in preterm infants

BACKGROUND

Preterm infants are at high risk of encountering oral feeding difficulties. Early sensorimotor interventions may improve oral feeding skills in preterm infants.

AIM

To further explore the effects of an oral (O), tactile/kinesthetic (T/K), and combined (O+T/K) sensorimotor intervention on preterm infants' nutritive sucking, swallowing and their coordination with respiration.

STUDY DESIGN

Seventy-five infants (29 [0.3, standard error of mean, SEM] weeks gestation, 49 males/26 females) were randomly assigned to an O group involving sensorimotor input to the oral structures; a T/K group involving sensorimotor input to the trunk and limbs; a combined (O+T/K) group; and a control group.

OUTCOME MEASURES

Stage of sucking, suction and expression amplitudes (mmHg), suck-swallow ratio, stability of suck-swallow interval, and swallow-respiration patterns.

RESULTS

The O group had significantly more advanced sucking stages, and greater suction and expression amplitudes than controls [p≤0.035, effect size (ES) >0.6]. The suck-swallow ratio and stability of suck-swallow intervals did not significantly differ among groups (p≥0.181, ES≤0.3). The three interventions led to fewer swallows bracketed by prolonged respiratory pauses compared to controls (pause-swallow-pause, p≤0.044, ES≥0.7). The T/K and combined (O+T/K) groups had greater occurrence of swallows bracketed by expiration than the control and O groups (expiration-swallow-expiration, p≤0.039, ES≥0.3).

CONCLUSION

The O intervention enhanced specific components of nutritive sucking. All three interventions resulted in improved swallow-respiration coordination. Sensorimotor interventions have distributed beneficial effects that go beyond the specific target of input.

Oral feeding competences of healthy preterm infants: a review

Background. With increasing sophistication and technology, survival rates hugely improved among preterm infants admitted to the neonatal intensive care unit. Nutrition and feeding remain a challenge and preterm infants are at high risk of encountering oral feeding difficulties. Objective. To determine what facts may impact on oral feeding readiness and competence and which kind of interventions should enhance oral feeding performance in preterm infants. Search Strategy. MEDILINE database was explored and articles relevant to this topic were collected starting from 2009 up to 2011. Main Results. Increasingly robust alertness prior to and during feeding does positively impact the infant's feeding Skills. The review found that oral and non-oral sensorimotor interventions, provided singly or in combination, shortened the transition time to independent oral feeding in preterm infants and that preterm infants who received a combined oral and sensorimotor intervention demonstrated more advanced nutritive sucking, suck-swallow and swallow-respiration coordination than those who received an oral or sensorimotor intervention singly.

Oxygen Saturation and Suck-Swallow-Breathe Coordination of Term Infants during Breastfeeding and Feeding from a Teat Releasing Milk Only with Vacuum

Background. Vacuum is an important factor in milk removal from the breast, yet compression is the predominant component of milk removal from bottle teats. Since bottle-feeding infants have lower oxygen saturation, vacuum levels, and different suck-swallow-breathe (SSwB) coordination to breastfeeding infants, we hypothesised that when infants fed from a teat that required a vacuum threshold of -29 mmHg for milk removal, that oxygen saturation, heart rate, and suck-swallow-breathe (SSwB) patterns would be similar to those of breastfeeding. Study Design. Infants (n = 16) were monitored during one breastfeed and one feed from the experimental teat. Simultaneous recordings were made of oxygen saturation, heart rate, vacuum, tongue movement, respiration, and swallowing. Results. There were no differences in oxygen saturation and heart rate between the breast and the teat. Infants displayed fewer sucks and breaths per swallow during nutritive sucking (NS) compared to non-nutritive sucking (NNS). The number of sucks per breath was similar for NS and NNS although respiratory rates were slower during NS. These patterns did not differ between the breast and the teat. Conclusion. These results suggest that vacuum may be conducive to safe and coordinated milk removal by the infant during both breast and bottle-feeding.

Effects of nasal continuous positive-airway pressure on nutritive swallowing in lambs

Current knowledge suggests that, to be successful, oral feeding in preterm infants should be initiated as soon as possible, often at an age where immature respiration still requires ventilatory support in the form of nasal continuous positive airway pressure (nCPAP). While some neonatologist teams claim great success with initiation of oral feeding in immature infants with nCPAP, others strictly wait for this ventilatory support to be no longer necessary before any attempt at oral feeding, fearing laryngeal penetration and tracheal aspiration. Therefore, the aim of the present study was to provide a first assessment of the effect of various levels of nCPAP on bottle-feeding in a neonatal ovine model, including feeding safety, feeding efficiency, and nutritive swallowing-breathing coordination. Eight lambs born at term were surgically instrumented 48 h after birth to collect recordings of electrical activity of laryngeal constrictor muscle, electrocardiography, and arterial blood gases. Two days after surgery, lambs were bottle-fed under five randomized nCPAP conditions, including without any nCPAP or nasal mask and nCPAP of 0, 4, 7, and 10 cmH(2)O. Results revealed that application of nCPAP in the full-term lamb had no deleterious effect on feeding safety and efficiency or on nutritive swallowing-breathing coordination. The present study provides a first and unique insight on the effect of nCPAP on oral feeding, demonstrating its safety in newborn lambs born at term. These results open the way for further research in preterm lambs to better mimic the problems encountered in neonatology.

Eating as a neurodevelopmental process for high-risk newborns

Many high-risk and preterm infants have difficulty with successful feeding and subsequent optimal growth during their stay in the neonatal intensive care unit as well as in the months after discharge. Environmental, procedural, and medical issues necessary for treatment of the hospitalized infant present challenges for the development of successful eating skills. Emerging data describe eating as a predictable neurodevelopmental process that depends on the infant's organization of physiologic processes, motor tone and movement, level of arousal, and ability to simultaneously regulate these processes.

