Responsive versus scheduled feeding for preterm infants

Effect of Cue-Based Feeding on the Feeding Outcomes of Preterm Infants: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically evaluate the effect of cue-based feeding (CBF) on feeding outcomes in preterm infants.

METHODS

Databases including CNKI, Wanfang, PubMed, Embase, CINAHL and Cochrane Library were searched from the database's inception to November 2023. The literature screening and quality assessment were conducted by two researchers independently, and a meta-analysis was performed using Review Manager (RevMan) 5.4 software.

RESULTS

A total of six randomised controlled trials and eight quasi-experimental studies involving 2239 preterm infants were included. The results indicated that CBF was effective in shortening the time to achieve full oral feeding (Z = 22.32, p < 0.01) and reducing the incidence of feeding intolerance (Z = 2.18, p < 0.05). Compared with scheduled feeding (SF), CBF was found to enhance parental participation and satisfaction. Health professionals such as paediatricians, nurses and feeding specialists, highly agreed on the positive effects of CBF.

CONCLUSION

Cue-based feeding has the potential to shorten the time to achieve full oral feeding, reduce the incidence of feeding intolerance and promote parental involvement in feeding behaviour for preterm infants.

IMPLICATIONS FOR PRACTICE

Cue-based feeding is recommended for preterm infants, as it could enhance oral feeding competence, facilitate feeding progression and reduce the incidence of feeding complications.

NO PATIENT OR PUBLIC CONTRIBUTION

Our paper is a systematic review and meta-analysis, and such details do not apply to our work.

TRIAL REGISTRATION

The detailed study protocol can be found on the PROSPERO website.

Practices supporting cue-based breastfeeding of preterm infants in neonatal intensive care units across Europe

BACKGROUND

Emerging knowledge about supportive neurodevelopmental neonatal care shows the need for an individual approach to establish breastfeeding. However, evidence on how cue-based breastfeeding is supported in neonatal intensive care units (NICUs) is scarce. Therefore, the aim was to describe supporting practices for cue-based breastfeeding.

METHOD

Through Delphi rounds, a questionnaire was developed comprising questions on the usage and occurrence of supportive practices for cue-based breastfeeding. A multinational online survey was distributed September to October in 2023 to NICUs in Europe using snowball sampling. Practices such as the practice of skin-to-skin contact (SSC), restrictions for breastfeeding, providing information to parents, observing and responding to infants' cues were explored.

RESULTS

The survey was completed by 105 neonatal units across 15 European countries. Less than half (46%) of the NICUs had no restrictions upon placing the infant in SSC with the parents. Approximately half (49%) of the NICUs stated that infants had SSC within the first hour after birth. Many units (68%) had some restriction for breastfeeding. One week after birth, 48% of the NICUs encouraged breastfeeding for infants at 33 postmenstrual age whenever the infant showed cues, regardless of scheduled tube feeding time. This percentage increased to 59% at 33-35 gestational age. Less than half of the units (47%) stated that they had the necessary tools/instruments to support the transition from tube feeding to breastfeeding. There were variations in how milk intake was assessed, such as weighing before and after breastfeeding or estimating milk intake by time spent sucking. Infants in 50% of the units had to be fed exclusively orally before discharge. Many units (65%) provided specific support to or enabled discharge before the infant was exclusively orally fed.

CONCLUSION

European NICUs employ supportive practices, SSC, early initiation of breastfeeding, and provide information to parents. Staff plays a significant role in fostering cue-based feeding in preterm infant-mother dyads. There still exist restrictions for SSC and breastfeeding. To understand the impact of different strategies and practices, there is need for evaluations by parents and testing of the implementation of cue-based feeding practices in neonatal care.

Scoping review of systematic reviews of nursing interventions in a neonatal intensive care unit or special care nursery

AIM(S)

To identify, synthesise and map systematic reviews of the effectiveness of nursing interventions undertaken in a neonatal intensive care unit or special care nursery.

DESIGN

This scoping review was conducted according to the JBI scoping review framework.

METHODS

Review included systematic reviews that evaluated any nurse-initiated interventions that were undertaken in an NICU or SCN setting. Studies that reported one or more positive outcomes related to the nursing interventions were only considered for this review. Each outcome for nursing interventions was rated a 'certainty (quality) of evidence' according to the Grading of Recommendations, Assessment, Development and Evaluations criteria.

