A comparison of the nutritive sucking performance of full term and preterm neonates at hospital discharge: A prospective study

Application of Statistical Analysis and Machine Learning to Identify Infants' Abnormal Suckling Behavior

OBJECTIVE

Identify infants with abnormal suckling behavior from simple non-nutritive suckling devices.

BACKGROUND

While it is well known breastfeeding is beneficial to the health of both mothers and infants, breastfeeding ceases in 75 percent of mother-child dyads by 6 months. The current standard of care lacks objective measurements to screen infant suckling abnormalities within the first few days of life, a critical time to establish milk supply and successful breastfeeding practices.

MATERIALS AND METHODS

A non-nutritive suckling vacuum measurement system, previously developed by the authors, is used to gather data from 91 healthy full-term infants under thirty days old. Non-nutritive suckling was recorded for a duration of sixty seconds. We establish normative data for the mean suck vacuum, maximum suck vacuum, suckling frequency, burst duration, sucks per burst, and vacuum signal shape. We then apply computational methods (Mahalanobis distance, KNN) to detect anomalies in the data to identify infants with abnormal suckling. We finally provide case studies of healthy newborn infants and infants diagnosed with ankyloglossia.

RESULTS

In a series of case evaluations, we demonstrate the ability to detect abnormal suckling behavior using statistical analysis and machine learning. We evaluate cases of ankyloglossia to determine how oral dysfunction and surgical interventions affect non-nutritive suckling measurements.

CONCLUSIONS

Statistical analysis (Mahalanobis Distance) and machine learning [K nearest neighbor (KNN)] can be viable approaches to rapidly interpret infant suckling measurements. Particularly in practices using the digital suck assessment with a gloved finger, it can provide a more objective, early stage screening method to identify abnormal infant suckling vacuum. This approach for identifying those at risk for breastfeeding complications is crucial to complement complex emerging clinical evaluation technology.

CLINICAL IMPACT

By analyzing non-nutritive suckling using computational methods, we demonstrate the ability to detect abnormal and normal behavior in infant suckling that can inform breastfeeding intervention pathways in clinic.Clinical and Translational Impact Statement: The work serves to shed light on the lack of consensus for determining appropriate intervention pathways for infant oral dysfunction. We demonstrate using statistical analysis and machine learning that normal and abnormal infant suckling can be identified and used in determining if surgical intervention is a necessary solution to resolve infant feeding difficulties.

Differences in the swallowing process of newborns and healthy preterm infants: first results with a non-invasive bioimpedance and electromyography measurement system

PURPOSE

Preterm infants (PI) have difficulty coordinating sucking, swallowing and breathing, and there is a risk of aspiration. The causes of this are not yet sufficiently understood. The aim of this study was to test a novel measurement device to measure breathing and pharyngeal processes involved in swallowing externally in everyday life to identify possible differences in neonates (NB) and PI.

METHODS

Forty healthy NB were studied at 4-8 weeks of age (mean: 6.7 weeks) and 20 healthy PI (mean gestational age 30.5 weeks) at postmenstrual age (PMA) 34/35 weeks (mean PMA 35.1 weeks) during a single feeding. Surface electrodes were used to measure bioimpedance and electromyography reflecting swallow-related changes in the pharynx and muscle activation of the tongue and submental muscles. A respiratory belt was combined with recording of the depth of chest movements and the occurrence of pauses in breathing.

RESULTS

Velocity and extent of pharyngeal closure did not differ significantly across the feeding period (velocity: p=0.09, closure: p=0.17), but during the first two suck-swallow bursts PI had greater velocity (p<0.001*) and extent of pharyngeal closure (p=0.004*) than NB. The duration of swallowing phases was significantly longer in PIs (p<0.001*), their muscle activation decreased faster (p<0.001*), and they had more pauses in breathing than NBs.

CONCLUSIONS

The novel measurement device allowed, for the first time in everyday life, the measurement of factors influencing swallowing and breath-swallow coordination in NBs and PIs. PIs showed differences from NBs most likely due to differences in muscle strength and condition.