Assessment of Primitive Reflexes in High-risk Newborns

BACKGROUND

Assessment of primitive reflexes is one of the earliest, simplest, and most frequently used assessment tools among health care providers for newborns and young infants. However, very few data exist for high-risk infants in this topic. Among the various primitive reflexes, this study was undertaken particularly to describe the sucking, Babinski and Moro reflexes in high-risk newborns and to explore their relationships with clinical variables.

METHODS

This study is a cross-sectional descriptive study. Sixty seven high-risk newborns including full-term infants required intensive care as well as premature infants were recruited in a neonatal intensive care unit using convenient sampling method. The sucking, Babinski and Moro reflexes were assessed and classified by normal, abnormal and absence. To explore their relationships with clinical variables, birth-related variables, brain sonogram results, and behavioral state (the Anderson Behavioral State Scale, ABSS) and mental status (the Infant Coma Scale, ICS) were assessed.

RESULTS

The sucking reflex presented a normal response most frequently (63.5%), followed by Babinski reflex (58.7%) and Moro reflex (42.9%). Newborns who presented normal sucking and Babinski reflex responses were more likely to have older gestational age, heavier birth and current weight, higher Apgar scores, shorter length of hospitalization, better respiratory conditions, and better mental status assessed by ICS, but not with Moro reflex.

CONCLUSIONS

High risk newborns presented more frequent abnormal and absence responses of primitive reflex and the proportions of the responses varied by reflex. Further researches are necessary in exploring diverse aspects of primitive reflexes and revealing their clinical implication in the high-risk newborns that are unique and different to normal healthy newborns.

KEYWORDS

Primitive reflex; High risk infants; Korean; Moro reflex; Sucking reflex; Babinski reflex; The Anderson Behavioral State Scale; Infant Coma Scale.

Swallowing dysfunction in very low birth weight infants with oral feeding desaturation

BACKGROUND

We detected swallowing dysfunction by the modified barium swallow (MBS) test and determined risk factors for swallowing dysfunction in very low birth weight (VLBW) infants with oral feeding desaturation near discharge.

METHODS

We retrospectively reviewed 41 VLBW infants referred for MBS test because of significant oral feeding desaturation at ≥ 35 weeks of postmenstrual age. Infants who showed impaired airway protection, including inadequate epiglottic closure, laryngeal penetration and/or tracheal aspiration by MBS test, were compared to those without impaired airway protection.

RESULTS

Eleven infants (26.8%) showed impaired airway protection by MBS test. They had a significantly lower gestational age at birth but a similar postmenstrual age compared to those without impaired airway protection. All infants with impaired airway protection were born at ≤ 28 weeks of gestation.

CONCLUSIONS

Swallowing dysfunction resulting in aspiration should be considered as a cause of significant oral feeding desaturation in infants born at ≤ 28 weeks of gestation regardless of postmenstrual age.

Postdischarge feeding patterns in early- and late-preterm infants

OBJECTIVE

To compare the incidence of postdischarge feeding dysfunction and hospital/subspecialty visits for feeding problems during the first year of life in late (34 to 36 6/7 weeks) and early-preterm (25 to 33 6/7 weeks) infants.

METHODS

In this prospective study, the authors sent questionnaires to parents of early (n = 319) and late (n = 571) preterm infants at 3, 6, and 12 months corrected age. Parents' perceptions of infants' feeding skills, comfort with feeding, and hospital/subspecialty visits for feeding difficulties were obtained. Results were analyzed with χ(2) tests and Spearman's correlations.

RESULTS

Early preterms had more oromotor dysfunction at 3 (29% vs 17%) and 12 months (7% vs 4%) and more avoidant feeding behavior at 3 months (33% vs 29%). In both groups, oromotor dysfunction and avoidant feeding behavior improved over time. Frequency of poor appetite and hospitalization/subspecialty visits were similar.

CONCLUSION

Pediatricians should screen all preterm infants for feeding dysfunction during the first year.

Feeding Difficulties in Preterm Infants

Preterm infants often display difficulty establishing oral feeding in the weeks following birth. This article aims to provide an overview of the literature investigating the development of feeding skills in preterm infants, as well as of interventions aimed at assisting preterm infants to develop their feeding skills. Available research suggests that preterm infants born at a lower gestational age and/or with a greater degree of morbidity are most at risk of early feeding difficulties. Respiratory disease was identified as a particular risk factor. Mechanisms for feeding difficulty identified in the literature include immature or dysfunctional sucking skills and poor suck–swallow–breath coordination. Available evidence provides some support for therapy interventions aimed at improving feeding skills, as well as the use of restricted milk flow to assist with maintaining appropriate ventilation during feeds. Further research is needed to confirm these findings, as well as to answer remaining clinical questions.

Development of a technique for evaluating temporal parameters of sucking in breastfeeding preterm newborns

AIMS

The aim of the current study was to developed and test the reliability of a technique for measuring temporal parameters of sucking in breastfeeding infants.

METHODS

The technique was developed using a cohort of 11 term and 12 preterm infants, and subsequently evaluated using a cohort of 43 preterm infants. Measurements related to sucking pressure in the term and preterm infants were acquired. The signals were recorded for 5 min, saved on a computer, and stored for analysis. For purposes of analysis, the minute with the highest quality signal was chosen. Signal analysis was performed by two researchers, and inter- and intra-observer agreement was assessed. The newborns in the sample had different gestational ages.

RESULTS

A technique was developed for the analysis of temporal parameters of sucking during breastfeeding and evaluated in 43 preterm infants with different gestational ages for the following variables: number of bursts per minute, number of sucks per burst, sucking rate, pause rate, and duration of pauses. The intra-observer agreement was 0.85 and the inter-observer agreement was 0.85.

CONCLUSIONS

The technique that was developed and validated proved capable of measuring temporal parameters of sucking in breastfeeding newborns.

The effect of the odor of breast milk on the time needed for transition from gavage to total oral feeding in preterm infants

PURPOSE

The aim of this study was to investigate the effect of the application of the odor of breast milk in preterm infants during gavage feeding on the period of transition to total oral feeding.