DATA SOURCES

Systematic reviews were sourced from the Cochrane Database of Systematic Reviews and Joanna Briggs Institute Evidence Synthesis for reviews published until February 2023.

RESULTS

A total of 428 articles were identified; following screening, 81 reviews underwent full-text screening, and 34 articles met the inclusion criteria and were included in this review. Multiple nursing interventions reporting positive outcomes were identified and were grouped into seven categories. Respiratory 7/34 (20%) and Nutrition 8/34 (23%) outcomes were the most reported categories. Developmental care was the next most reported category 5/34 (15%) followed by Thermoregulation, 5/34 (15%) Jaundice 4/34 (12%), Pain 4/34 (12%) and Infection 1/34 (3%).

CONCLUSIONS

This review has identified nursing interventions that have a direct positive impact on neonatal outcomes. However, further applied research is needed to transfer this empirical knowledge into clinical practice.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Implementing up-to-date evidence on effective nursing interventions has the potential to significantly improving neonatal outcomes.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement in this scoping review.

The Effect of Breast Milk Odor on Feeding Cues, Transition Time to Oral Feeding, and Abdominal Perfusion in Premature Newborns: A Randomised Controlled Trial

PURPOSE

The present study was conducted to determine the effect of odor stimulation with breast milk (BM) applied to premature newborns before and during enteral feeding on feeding cues, transition time to oral feeding and abdominal perfusion.

DESIGN

This study was a parallel group pretest-post test randomised controlled trial (RCT).

METHODS

The study was conducted in the neonatal intensive care unit (NICU) in Türkiye. Study data were collected from 32 premature newborns between October 2020 and December 2021. Newborns were randomly assigned to either intervention (n = 16) or control (n = 16) groups. Odor stimulation with BM was applied to newborns in the intervention group (IG) before and during enteral feeding for 3 days. Data were collected with the Newborn Information Form, Abdominal Perfusion Follow-up Form, and Feeding Cues Follow-up Form. Yates corrected and Fisher chi-squared test, Mann-Whitney U test, Cohen Kappa statistics, Permanova analysis, and Wilcoxon test were used in the analysis. The study was registered in ClinicalTrials.gov (NCT04843293).

RESULTS

The frequency of feeding cues in newborns who were exposed to the odor of BM, was higher than in the control group (CG) (p < .05). The transition times to oral feeding were similar in newborns in the IG and CG (p > .05). Abdominal perfusion level of newborns in the IG was higher than the CG (p < .05), and the level of abdominal perfusion showed a significant difference in terms of group*time interaction (p < .05).

CONCLUSION

Our findings suggest that odor stimulation with BM will be beneficial in improving the digestive functions of premature newborns.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' post-menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review.

OBJECTIVES

To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA.

SEARCH METHODS

Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

Following the updated search, two review authors screened the titles and abstracts of studies and full-text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) -4.07 days, 95% confidence interval (CI) -4.81 to -3.32 days, 6 studies, 292 infants; I2 =85%, very low-certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD -4.33, 95% CI -5.97 to -2.68 days, 5 studies, 249 infants; i2 =68%, very low-certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non-oral intervention Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non-oral intervention (MD -7.17, 95% CI -8.04 to -6.29 days, 10 studies, 574 infants; I2 =80%, very low-certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD -6.15, 95% CI -8.63 to -3.66 days, 10 studies, 591 infants; I2 =0%, low-certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD -2.85, 95% CI -6.13 to 0.42, 3 studies, 268 infants; very low-certainty evidence due to serious risk of bias, inconsistency and imprecision).

AUTHORS' CONCLUSIONS

There remains uncertainty about the effects of oral stimulation (versus either standard care or a non-oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta-analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions.

Remote provision of breastfeeding support and education: Systematic review and meta-analysis