Characterization of a Vigorous sucking style in early infancy and its predictive value for weight gain and eating behaviors at 12 months

This study sought to identify sucking profiles among healthy, full-term infants and assess their predictive value for future weight gain and eating behaviors. Pressure waves of infant sucking were captured during a typical feeding at age 4 months and quantified via 14 metrics. Anthropometry was measured at 4 and 12 months, and eating behaviors were measured by parent report via the Children's Eating Behavior Questionnaire-Toddler (CEBQ-T) at 12 months. Sucking profiles were created using a clustering approach on the pressure wave metrics, and utility of these profiles was assessed for predicting which infants will have weight-for-age (WFA) percentile changes from ages 4-12 months that exceed thresholds of 5, 10, and 15 percentiles, and for estimating each CEBQ-T subscale score. Among 114 infants, three sucking profiles were identified: Vigorous (51%), Capable (28%), and Leisurely (21%). Sucking profiles were found to improve estimation of change in WFA from 4 to 12 months and 12-month maternal-reported eating behaviors above infant sex, race/ethnicity, birthweight, gestational age, and pre-pregnancy body mass index alone. Infants with a Vigorous sucking profile gained significantly more weight during the study period than infants with a Leisurely profile. Infant sucking characteristics may aid in predicting which infants may be at greater risk of obesity, and therefore sucking profiles deserve more investigation.

Non-Nutritive Suckling System for Real-Time Characterization of Intraoral Vacuum Profile in Full Term Neonates

Infant breastfeeding diagnostics remain subjective due to the absence of instrumentation to objectively measure and understand infant oral motor skills and suckling characteristics. Qualitative diagnostic exams, such as the digital suck assessment which relies upon a clinician's gloved finger inserted into the infant's mouth, produce a diversity of diagnoses and intervention pathways due to their subjective nature. In this paper, we report on the design of a non-nutritive suckling (NNS) system which quantifies and analyzes quantitative intraoral vacuum and sucking patterns of full-term neonates in real time. In our study, we evaluate thirty neonate suckling profiles to demonstrate the technical and clinical feasibility of the system. We successfully extract the mean suck vacuum, maximum suck vacuum, frequency, burst duration, number of sucks per burst, number of sucks per minute, and number of bursts per minute. In addition, we highlight the discovery of three intraoral vacuum profile shapes that are found to be correlated to different levels of suckling characteristics. These results establish a framework for future studies to evaluate oromotor dysfunction that affect the appearance of these signals based on established normal profiles. Ultimately, with the ability to easily and quickly capture intraoral vacuum data, clinicians can more accurately perform suckling assessments to provide timely intervention and assist mothers and infants towards successful breastfeeding outcomes.

Factors Affecting Oral Feeding Ability in Indonesian Preterm Infants

Most preterm infants exhibit atypical and immature feeding skills. Even though preterm infants have fulfilled the oral feeding readiness criteria, they still do not have optimal oral feeding ability. This study aimed to determine various factors affecting oral feeding ability in Indonesian preterm infants who have fulfilled oral feeding readiness criteria but still have not been able to feed orally. A cross-sectional study included 120 preterm infants admitted to five tertiary hospitals in Jakarta, Indonesia. Participants were preterm infants born at 28-34 weeks gestational age who had fulfilled the oral feeding readiness as the inclusion criteria: (1) stable cardiorespiratory status, (2) have achieved full enteral feeding via orogastric tube (OGT) 120 mL/kg/day without vomiting or bloating, and (3) strong and rhythmic non-nutritive sucking (NNS) through objective measurement. Infants' oral feeding ability and various factors that were assumed to affect oral feeding ability, including physiological flexion postural tone, physiological stability, rooting reflex, self-regulation, behavioral state, and level of morbidity were evaluated. Chi-square and multivariate analysis with Poisson regression were performed. Results indicated that postural tone, rooting reflex, physiological stability, self-regulation, behavioral state, and level of morbidity were significantly related to oral feeding ability in preterm infants. The most influencing factors were self-regulation with a prevalence ratio (PR) of 1.96 (1.16-3.34; CI 95%) and p = 0.012, followed by postural tone, high morbidity, and behavioral state (PR 1.91; 1.59; 1.56; CI 95%, respectively). In conclusion, despite meeting the oral feeding readiness criteria, most preterm infants were still not able to feed orally. There are other factors affecting oral feeding ability in Indonesian preterm infants.

Objective Improvement After Frenotomy for Posterior Tongue-Tie: A Prospective Randomized Trial

OBJECTIVE

Infants with posterior tongue-tie (PTT) can have substantial difficulty with breastfeeding and bottle-feeding. This study aimed to address the dearth in investigational objective data surrounding PTT release to better quantify the postoperative impacts of frenotomy for ankyloglossia.