DESIGN

This prospective experimental study was performed on a total of 80 preterm infants: 40 infants in the study group and 40 in the control group.

METHODS

This experimental study was performed in eastern Turkey at the Neonatal Intensive Care and Premature Unit of a university hospital between September 2007 and December 2008. The demographic data were collected via a questionnaire, and an intervention and follow-up table was prepared by the researcher based on relevant literature. The study was approved by the local institution, and written informed consent was obtained from all parents.

FINDINGS

The findings of the study indicated that the preterm infants who were stimulated by the odor of breast milk during gavage feeding transitioned to oral feeding 3 days earlier than control subjects. Moreover, the mean hospitalization time of these infants was 4 days shorter.

CONCLUSIONS

The results show that stimulation with breast milk odor is an effective method for decreasing transition of preterm infants from gavage to oral feeding.

CLINICAL RELEVANCE

Nurses can train mothers to pump their breast milk, stimulate their infants with the odor of their breast milk, and feed it to their infants in the premature unit. This may lead to a quicker transition to oral feeding.

Intervenção fonoaudiológica em recém-nascido pré-termo: estimulação oromotora e sucção não-nutritiva

TEMA: intervenção fonoaudiológica em recém-nascido pré-termo, com uso das técnicas de estimulação oromotora e sucção não-nutritiva. PROCEDIMENTOS: participaram da intervenção fonoaudiológica dois recém-nascidos gemelares com idade gestacional corrigida de 35 semanas e 2/7 dias. Foi realizada a avaliação fonoaudiológica para verificar a prontidão do prematuro para o início da alimentação por via oral e a eficiência da alimentação por via oral por meio das relações: volume aceito pelo volume total prescrito e volume aceito pelo tempo de aceitação da dieta. Posteriormente foi sorteada a técnica que cada recém-nascido receberia. RN1 recebeu a técnica de estimulação oromotora e o RN2 recebeu a técnica de sucção não-nutritiva. Em seguida, receberam 10 sessões de terapia fonoaudiológica e foram reavaliados. RESULTADOS: após as sessões de estimulação os recém-nascidos apresentaram melhora nos reflexos orais e no padrão de sucção não nutritiva e melhoraram no aproveitamento da dieta oral. CONCLUSÃO: ambos os recém-nascidos foram beneficiados com a intervenção fonoaudiológica.

Making the literature palatable at the bedside: Reference poster promotes oral feeding best practice

Neonatal nurses often draw upon prior experiences and intuition to feed neonates. Such experience and skill vary from nurse to nurse and may not be based on recent research, nor tailored to each neonate's feeding skill. An evidence-based neonatal oral feeding guideline was produced to improve oral feeding practices among nurses and parents. The implementation was initially less than ideal, resulting in poor compliance. A bedside reference poster was designed to serve as a visual succinct reminder of the oral feeding guideline.

Evidence-based systematic review: effects of oral motor interventions on feeding and swallowing in preterm infants

PURPOSE

To conduct an evidence-based systematic review and provide an estimate of the effects of oral motor interventions (OMIs) on feeding/swallowing outcomes (both physiological and functional) and pulmonary health in preterm infants.

METHOD

A systematic search of the literature published from 1960 to 2007 was conducted. Articles meeting the selection criteria were appraised by 2 reviewers and vetted by a 3rd for methodological quality.

RESULTS

Twelve studies were included and focused on 3 OMIs-nonnutritive sucking (NNS), oral/perioral stimulation, and NNS plus oral/perioral stimulation. Six studies addressed the effects of OMI on the feeding/swallowing physiology outcomes of feeding efficiency or sucking pressures. Ten studies addressed the functional feeding/swallowing outcomes of oral feeding or weight gain/growth. No studies reported data on pulmonary health. Methodological quality varied greatly. NNS alone and with oral/perioral stimulation showed strong positive findings for improvement in some feeding/swallowing physiology variables and for reducing transition time to oral feeding. Prefeeding stimulation showed equivocal results across the targeted outcomes. None of the OMIs provided consistent positive results on weight gain/growth.

CONCLUSIONS

Although some OMIs show promise for enhancing feeding/swallowing in preterm infants, methodological limitations and variations in results across studies warrant careful consideration of their clinical use.

Prediction for developmental delay on Neonatal Oral Motor Assessment Scale in preterm infants without brain lesion

BACKGROUND

Preterm infants often have difficulty in achieving a coordinated sucking pattern. To analyze the correlation between preterm infants with disorganized sucking and future development, weekly studies were performed of 27 preterm infants from initiation of bottle feeding until a normal sucking pattern was recognized.

METHODS

A total of 27 preterm infants without brain lesion participated in the present study. Neonatal Oral Motor Assessment Scale (NOMAS) was utilized to evaluate the sucking pattern. Infants who were initially assessed as having disorganized sucking on NOMAS and regained a normal sucking pattern by 37 weeks old were assigned to group I; infants with a persistent disorganized sucking pattern after 37 weeks were assigned to group II. The mental (MDI) and psychomotor (PDI) developmental indices of Bayley Scales of Infant Development, second edition were used for follow-up tests to demonstrate neurodevelopment at 6 months and 12 months of corrected age.

RESULTS

At 6 months follow up, subjects in group I had a significantly higher PDI score than group II infants (P= 0.04). At 12 months follow up, group I subjects had a significantly higher score on MDI (P= 0.03) and PDI (P= 0.04). There was also a higher rate for development delay in group II at 6 months (P= 0.05).

CONCLUSION

NOMAS-based assessment for neonatal feeding performance could be a helpful tool to predict neurodevelopmental outcome at 6 and 12 months. Close follow up and early intervention may be necessary for infants who present with a disorganized sucking pattern after 37 weeks post-conceptional age.