The Covid-19 pandemic has led to a substantial increase in remotely provided maternity care services, including breastfeeding support. It is, therefore, important to understand whether breastfeeding support provided remotely is an effective method of support. To determine if breastfeeding support provided remotely is an effective method of support. A systematic review and meta-analysis were conducted. Twenty-nine studies were included in the review and 26 contributed data to the meta-analysis. Remotely provided breastfeeding support significantly reduced the risk of women stopping exclusive breastfeeding at 3 months by 25% (risk ratio [RR]: 0.75, 95% confidence interval [CI]: 0.63, 0.90). There was no significant difference in the number of women stopping any breastfeeding at 4-8 weeks (RR: 1.10, 95% CI: 0.74, 1.64), 3 months (RR: 0.89, 95% CI: 0.71, 1.11), or 6 months (RR: 0.91, 95% CI: 0.81, 1.03) or the number of women stopping exclusive breastfeeding at 4-8 weeks (RR: 0.86, 95% CI: 0.70, 1.07) or 6 months (RR: 0.93, 95% CI: 0.85, 1.0). There was substantial heterogeneity of interventions in terms of mode of delivery, intensity, and providers. This demonstrates that remote interventions can be effective for improving exclusive breastfeeding at 3 months but the certainty of the evidence is low. Improvements in exclusive breastfeeding at 4-8 weeks and 6 months were only found when studies at high risk of bias were excluded. They are also less likely to be effective for improving any breastfeeding. Remote provision of breastfeeding support and education could be provided when it is not possible to provide face-to-face care.

Cue-based versus scheduled feeding for preterm infants transitioning from tube to oral feeding: the Cubs mixed-methods feasibility study

BACKGROUND

There is a lack of evidence of the effect of cue-based feeding compared with scheduled feeding on important outcomes for preterm infants.

OBJECTIVES

The objectives were as follows: (1) to describe the characteristics, components, theoretical basis and outcomes of approaches to feeding preterm infants transitioning from tube to oral feeding; (2) to identify operational policies, barriers and facilitators, and staff and parents' educational needs in neonatal units implementing cue-based feeding; (3) to co-produce an intervention for feeding preterm infants in response to feeding cues; (4) to appraise the willingness of parents and staff to implement and sustain the intervention; (5) to assess associated costs of implementing cue-based feeding; (6) to determine the feasibility and acceptability of a future trial; (7) to scope existing data-recording systems and potential outcome measures; and (8) to determine stakeholders' views of whether or not a randomised controlled trial of this approach is feasible.

DESIGN

This was a mixed-methods intervention development and feasibility study comprising (1) a systematic review, case studies, qualitative research and stakeholder consensus; (2) the co-production of the intervention; (3) a mixed-methods feasibility study; and (4) an assessment of stakeholder preferences for a future evaluation.

SETTING

Three neonatal units in the UK (two level 3 units and one level 2 unit).

PARTICIPANTS

Developmentally normal, clinically stable preterm infants receiving enteral feeds (n = 50), parents (n = 15 pre intervention development; n = 14 in the feasibility study) and health-care practitioners (n = 54 pre intervention development; n = 16 in the feasibility study).

INTERVENTION

An evidence-informed multicomponent intervention comprising training, a feeding protocol, feeding assessment tools, supplementary training materials [including posters, a film and a narrated PowerPoint (Microsoft Corporation, Redmond, WA, USA) presentation] and the 'Our Feeding Journey' document.

MAIN OUTCOME MEASURES

The main outcome measures were recruitment and screening rates, infant weight gain, duration of the intervention, feeding outcomes, implementation outcomes (contextual facilitators and barriers, acceptability, adoption, appropriateness and fidelity) and stakeholder preferences for a future evaluation.

RESULTS

The systematic review of 25 studies concluded that evidence in favour of cue-based feeding should be treated cautiously. The case studies and qualitative research highlighted contextual barriers to and facilitators of the implementation of cue-based feeding. The telephone survey found that many neonatal units are considering implementing cue-based feeding. We recruited 37% of eligible infants, and there was good retention in the study until discharge but a high loss to follow-up at 2 weeks post discharge. The mean number of days from intervention to transition to full oral feeding was 10.8, and the mean daily change in weight gain was 25 g. The intervention was acceptable to parents and staff, although there was dissatisfaction with the study documentation. Intervention training did not reach all staff. A cluster-randomised design with a composite outcome was suggested by stakeholders for a future study.

LIMITATIONS

The intervention was available only in English. Intervention training did not reach all staff. There was low recruitment to qualitative interviews and observations. Only a small number of medical staff engaged in either the training or the interviews.

CONCLUSIONS

It is feasible to implement a cue-based feeding intervention with improved training and documentation. Further work is needed to assess the feasibility of a future trial, noting evidence of existing lack of equipoise.

FUTURE WORK

The next steps are to digitalise the intervention and conduct a survey of all neonatal units in the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018097317 and ISRCTN13414304.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 74. See the NIHR Journals Library website for further project information.