STUDY DESIGN

Prospective randomized, controlled trial.

SETTING

Private practice clinic.

METHODS

In a prospective, randomized controlled trial, infants 3 to 16 weeks of age with PTT undergoing frenotomy were examined using a bottle-feeding system capable of objectively measuring tongue function. Validated patient-reported outcome measures were also obtained simultaneously.

RESULTS

Forty-seven infants with PTT were enrolled into an observational/control arm (n = 23) or interventional/surgical treatment arm (n = 24). The total cohort consisted of 29 (61.7%) male infants with a median age of 39 days. At the day 10 time point, the interventional arm demonstrated statistically significant improvement in 11 objectively obtained feeding metrics, indicating faster tongue speed, more rhythmic and coordinated sucking motions, and a tongue more capable of adapting to varying feeding demands. Significant improvement in breastfeeding self-efficacy was reported in the interventional group while poor self-confidence persisted in the observational group. Infant reflux symptoms improved in the interventional group while not in the control group. Nipple pain also persisted in the control group but improved in the surgical cohort.

CONCLUSIONS

When measured 10 days after frenotomy for PTT, infants improve feeding parameters using an objective bottle-feeding system. Similar improvements are seen with patient-reported outcomes when PTT is released. Posterior tongue-tie is a valid clinical concern, and surgical release can improve infant and maternal symptoms.

Abnormal Nutritive Sucking as an Indicator of Neonatal Brain Injury

A term neonate is born with the ability to suck; this neuronal network is already formed and functional by 28 weeks gestational age and continues to evolve into adulthood. Because of the necessity of acquiring nutrition, the complexity of the neuronal network needed to suck, and neuroplasticity in infancy, the skill of sucking has the unique ability to give insight into areas of the brain that may be damaged either during or before birth. Interpretation of the behaviors during sucking shows promise in guiding therapies and how to potentially repair the damage early in life, when neuroplasticity is high. Sucking requires coordinated suck-swallow-breathe actions and is classified into two basic types, nutritive and non-nutritive. Each type of suck has particular characteristics that can be measured and used to learn about the infant's neuronal circuitry. Basic sucking and swallowing are present in embryos and further develop to incorporate breathing ex utero. Due to the rhythmic nature of the suck-swallow-breathe process, these motor functions are controlled by central pattern generators. The coordination of swallowing, breathing, and sucking is an enormously complex sensorimotor process. Because of this complexity, brain injury before birth can have an effect on these sucking patterns. Clinical assessments allow evaluators to score the oral-motor pattern, however, they remain ultimately subjective. Thus, clinicians are in need of objective measures to identify the specific area of deficit in the sucking pattern of each infant to tailor therapies to their specific needs. Therapeutic approaches involve pacifiers, cheek/chin support, tactile, oral kinesthetic, auditory, vestibular, and/or visual sensorimotor inputs. These therapies are performed to train the infant to suck appropriately using these subjective assessments along with the experience of the therapist (usually a speech therapist), but newer, more objective measures are coming along. Recent studies have correlated pathological sucking patterns with neuroimaging data to get a map of the affected brain regions to better inform therapies. The purpose of this review is to provide a broad scope synopsis of the research field of infant nutritive and non-nutritive feeding, their underlying neurophysiology, and relationship of abnormal activity with brain injury in preterm and term infants.

Quantitative assessment of nutritive sucking patterns in preterm infants

OBJECTIVE

To assess patterns of nutritive sucking in very preterm infants ≤32 weeks of gestation.

STUDY DESIGN

Very preterm infants who attained independent oral feeding were prospectively assessed with an instrumented feeding bottle that measures nutritive sucking. The primary outcome measure was nutritive sucking performance at independent oral feeding.

RESULT

We assessed nutritive sucking patterns in 33 very preterm infants. We recorded 63 feeding sessions. The median number of sucks was 784 (IQR: 550-1053), the median sucking rate was 36/min (IQR: 27-55), and the median number of sucking bursts during the first 5 min of oral feeding was 14 (IQR: 12-16). Maximum sucking strength correlated with the number of sucks (r = 0.62; p < 0.01). No safety concerns were identified during the study.