The preterm piglet - a model in the study of oesophageal development in preterm neonates

AIM

Preterm infants have difficulty in attaining independent oral feeding. This can ensue from inadequate sucking, swallowing and/or respiration. In impeding bolus transport, immature oesophageal motility may also be a cause. As studies on the development of oesophageal motility are invasive in preterm infants, the preterm piglet was investigated as a potential research model.

METHODS

Oesophageal motility (EM) of term (n = 6) and preterm (n = 15) piglets were monitored by manometry for 10 min immediately following bottle feeding on days 1-2 and 3-4 of life.

RESULTS

Piglets' oral feeding performance and EM were similar to those of their human counterparts. Term piglets readily completed their feeding, whereas their preterm counterparts did not. They also presented with greater peristaltic activity and propagating velocity. Peristaltic activity remained unchanged over time in preterm piglets, but an increase in synchronous and decrease in incomplete motor activity were noted. Preterm piglets that developed symptoms analogous to necrotizing enterocolitis (NEC) demonstrated uncharacteristic oesophageal activity.

CONCLUSION

Immature EM may cause oral feeding difficulties. NEC-like symptoms may adversely affect EM. The piglet is a valid research model for studying human infant oral feeding and oesophageal development.

Os efeitos da estimulação sensório motora oral na sucção nutritiva na mamadeira de recém-nascidos pré-termo

OBJETIVO: verificar o desempenho da sucção nutritiva, na mamadeira, em recém-nascidos pré-termo submetidos à estimulação sensório-motora-oral. MÉTODOS: pesquisa do tipo ensaio clínico controlado de intervenção. 20 recém-nascidos pré-termo foram distribuídos em grupo estimulado e grupo controle. Estes grupos foram submetidos à avaliação fonoaudiológica em dois diferentes momentos: na liberação da alimentação por via oral; e quando atingiam alimentação plena por via oral num período de 24 horas. As avaliações foram filmadas, e os resultados foram analisados pela pesquisadora. Para análise dos dados utilizou-se o Teste exato de Fishe r e o Teste "T" de Studen t do software estatístico STATA 10.0. Considerou-se p < 0,05. RESULTADOS: recém-nascidos do grupo estimulado, na segunda avaliação, apresentaram resultados com diferença estatística significante quanto a força de sucção forte (p=0,003), presença dos três reflexos adaptativos (p=0,001), coordenação da sucção/deglutição/respiração (p=0,003), no tempo total de sucções (p=0,01) e na frequência de sucção (p<0,01). O número total de sucções apresentou diferença estatística significante (p<0,05) entre as avaliações do grupo controle. Quanto ao ritmo e a relação entre o volume de leite prescrito e ingerido não apresentou resultados com diferença estatística significante. CONCLUSÃO: a estimulação sensório-motora oral parece favorecer o desempenho nas funções de sucção nutritiva de recém-nascidos pré-termo.

Energy expenditure for breastfeeding and bottle-feeding preterm infants

OBJECTIVE

We hypothesized that resting energy expenditure (REE) would be higher after breastfeeding than after bottle-feeding.

METHODS

Nineteen preterm infants (gestational age: 32 weeks) in stable condition who were nourished entirely with their mothers' breast milk were assigned randomly to feeding either by bottle or at the breast. Each infant served as his or her own control subject. REE was measured for 20 minutes after feeding. Breast milk quantity was evaluated with prefeeding and postfeeding weighing. REE values for bottle-feeding and breastfeeding were compared with paired t tests.

RESULTS

Contrary to our null hypothesis, the group's mean REE values after bottle-feeding and breastfeeding were very similar (284.7 +/- 26.8 kJ/kg per day [68.3 +/- 6.4 kcal/kg per day] vs 282.6 +/- 28.5 kJ/kg per day [67.5 +/- 6.8 kcal/kg per day]; not significant). The duration of feeding was significantly longer for breastfeeding than for bottle-feeding (20.1 +/- 7.9 vs 7.8 +/- 2.9 minutes; P < .0001).

CONCLUSION

There was no significant difference in REE when infants were breastfed versus bottle-fed. Longer feeding times at the breast did not increase REE. We speculate that it is safe to recommend feeding at the breast for infants born at >32 weeks when they can tolerate oral feeding.

Central pattern generation involved in oral and respiratory control for feeding in the term infant

PURPOSE OF REVIEW

Drinking and eating are essential skills for survival and benefit from the coordination of several pattern generating networks and their musculoskeletal effectors to achieve safe swallows. Oralpharyngoesophageal motility develops during infancy and early childhood, and is influenced by various factors, including neuromuscular maturation, dietary and postural habits, arousal state, ongoing illnesses, congenital anomalies, and the effects of medical or surgical interventions. Gastroesophageal reflux is frequent in neonates and infants, and its role in neonatal morbidity including dysphagia, chronic lung disease, or apparent life-threatening events is not well understood. This review highlights recent studies aimed at understanding the development of oral feeding skills, and cross-system interactions among the brainstem, spinal, and cerebral networks involved in feeding.

RECENT FINDINGS

Functional linkages between suck-swallow and swallow-respiration manifest transitional forms during late gestation through the first year of life, which can be delayed or modified by sensory experience or disease processes, or both. Relevant central pattern generator (CPG) networks and their neuromuscular targets attain functional status at different rates, which ultimately influences cross-system CPG interactions. Entrainment of trigeminal primary afferents accelerates pattern genesis for the suck CPG and transition-to-oral feed in the RDS preterm infant.

SUMMARY

The genesis of within-system CPG control for rate and amplitude scaling matures differentially for suck, mastication, swallow, and respiration. Cross-system interactions among these CPGs represent targets of opportunity for new interventions, which optimize experience-dependent mechanisms to promote safe swallows among newborn and pediatric patients.