Positive breastfeeding experiences and facilitators in mothers of preterm and low birthweight infants: a meta-ethnographic review

Background

Most qualitative research on breastfeeding the preterm or low-birthweight (LBW) infant has focused on negative insights; there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences. We aimed to address this knowledge gap by exploring what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants.

Methods

A systematic review using meta-ethnographic methods was conducted. Search strategies involved a comprehensive search strategy on six bibliographic databases, citation tracking and reference checking. The analysis involved a reciprocal level of translation and a line of argument synthesis.

Results

Searches identified 1774 hits and 17 articles from 14 studies were included, representing the views of 697 mothers. A positive breastfeeding experience was identified as being ‘attuned’. Three themes and eight sub-themes were developed to describe what characterizes attuned breastfeeding. ‘Trusting the body and what it can do’, concerned how attuned breastfeeding was facilitated through understanding the bodily responses and capacity and feeling comfortable with holding the infant and to breastfeed. ‘Being emotionally present – in the here and now’ described the importance of feeling relaxed and reassured. ‘Experiencing mutual positive responses’, illuminated how attunement was related to feelings of mutuality - when the mother recognises the infant’s cues, responds to these signals and receives a positive response from the infant. The key factors to facilitate attuned breastfeeding were opportunities for prolonged close physical contact with the infant, positive relationships with and support from staff and peers, and being facilitated to breastfeed when the infant showed feeding cues.

Conclusions

This study provides new insights into what characterizes a positive breastfeeding experience and how staff can facilitate and enable mothers to achieve attuned breastfeeding. Improvements in units’ design, such as for rooming-in and having prolonged skin-to-skin contact, and care provided by knowledgeable, supportive and encouraging staff and peers, are crucial. The mother’s physical and emotional states and the infant’s behavioural responses and physiological signals should guide the process towards positive breastfeeding practices.

To Individualize the Management Care of High-Risk Infants With Oral Feeding Challenges: What Do We Know? What Can We Do?

The increase in preterm infants' survival over the last 30 years has shed light over their inability to feed by mouth safely and efficiently. With adverse events such as increased risks for oxygen desaturation, bradycardia, penetration/aspiration, infants' hospitalization in neonatal intensive care units (NICUs) are understandably prolonged. Unfortunately, this leads to delayed mother-infant reunion, maternal stress, breastfeeding obstacles, and increased medical costs. Such impediments have stimulated clinicians and researchers to better understand the underlying causes and develop evidence-based solutions to assist these infants. However, it is notable that the research-to-practice translation of this knowledge has been limited as there are still no validated guidelines or protocols as how to best diagnose and care for these infants. This report revisits the immature physiologic functions at the root of these infants' oral feeding difficulties, the current practices, and the recent availability of evidence-based efficacious tools and interventions. Taking advantage of the latter, it presents a renewed perspective of how management strategies can be tailored to the specific needs of individual patients.

Inflammatory mediators of stress exposure and neurodevelopment in very preterm infants: Protocol for the stress neuro-immune study

AIMS

(a) Determine relationships among stress exposure, inflammation, and neurodevelopment in very preterm infants and determine the mediated effect of inflammation on the relationship between stress exposure and neurodevelopment; (b) describe cytokine trajectories following birth and determine the effect of stress exposure on these trajectories; and (c) examine relationships between stress exposure and chronic stress responses in very preterm infants.

DESIGN

Non-experimental, repeated measures.

METHODS

Very preterm infants born 28-31 weeks post menstrual age will be enrolled. Cumulative stress exposure over the first 14 days of life will be measured using the Neonatal Infant Stressor Scale. Blood will be collected weekly for the quantification of cytokines. Neurodevelopment will be assessed using the Neurobehavioral Assessment of the Preterm Infant and hair for quantification of hair cortisol will be collected at 35 weeks post menstrual age. Multiple linear regression and conditional process analysis will be used to analyse the relationships among stress exposure, inflammation and neurodevelopment. Linear mixed models will be used to determine inflammatory trajectories over time. IRB approval for the study was received May 2017, and funding from the National Institute of Nursing Research was awarded July 2017.

DISCUSSION

This study will determine the extent to which inflammation mediates the relationship between stress exposure and neurodevelopment. Interventions to attenuate inflammation in preterm infants may improve outcomes.