CONCLUSION

The quantitative analysis of nutritive sucking patterns with a newly developed instrumented bottle in stable, very preterm infants is safe and feasible. More research is needed to develop and refine the instrument further.

Feeding and Swallowing Difficulties in Neonates: Developmental Physiology and Pathophysiology

Development of enteral and oral feeding milestones in infants is intricately linked to physiologic maturation of the gastrointestinal tract and its complex interplay with cardiorespiratory and central nervous system control and coordination. Assessment of an infant's developmental skills and maturation can guide us with targeted management approaches and prediction of feeding outcomes. In this article, we review and summarize the developmental aspects of oral feeding and swallowing physiology, and current understanding of the pathophysiological changes associated with feeding difficulties in infants.

Preterm infant feeding performance at term equivalent age differs from that of full-term infants

OBJECTIVE

To identify differences in feeding skill performance among preterm infants at term equivalent age compared with full-term infants.

STUDY DESIGN

Ninety-two infants (44 preterm infants born ≤32 weeks gestation at term equivalent age and 48 full-term infants within 4 days of birth) had a standardized oral feeding assessment.

RESULT

Preterm infants at term equivalent age had lower Neonatal Eating Outcome Assessment scores (67.8 ± 13.6 compared with 82.2 ± 8.1; p < 0.001) and were more likely to have poor arousal (p = 0.04), poor tongue positioning (p = 0.04), suck-swallow-breathe discoordination (p < 0.001), inadequate sucking bursts (p = 0.01), tonal abnormalities (p < 0.001), discoordination of the jaw and tongue during sucking (p < 0.001), lack of positive engagement with the feeder and/or discomfort (p < 0.001), signs of aspiration (p < 0.001), difficulty regulating breathing (p < 0.001), and have an inability to maintain an appropriate state (p < 0.001), and complete the feeding (<0.001).

CONCLUSION

A broad range of feeding-related difficulties appear to remain evident in preterm infants at term equivalent age.

Nutritive sucking abnormalities and brain microstructural abnormalities in infants with established brain injury: a pilot study

OBJECTIVE

To determine the relationship between nutritive sucking and microstructural integrity of sensorimotor tracts in newborns with brain injury.

STUDY DESIGN

Diffusion imaging was performed in ten newborns with brain injury. Nutritive sucking was assessed using Nfant®. The motor, sensory, and corpus callosum tracts were reconstructed via tractography. Fractional anisotropy, radial, axial, and mean diffusivity were estimated for these tracts. Multiple regression models were developed to test the association between sucking features and diffusion parameters.

RESULTS

Low-sucking smoothness correlated with low-fractional anisotropy of motor tracts (p = 0.0096). High-sucking irregularity correlated with high-mean diffusivity of motor (p = 0.030) and corpus callosum tracts (p = 0.032). For sensory tracts, high-sucking irregularity (p = 0.018) and low-smoothness variability (p = 0.002) correlated with high-mean diffusivity.

INTERPRETATION

We show a correlation between neuroimaging-demonstrated microstructural brain abnormalities and variations in sucking patterns of newborns. The consistency of this relationship should be shown on larger cohorts.

Bronchopulmonary dysplasia: what are its links to COPD?

Emerging evidence suggests that adverse early life events can affect long-term health trajectories throughout life. Preterm birth, in particular, is a significant early life event that affects approximately 10% of live births. Worldwide, prematurity is the number one cause of death in children less than 5 years of age and has been shown to disrupt normal lung development with lasting effects into adult life. Along with impaired lung development, interventions used to support gas exchange and other sequelae of prematurity can lead to the development of bronchopulmonary dysplasia (BPD). BPD is a chronic respiratory disease of infancy characterized by alveolar simplification, small airways disease, and pulmonary vascular changes. Although many survivors of BPD improve with age, survivors of BPD often have chronic lung disease characterized by airflow obstruction and intermittent pulmonary exacerbations. Long-term lung function trajectories as measured by FEV1 can be lower in children and adults with a history BPD. In this review, we discuss the epidemiology and manifestations of BPD and its long-term consequences throughout childhood and into adulthood. Available evidence suggests that disrupted lung development, genetic susceptibility and subsequent environment and infectious events that occur in prenatal and postnatal life likely increase the predisposition of children with BPD to develop early onset chronic obstructive pulmonary disease (COPD). The reviews of this paper are available via the supplemental material section.