Oral and respiratory control for preterm feeding

PURPOSE OF REVIEW

Feeding competency is a frequent and serious challenge to the neonatal intensive care unit survivors and to the physician-provider-parent teams. The urgency of effective assessment and intervention techniques is obviated to promote safe swallow, as attainment of oral feeding for the preterm infant/newborn is one of the prerequisites for hospital discharge. If left unresolved, feeding problems may persist into early childhood and may require management by pediatric gastroenterologists and feeding therapists. This review highlights studies aimed at understanding the motor control and development of nonnutritive and nutritive suck, swallow, and coordination with respiration in preterm populations.

RECENT FINDINGS

Functional linkages between suck-swallow and swallow-respiration manifest transitional forms during late gestation and can be delayed or modified by sensory experience and/or disease processes. Moreover, brainstem central pattern generator (CPG) networks and their neuromuscular targets attain functional status at different rates, which ultimately influences cross-system interactions among individual CPGs. Entrainment of trigeminal primary afferents to activate the suck CPG is one example of a clinical intervention to prime cross-system interactions among ororhythmic pattern generating networks in the preterm and term infants.

SUMMARY

The genesis of within-system CPG control for rate and amplitude scaling matures differentially for suck, mastication, swallow, and respiration. Cross-system interactions among these CPGs represent targets of opportunity for new interventions that optimize experience-dependent mechanisms to promote robust ororhythmic patterning and safe swallows among preterm infants.

The oral motor capacity and feeding performance of preterm newborns at the time of transition to oral feeding

The objective of the present study was to determine the oral motor capacity and the feeding performance of preterm newborn infants when they were permitted to start oral feeding. This was an observational and prospective study conducted on 43 preterm newborns admitted to the Neonatal Intensive Care Unit of UFSM, RS, Brazil. Exclusion criteria were the presence of head and neck malformations, genetic disease, neonatal asphyxia, intracranial hemorrhage, and kernicterus. When the infants were permitted to start oral feeding, non-nutritive sucking was evaluated by a speech therapist regarding force (strong vs weak), rhythm (rapid vs slow), presence of adaptive oral reflexes (searching, sucking and swallowing) and coordination between sucking, swallowing and respiration. Feeding performance was evaluated on the basis of competence (defined by rate of milk intake, mL/min) and overall transfer (percent ingested volume/total volume ordered). The speech therapist's evaluation showed that 33% of the newborns presented weak sucking, 23% slow rhythm, 30% absence of at least one adaptive oral reflex, and 14% with no coordination between sucking, swallowing and respiration. Mean feeding competence was greater in infants with strong sucking fast rhythm. The presence of sucking-swallowing-respiration coordination decreased the days for an overall transfer of 100%. Evaluation by a speech therapist proved to be a useful tool for the safe indication of the beginning of oral feeding for premature infants.

Deprivation and dysphagia in premature infants

The developmental trajectory of feeding features increasingly rhythmic ingestive behavior patterns. Sucking and swallowing by the fetus and infant, including fetal consumption of amniotic fluid, depend upon brainstem central pattern generators whose activity is increasingly influenced by chemosensory and oral-tactile input. This neurobiological fact underlies the clinical discovery that oral-tactile stimulation via pacifier stimulates ingestive behavior in tube-fed, premature infants and improves their feeding skills. However, little is known regarding the degree to which oral sensory deprivation may contribute to feeding problems in these patients. Evidence of deprivation-induced neuropathologic effects in rodents further underlines the potential impact of sensory deprivation in premature newborns, whose transition period from tube to oral feeding often lasts weeks beyond term equivalent gestational age. Studies exploring the link between early dysphagia and later developmental impairment could clarify experiential antecedents of cerebral injury. Trials of sensory interventions to promote feeding development are warranted.

Prevention and Treatment of Tube Dependency in Infancy and Early Childhood

Tube dependency is recognized as an unintended result of long-term tube feeding in infants and young children. The condition involves disturbing side effects such as vomiting, gagging, and active food refusal. It prevents infants from making the transition from tube to oral feeding and from starting to learn to eat in the absence of any medical indication for continuation of enteral feeding. Tube dependency can have a destructive impact on the child's development, even in cases when the nutritional influence might be beneficial. The authors set up recommendations for the prevention of tube dependency and suggest guidelines for weaning tube-dependent children based on the results of the Graz program and satellite programs using a similar model. A sample of 221 tube-dependent patients aged 4 months to 15 years of age provided the clinical study group on which this article is based. Begun in 1987, a comprehensive tube-weaning program was developed on the basis of clinical experience and encounters with more than 430 tube-dependent children in 20 years, resulting in a success rate of 78/81 (96% for 2007) and 79/84 (94% for 2008). Placement must be preceded by clear criteria and a decision as to the indicated nutritional goal and time of use. The placement of a temporary tube must generate a plan covering maintenance issues, including time, method, and team for weaning. Aspects of tube feeding that go beyond purely medical and nutritional issues need to be considered to minimize the frequency and severity of unintended tube dependency in early childhood.

Nutritive sucking pattern--from very low birth weight preterm to term newborn

The contribution of maturation and stimulation to the development of oral feeding was investigated, with two main objectives: (1) to analyze the nutritive sucking pattern of very-low-birth-weight newborns from their first oral feeding to the acquisition of independent oral feeding, and (2) to compare the nutritive sucking patterns of these babies, after feeding autonomy, with healthy term newborns.

METHODS

Two groups were considered for analysis. Group 1: N=15 Very-Low-Birth-Weight (VLBW), gestacional age (GA)=28.15+/-1.5, birth weight (BW)=1178.3+/-174.4. The intervention program began at 30.19+/-1.52 weeks GA. Group 2: N=25 term newborns, healthy, GA=39.04+/-1.2, BW=3370.42+/-310.76. Repeated measures of the following variables were taken (weekly for group 1): suction efficacy (SEF), rhythm of milk transfer (RMT), suctions, bursts and pauses. Group 2 was analysed only once between the 2nd and 5th day of life.