IMPACT

Determining the potentially modifiable mediators of stress exposure and neurodevelopment in preterm infants is critical to improving long-term outcomes.

Transition From Nasogastric Tube to Oral Feeding: The Role of Parental Guided Responsive Feeding

Background and Objective: Strategies to transition preterm infants from tube to oral feeding vary greatly and the transition may take days to weeks. The study objective was to evaluate the effect of parental guided responsive feeding (PGRF) on this transition. Methods: We conducted a randomized controlled trial on infants born at <32 weeks gestation. The PGRF intervention was performed by parents, and included feeding intervals and volumes which were guided by the infants' behavioral cues of hunger and satiety. If a minimum volume was not taken orally, an intermediate volume was supplemented via nasogastric tube. The control group was traditionally fed (TF), with pre-planned volumes of intake and at given scheduled intervals. Results: The study comprised 67 infants (PGRF 32, TF 35). PGRF infants reached full oral feeding within less days (median 2 vs. 8 days, p = 0.001), at an earlier age (median 34.28 vs. 35.14 weeks, p < 0.001), returned to baseline weight gain at 35 weeks (1.77 ± 0.70 vs. 1.25 ± 0.63 g/kg/day, p = 0.002), were discharged earlier (36.34 ± 0.6 vs. 36.86 ± 0.9 weeks, p = 0.001), were more likely to be fed by their parents (p < 0.001), and experienced less apnea/bradycardia events at 34 weeks (median 3.5 vs. 9 per week p = 0.047) compared to the TF infants. The regression model demonstrated that independent variables predicted 43.7% of the variance of time to full oral feeding [F _{(9, 65)} = 4.84 p < 0.001]. The only significant variable was feeding group (B = -6.43 p < 0.001); The PGRF infants were more likely to reach full oral feeding earlier. Conclusion: PGRF is safe, and associated with short-term advantages, higher parental engagement, and earlier discharge. Clinical Trial Registration: Identifier: SHEBA-12-9574-IM-CTIL; "Adjusted Individual Oral Feeding for Improving Short and Long Term Outcomes of Preterm Infants."

Turkish Neonatal Society guideline on enteral feeding of the preterm infant

Early initiation of enteral feeding with the own mother's milk and prevention of postnatal growth failure is the target of nutrition in preterm infants. Together with total parenteral nutrition, mouth care and minimal enteral nutrition is started with colostrum in the very early hours of life in small preterm infants. Expressed mother's milk is given via a gastric tube and gradually increased in accordance with the gestational age/birth weight and the risk factors. For infants born heavier than 1 000 grams, the aim is to reach total enteral feeding at the end of first week, and at the end of the second week for infants weighing less than 1000 grams. Supporting mothers in milk expression and kangaroo mother care, promoting non-nutritive feeding, appropriate fortification of mother' milk, and initiating and advancing breastfeeding as soon as the infant is ready are all crucial. Donor mother milk, and as a second choice, preterm formula is advised if the mother's milk is not available. Individualized post-discharge nutrition decisions can be taken in accordance with the actual growth at the time of discharge. The goal is optimal neurodevelopmental achievement together with the prevention of long-term metabolic problems. Late preterm infants, which constitute the majority of preterm infants, also need close nutritional attention and follow-up.

Systematic Review of Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants

OBJECTIVE

To examine and synthesize the outcomes of quality improvement (QI) initiatives related to cue-based feeding of preterm infants to facilitate implementation of findings to improve nursing practice.

DATA SOURCES

Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete and PubMed were searched for full-text articles published from 2000 through 2017 included under the medical subject heading quality improvement and whose titles included any form of the term feeding combined with any of the following: bottle, breast, cue-based, demand, infant, neonate, newborn, oral, or responsive.

STUDY SELECTION

Articles were considered for inclusion if they were published in English-language journals and focused on QI initiatives concerning cue-based feeding of preterm infants in NICU settings.

DATA EXTRACTION

After initial article review, we examined clinical outcomes and assessed study methodology using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS) framework.

DATA SYNTHESIS

Our review yielded seven studies related to cue-based feeding of preterm infants. Five studies included multidisciplinary stakeholder teams to assess their respective NICU environments and facilitate project completion. In two studies, feeding "champions" were designated as facilitators. In one study, researchers used a Plan-Do-Study-Act approach and emphasized process over outcome. In six studies, researchers measured hospital length of stay, which decreased in five intervention groups. In three studies, researchers measured infant weight gain, which increased in two intervention groups. In two studies, researchers monitored weight gain velocity, and in five studies, researchers reported earlier gestational attainment of full oral feedings.