RESULTS

Group 1 has revealed a minimal suction number at 32 GA weeks (82+/-77.6) and maximal suction number at 36-37 GA weeks (162.7+/-60.7). The number of sucks seemed to be dependent of weight (p=0.005), duration of intervention (p=0.001) and chronological age (p=0.000). Significant statistical effects of gestational age were not observed (p=0.904). Sucks in bursts represented 77% at the beginning of oral feeding (32 weeks GA), and 96% at 33 weeks GA, remaining constant thereafter. The number of sucks and bursts increased with GA and weeks of feeding. The mean duration of the pauses decreased from first to fourth week of feeding (week1=14.1+/-9.1 and week4=6.4+/-1.4 s). The sucking efficacy (SEF) was better explained by weight (p=0.000), number of sucks in 5 min (p=0.025) and chronological age (p=0.044). Gestational age (p=0.051) and nutritive intervention duration (NDI) (p=0.110) did not contribute to explain SEF. Despite the observation of significant statistical differences between groups regarding GA (35.9/39.08; p=0.00), chronological age (53.3/2.5; p=0.00) and weight (1875/3360; p=0.00), the nutritive suction pattern was not statistically different between groups after feeding autonomy.

CONCLUSION

in VLBW oral feeding before 32 weeks GA allows the attainment of a mature nutritive suction pattern before term (37-40 weeks). Experience seems to be one of the influencing factors in the change of the nutritive suction pattern.

Sucking behavior of preterm neonates as a predictor of developmental outcomes

OBJECTIVES

The relationship between the pattern of sucking behavior of preterm infants during the early weeks of life and neurodevelopmental outcomes during the first year of life was evaluated.

METHODS

The study sample consisted of 105 preterm infants (postmenstrual age [PMA] at birth = 30.5 +/- 2.8 weeks [mean +/- SD]; birth weight = 1476 +/- 460 g; mean length of hospital stay = 41.6 +/- 31.4 days). All infants received a 5-minute sucking test at 34 and at 40 weeks PMA, with outcomes evaluated at 6 and/or 12 months corrected gestational age via the Bayley Scales of Infant Development.

RESULTS

As expected, 6- and 12-month values for the Psychomotor Developmental Index (PDI) and Mental Developmental Index (MDI) of the Bayley Scales of Infant Development were significantly below the normative levels established for infants delivered at term. A significant association between neonatal sucking pattern at 40 weeks PMA and developmental outcome at 12 months corrected gestational age was obtained. Each of the 3 simple sucking parameters evaluated (number of sucks, mean number of sucks per bursts and mean sucking pressure peaks), as well as a composite parameter (average of the respective parameter z-scores), was significantly related to both PDI and MDI at 12 months.

CONCLUSIONS

Multivariable models, adjusting for PMA at birth, length of hospital stay, and other predictors, affirmed that sucking performance at 40 weeks PMA was a significant, independent predictor of developmental status 1 year later. Standardization of an instrument for neonatal sucking assessment may offer a cost-effective early screening strategy for preterm infants at greatest risk for developmental delay.

A comparison of the efficiency, efficacy, comfort, and convenience of two hospital-grade electric breast pumps for mothers of very low birthweight infants

OBJECTIVE

Many mothers of very low birthweight infants are breast pump-dependent for weeks or months and need a breast pump that is efficient, effective, comfortable, and convenient.

STUDY DESIGN

This multisite, blinded, randomized clinical trial compared the efficiency, efficacy, comfort, and convenience of the Symphony breast pump (Medela, McHenry, IL) (SBP) to the Classic breast pump (Medela) (CBP) and also compared these same outcome measures for single- and multiphase suction patterns used in the SBP. All 100 mothers initiated lactation with the CBP and were randomized to single- and multiphase suction patterns in the SBP when daily milk output was at least 350 mL/day. Protocol I included 35 mothers who compared each of three suction patterns in the SBP on two separate occasions (six observations) in the neonatal intensive care unit and used the CBP for all other pumpings. Protocol II included 65 mothers who compared single- and multiphase patterns in the SBP for 7 days and then returned to the CBP for 5 days.

RESULTS

The onset of milk ejection was quicker (P < 0.05) for the single- versus multiphase patterns in the SBP, suggesting that mothers had become conditioned to the unphysiolologic single-phase pattern in the CBP. However, all other measures of efficiency and efficacy were not significantly different, including milk output at 5-minute intervals. When asked to compare the SBP and the CBP, mothers in Protocol 1 rated the SBP as significantly more efficient, effective, comfortable, and convenient than the CBP (P < 0.05), regardless of the suction pattern in the SBP. Similarly, mothers in Protocol II rated the SBP significantly (P < 0.05) more comfortable than the CBP, regardless of the specific pattern in the SBP.

CONCLUSIONS

These findings suggest that the SBP was as efficient and effective as the CBP but was significantly more comfortable to use for pump-dependent mothers of very low birthweight infants.

Attainment of early feeding milestones in preterm neonates

OBJECTIVE

This study aimed to document the ages at which preterm neonates commence suckle-feeds and attain exclusive suckle-feeding, as well as the time taken to transition from commencement of suckle-feeds to exclusive suckle-feeding. It was hypothesized that gestational age (GA) at birth and degree of neonatal morbidity would influence the timing of these early feeding milestones.

STUDY DESIGN

A chart review was conducted for all neonates born <37;0 weeks GA admitted to a tertiary level perinatal facility over a 12-month period (n=735). Complete data relating to attainment of feeding milestones were available on 472 neonates.

RESULTS

Correlation analysis indicated that both a low GA at birth and a high neonatal morbidity rating were statistically significantly correlated with an increased transition time from commencement of suckle-feeds to exclusive suckle-feeding. Cox regression indicated that both of these variables were statistically significant risk factors for a delayed GA at attainment of exclusive suckle-feeding.

CONCLUSION

Preterm neonates who were less mature at birth and/or who displayed a greater degree of neonatal morbidity took longer to transition from starting suckle-feeds to achieving independent suckle-feeding, and were more mature at attainment of independent suckle-feeding.

Respiratory patterns and strategies during feeding in preterm infants

Because patterns of integration of respiration into rhythmic suck-swallow efforts are highly variable, we examined the vagaries of respiratory efforts as they evolve from the first tentative attempts at integration through more complex rhythmic interactions, with a focus on several strategies in which breathing and suck-swallow are coordinated. Thirty-four preterm infants (18 males, 16 females) of 26 to 33 weeks gestational age, 32 to 40 weeks postmenstrual age (PMA), and 2 to 12 weeks postnatal age were studied weekly from initiation of bottle feeding (using breast milk or preterm formula, both fed from a bottle) until discharge, with simultaneous digital recordings of pharyngeal pressure, nasal thermistor airflow, and thoraco-abdominal strain-gauge readings. Exceptional patterns of feeding-adapted variations of respiration were noted, including breathing during swallow, alternating blocks of suck-swallow and respiration efforts, narial airflow without thoracic movement, modulation of respiratory phase relationship against swallow rhythm, and paired rhythms with swallow:breath ratios of more than 1:1. Some of these strategies were developmentally regulated. Alternating blocks of suck-swallow and respiratory efforts were only seen in the earliest (PMA 32-33 wks) studies. In contrast, coordination and phase relationships of suck-swallow and breathing stabilized over time, as did the percentage of synchronized narial and thoracic respiratory efforts, which increased significantly after 36 weeks PMA compared with synchronization at 32 to 33.9 and 34 to 35.9 weeks PMA (p<0.05). There was also a significant positive correlation between percentage synchronization and PMA (r=0.58; p<0.001). The strategies and patterns noted here further clarify the developmentally regulated coordination of suck, swallow, and respiration into mature infant feeding, and may be predictive of those infants with short- and long-term feeding or developmental difficulties.

[Development of sucking rhythm and the influence of stimulation in premature infants]

BACKGROUND

The sucking development pattern of the preterm newborn (PTNB) in the neonatal period is important for an effective sucking and oral motor development. The establishment of a safe and efficient feeding in pre-term newborns is related to a rhythmic and coordinated sucking. Nonnutritive sucking stimulation can have an influence on the development of sucking and the development of sucking rhythm of pre-term newborns.

AIM

To analyze the development of the sucking rhythm, in non-nutritive and nutritive sucking in preterm newborns, as a consequence of non-nutritive sucking stimulation and in terms of corrected gestational age.

METHOD

95 preterm newborns randomly divided in three groups: Group 1, control group (35 PTNB), did not receive non-nutritive sucking stimulation; Group 2 (30 PTNB), received non-nutritive sucking stimulation using an orthodontic pacifier for premature infants (Nuk); and Group 3 (30 PTNB), received non-nutritive sucking stimulation using a gloved finger.

RESULTS

The mean gestational age was of 30.5 weeks (+/- 1.57), the mean corrected gestational age at the moment of enrollment in the study was of 31.6 weeks (+/- 1.31), and the mean birth weight was of 1.390 grams, with no statistical differences between the groups. The number of sucking bursts and pauses per minute increased by 0.16 per week and the duration of the bursts by 0.81 seconds; the duration of pauses decreased by 3.8 seconds per week while the number of sucks/second was constant, 1.15 and 0.95 for non-nutritive and nutritive sucking, respectively. No statistically significant differences were found between the groups for any of the studied variables.

CONCLUSION

The stimulation of non-nutritive suction in preterm newborns did not modify the post-natal development of sucking rhythm. The process of maturation, represented by the corrected gestational age, was considered the most responsible factor for this process.

Sucking and swallowing in infants and diagnostic tools

Preterm infants often have difficulties in learning how to suckle from the breast or how to drink from a bottle. As yet, it is unclear whether this is part of their prematurity or whether it is caused by neurological problems. Is it possible to decide on the basis of how an infant learns to suckle or drink whether it needs help and if so, what kind of help? In addition, can any predictions be made regarding the relationship between these difficulties and later neurodevelopmental outcome? We searched the literature for recent insights into the development of sucking and the factors that play a role in acquiring this skill. Our aim was to find a diagnostic tool that focuses on the readiness for feeding or that provides guidelines for interventions. At the same time, we searched for studies on the relationship between early sucking behavior and developmental outcome. It appeared that there is a great need for a reliable, user-friendly and noninvasive diagnostic tool to study sucking in preterm and full-term infants.

Transitioning premature infants from gavage to breast

Breast milk provides physiologic and neurodevelopmental protection for premature infants. Most hospitals are breast-milk friendly, but the number of premature infants breastfeeding successfully at discharge is relatively small. There are evidence-based techniques to improve the odds of premature infants breastfeeding at discharge and into the first year of life. Measures that help the infant make the transition to the breast include kangaroo care, nonnutritive sucking, avoidance of bottles, and consistent and supportive staff. A guide to management of the transition process is provided in this article.

The reliability of the Neonatal Oral-Motor Assessment Scale

OBJECTIVES

Sucking problems in preterm infants can be specified by means of visual observation. The Neonatal Oral-Motor Assessment Scale (NOMAS) is the visual observation method most commonly used to assess the non-nutritive sucking (NNS) and nutritive sucking (NS) skills of infants up to approximately 8 weeks postterm. During the first 2 min of a regular feeding the infant's sucking skill is assessed, either immediately or on video. Although NOMAS has been used since 1993, little is known about the method's reliability. The aim of our study was to determine the test-retest and inter-rater reliability of NOMAS.

METHODS

The 75 infants included in this study were born at 26-36 weeks postmenstrual age (PMA). Four observers participated in the study. They were trained and certified to administer NOMAS in the Netherlands by M.M. Palmer between 2000 and 2002.