CONCLUSION

Weight gain, time to full oral feedings, and hospital length of stay may be improved with the use of cue-based feeding. QI initiatives are a practical means to bring best evidence and multidisciplinary collaboration to the NICU.

Feeding behavior in three-year-old children born <30 weeks and term-born peers

BACKGROUND

Feeding difficulties threaten growth, health and neurodevelopment, and are prevalent among infants born preterm. The literature differs on (i) whether these problems persist into early childhood, and (ii) risk factors in the preterm population. In this study we explore feeding difficulties and risk factors in preterm and term-born three-year-olds.

OBJECTIVES

To determine whether three-year-olds born <30 weeks have poorer feeding outcomes than their term-born peers; and identify predictors of feeding outcomes in children born <30 weeks.

METHODS

Feeding outcomes were examined in three-year-old children born <30 weeks, and a term-born comparison group, using parent report and the Behavioral Pediatric Feeding Assessment Scale (BPFAS). Factors hypothesized to be associated with feeding difficulties and preterm birth were examined in the preterm group, including: gestational age at birth, birth weight z-score, chronic lung disease (CLD), nasogastric tube (NGT) feeding at hospital discharge, age at breastfeeding cessation, oromotor feeding impairment at 12 months, weight at 12 months in kilograms and neurodevelopmental diagnoses.

RESULTS

In 217 children (111 born <30 weeks, 106 term-born), parents of children born <30 weeks reported more feeding concerns on parent report questions than parents of term-born peers. CLD, NGT at discharge, neurodevelopmental diagnoses and weight at 12 months predicted these parent-reported outcomes. By contrast, there was no difference in BPFAS results between preterm and term groups, and BPFAS scores were predicted only by birth-weight z-score in the preterm group.

CONCLUSIONS

Behavioral feeding outcomes for three-year-old children born <30 weeks were equivalent to term-born peers in this study, however parental concerns about feeding differed. Further investigation is required to identify the drivers of parent concerns about feeding. Children displaying core risk factors warrant specific follow-up of feeding outcomes.

Stress Signals During Sucking Activity Are Associated With Longer Transition Time to Full Oral Feeding in Premature Infants

Several treatments have been proposed to shorten the time to the attainment of full oral feeding (FOF) for premature infants, but there are only a few evaluation methods useful in estimating predictors of this period. We investigated whether specific items within the disorganized sucking patterns described by the Neonatal Oral-Motor Assessment Scale (NOMAS) could estimate the time to FOF in preterm infants with feeding difficulty. Preterm infants diagnosed with a disorganized sucking pattern in the NOMAS evaluation before 50 weeks of postmenstrual age were included. Video recordings of at least 2 min of oral feeding were further analyzed retrospectively by two assessors and the premature infants who exhibited disorganized sucking patterns (n = 109) were divided into three clusters (clusters 2-4). The observational items compatible with disorganization in the original NOMAS were divided into three groups: cluster 2 (disorganized: arrhythmical), cluster 3 (disorganized: arrhythmical + unable to sustain), and cluster 4 (disorganized: arrhythmical + incoordination ± unable to sustain) and further divided into incoordination-positive (cluster 4) and incoordination-negative groups (clusters 2 and 3). Premature infants in the incoordination-positive group (cluster 4, which means stress signals) showed a median transition time of 22 days (range: 4-121 days) which was longer than that in the incoordination-negative group (median 6 days; range: 1-25 days). Univariate linear regression analysis revealed that the presence of incoordination among disorganized sucking patterns (NOMAS cluster 4 vs. clusters 2 and 3), birth weight, total parenteral nutrition (TPN) duration, non-invasive positive pressure ventilation duration, the presence of moderate to severe bronchopulmonary dysplasia, pulmonary hypertension, sepsis, small for gestational age (SGA), and necrotizing enterocolitis are associated with the transition time to FOF. In a multivariate linear regression analysis, the variables revealed to be associated with the transition time were TPN duration, SGA, and the presence of stress signals (incoordination-positive group) among disorganized sucking patterns. When selecting premature infants to be treated with swallowing therapy, it is reasonable to pay more attention to the incoordination-positive group described in the NOMAS, that is, premature infants with stress signals to shorten the time to attain FOF.