RESULTS

We found the test-retest agreement of NOMAS to be 'fair' to 'almost perfect' (Cohen's kappa [kappa] between 0.33 and 0.94), whereas the inter-rater agreement with respect to the diagnosis was 'moderate' to 'substantial' (Cohen's kappa, between 0.40 and 0.65). As a diagnostic tool, however, the current version of NOMAS cannot be used for both full-term and preterm infants. For a measuring instrument such as NOMAS, one should aim at reliability coefficients for inter-rater and test-retest agreement of at least 0.8. A Cohen's kappa of 0.6 or less we find unacceptable. Nonetheless, by observing sucking and swallowing according to a protocol much useful information can be gathered about the development of an infant's sucking skills. For instance, whether the infant is able to co-ordinate sucking and swallowing, whether the infant can maintain sucking, swallowing and breathing during the continuous phase and whether the infant is able to suck rhythmically with equally long bursts. In addition, NOMAS offers useful aids for intervention.

CONCLUSIONS

NOMAS should be re-adjusted in order to improve inter-rater agreement, and at the same time current insights into the development of sucking and swallowing should be incorporated in the method.

Maturation of oral feeding skills in preterm infants

AIM

Safe and successful oral feeding requires proper maturation of sucking, swallowing and respiration. We hypothesized that oral feeding difficulties result from different temporal development of the musculatures implicated in these functions.

METHODS

Sixteen medically stable preterm infants (26 to 29 weeks gestation, GA) were recruited. Specific feeding skills were monitored as indirect markers for the maturational process of oral feeding musculatures: rate of milk intake (mL/min); percent milk leakage (lip seal); sucking stage, rate (#/s) and suction/expression ratio; suction amplitude (mmHg), rate and slope (mmHg/s); sucking/swallowing ratio; percent occurrence of swallows at specific phases of respiration. Coefficients of variation (COV) were used as indices of functional stability. Infants, born at 26/27- and 28/29-week GA, were at similar postmenstrual ages (PMA) when taking 1-2 and 6-8 oral feedings per day.

RESULTS

Over time, feeding efficiency and several skills improved, some decreased and others remained unchanged. Differences in COVs between the two GA groups demonstrated that, despite similar oral feeding outcomes, maturation levels of certain skills differed.

CONCLUSIONS

Components of sucking, swallowing, respiration and their coordinated activity matured at different times and rates. Differences in functional stability of particular outcomes confirm that maturation levels depend on infants' gestational rather than PMA.

Psychometric characteristics of the Neonatal Oral-Motor Assessment Scale in healthy preterm infants

We examined the reliability, validity, and responsiveness of the Neonatal Oral-Motor Assessment Scale (NOMAS) in healthy preterm infants. Feeding records of 147 infants (71 males, 76 females; gestational age [GA] <or= 36 wks), taken from the day bottle-feeding was initiated to the day the infants were discharged, were used to examine the psychometric properties of the normal and disorganized categories of the NOMAS. The infants, with or without experience of breastfeeding, were all fed by bottle, with either formula and/or breast milk. GA ranged from 24 to 35.9 weeks (mean 29.7 wks, SD 2.7) and birthweight ranged from 470 g to 2570 g (mean 1251.1g, SD 425.9). Postmenstrual age (PMA) at the starting point of bottle-feeding ranged from 29.4 to 40.1 weeks (mean 33.8 wks, SD 1.7). We found that the NOMAS had satisfactory internal consistency (Cronbach's alpha >0.70) in the normal category for 32 to 35 weeks'PMA. Moderate correlations were found between scores on the NOMAS and feeding performance for all age groups except for PMA of >or= 36 weeks (absolute Spearman's r(s)=0.51-0.69), indicating acceptable convergent validity. The NOMAS demonstrated moderate responsiveness to changes in oral-motor skills in every 2-week period, ranging from 32 to 36 weeks'PMA (standard response mean greater than 0.5). This study demonstrated that the normal and disorganized categories of the NOMAS are useful, with acceptable psychometric properties, in assessing oral-motor function in preterm infants aged 32 to 35 weeks'PMA. Future research on infants with abnormal oral-motor skills is needed to further validate psychometric properties of the dysfunction category of the NOMAS.

The development of potentially better practices to support the neurodevelopment of infants in the NICU

OBJECTIVE

To review the existing evidence used to identify potentially better care practices that support newborn brain development.

STUDY DESIGN

Literature review.

RESULT

Sixteen potentially better practices are identified and grouped into two operational clinical bundles based upon timing for recommended implementation.

CONCLUSION

Existing evidence supports the implementation of selected care practices that potentially may support newborn brain development.

Infants with bronchopulmonary dysplasia suckle with weak pressures to maintain breathing during feeding

OBJECTIVE

Preterm infants with bronchopulmonary dysplasia often demonstrate sucking difficulties. The aim of this study was to determine whether the severity of bronchopulmonary dysplasia affects not only coordination among suck-swallow-respiration but also sucking endurance and performance itself.

PATIENTS AND METHODS

Twenty very low birth weight infants were studied. Infants with anomalies or intraventricular hemorrhage were excluded from the evaluation. Subjects were divided into 3 groups: no bronchopulmonary dysplasia (7 infants), bronchopulmonary dysplasia without home oxygen therapy (7 infants), and bronchopulmonary dysplasia with home oxygen therapy (6 infants). In addition to sucking efficiency, pressure, frequency, duration, and duration of sucking burst, length of deglutition apnea, number of swallows per burst, and respiratory rate were also measured during bottle-feeding at 40 weeks' postmenstrual age. In addition, PCO2 and oxygen saturation were measured at rest and during bottle-feeding.

RESULTS

Infants with severe bronchopulmonary dysplasia demonstrated not only the lowest sucking pressure and sucking frequency, shortest sucking burst duration, and lowest feeding efficiency but also the lowest frequency of swallows during the run and the longest deglutition apnea. The respiratory rate was highest, and the decrease in oxygen saturation was largest, in infants with severe bronchopulmonary dysplasia.

CONCLUSIONS

Feeding problems depend on the severity of bronchopulmonary dysplasia. Infants with bronchopulmonary dysplasia demonstrated not only poor feeding coordination but also poor feeding endurance and performance.