Developing a Co-Regulated, Cue-Based Feeding Practice: The Critical Role of Assessment and Reflection

Complementary feeding practices of caregivers of infants with Down syndrome as compared to caregivers of typically developing infants

Caregiver feeding practices during the complementary feeding period (6 months-2 years) may be particularly important for infants with Down syndrome (DS) as they are at higher risk for later health conditions (e.g., obesity, diabetes) that can be influenced by early feeding practices. However, how well caregivers of infants with DS are meeting infant feeding evidence-based practices is relatively unknown. Caregivers of infants with DS (N = 75) and caregivers of typically developing (TD) infants (N = 66) aged 0-2 years completed an online survey about their infant feeding practices and information sources. Caregiver practices and information sources were statistically compared between groups. Results indicated that there are significant differences in the feeding practices of caregivers of infants with DS when compared to caregivers of TD infants. Caregivers of infants with DS were less likely to meet infant feeding evidence-based practices than caregivers of TD infants. Caregivers of infants with DS were also more concerned about their infant's food intake and later weight status. Some individual feeding practices also significantly differed between groups, with caregivers of infants with DS more likely to meet evidence-based practices of purchasing iron rich foods and avoiding added salt, but less likely to use responsive feeding practices than caregivers of TD infants. Caregivers of infants with DS were also less likely to receive information about how to navigate the complementary feeding period than caregivers of TD infants. Coupled with existing research, the results of the present study suggest that infant feeding evidence-based practices should be reviewed for their appropriateness for this population and additional support for caregivers of infants with DS should be implemented to help them navigate this important period.

Developmental Care for Hospitalized Infants With Complex Congenital Heart Disease: A Science Advisory From the American Heart Association

Developmental disorders, disabilities, and delays are a common outcome for individuals with complex congenital heart disease, yet targeting early factors influencing these conditions after birth and during the neonatal hospitalization for cardiac surgery remains a critical need. The purpose of this science advisory is to (1) describe the burden of developmental disorders, disabilities, and delays for infants with complex congenital heart disease, (2) define the potential health and neurodevelopmental benefits of developmental care for infants with complex congenital heart disease, and (3) identify critical gaps in research aimed at evaluating developmental care interventions to improve neurodevelopmental outcomes in complex congenital heart disease. This call to action targets research scientists, clinicians, policymakers, government agencies, advocacy groups, and health care organization leadership to support funding and hospital-based infrastructure for developmental care in the complex congenital heart disease population. Prioritization of research on and implementation of developmental care interventions in this population should be a major focus in the next decade.

Assessment and management of feeding difficulties for infants with complex CHD

Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.

The Influence of Parent Education on the Neurobehavior and Sucking Reflexes of Very Preterm Infants

The diagnosis of neurobehavioral problems in very preterm neonates helps with planning and applying proper and direct therapeutic interventions. (1) Background: The aim of this study was to determine the direct impact of neurobehavior on the sucking reflex and eating abilities of neonates. (2) Methods: We assessed 18 preterm neonates twice hospitalized at the Gynecology and Obstetrics Clinical Hospital through the use of the Neonatal Behavioral Assessment Scale (NBAS). (3) Results: We found that that a neonate’s sucking ability positively correlated with the activity level item from the motor system cluster of the NBAS. (4) Conclusions: Neurobehavior should be closely assessed in very preterm neonates. Firstly, because assessments can detect fundamental problems and help a practitioner plan for early intervention. Secondly, the education of parents regarding the neurobehavior of their child can help in the facilitation of feeding skills and the planning of early rehabilitation.

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.

Effect of Left and Right Semi-elevated Side-Lying Positions on Feeding Performance of Preterm Infants

OBJECTIVE

To determine the effect of right and left semi-elevated side-lying positions on the feeding performance and skills of bottle-fed preterm infants.

DESIGN

A single-group, crossover experimental study.

SETTINGS

Level 3 NICU of a training and research hospital in Istanbul.

PARTICIPANTS

A total of 60 preterm infants born at 24 to 36 6/7 weeks gestation.

METHODS

We collected data using an infant information form, feeding observation form, and the Turkish version of the Early Feeding Skills Assessment (EFS-Turkish). For each infant, we collected data for two feeds: one in the right and one in the left semi-elevated side-lying position.

RESULTS

We found no difference between the right and left semi-elevated side-lying positions in the volume or percentage of food taken (p = .582 and p = .625, respectively), feeding duration (p = .901), or feeding efficiency (p = .423). We observed no significant differences between feedings in the left and right semi-elevated side-lying positions in mean EFS-Turkish total score (p = .251) or subscale scores (p > .05).

CONCLUSION

Neonatal nurses can feed preterm infants in both directions of the semi-elevated side-lying position when following evidence-based feeding guidelines.

An alternative supplemental feeding method for preterm infants: the supplemental feeding tube device

Background/aim

The purpose of this study was to determine the effects of the supplemental feeding tube device (SFTD) and bottle methods on weight gain, transition to full breastfeeding, breastfeeding success, and duration of discharge in preterm infants.

Materials and methods

This randomized controlled trial was conducted with a total of 46 preterm infants including 23 infants in study (SFTD) and control (bottle) groups. An information form, an infant follow-up form for feeding, and LATCH breastfeeding assessment instrument were used to collect the data.

Results

The gestation week of the infants in the study group was 31.22 ± 2.76, and in the control group it was 30.52 ± 2.47. The birth weight of the infants in the study group was 1586.3 ± 525.35 g and 1506.09 ± 454.77 g in the control group. The daily weight gain of the infants was 24.09 ± 15.21 g in the study group and 27.17 ± 17.63 g in the control group. The infants in the study group (4.70 ± 2.44 days) transitioned to full breastfeeding earlier than those in the control group (6.00 ± 4.10 days). LATCH 2nd measurement scores were significantly higher in both groups than LATCH 1st measurement scores (p < 0.01). Although it was not statistically significant (p > 0.05), the infants in the study group (10.22 ± 5.20 days) were discharged earlier than those in the control group (13.48 ± 8.78 days).

Conclusion

The SFTD and bottle methods were determined to be similar in terms of daily weight gain, transition to full breastfeeding, breastfeeding success, and duration of hospitalization.

Milk Flow Rates From Bottle Nipples: What We Know and Why It Matters

Feeding difficulties are common in infants hospitalized in the NICU and can be a challenge to manage. The purpose of this article is to explain how and why the flow rate from the bottle nipple affects physiologic stability in infants and to describe the current evidence available on the flow rates of nipples used in the hospital and after discharge. Study results have indicated that flow rate varies widely among different types of nipples. Within the same type of nipple, there can be significant variability in flow from one nipple to another. Other factors, such as type of infant formula and thickening, also affect flow. Altering the flow rate of the bottle nipple is a relatively simple intervention that may support safe oral feeding.

Nonnutritive Sucking Before Oral Feeding of Preterm Infants in Turkey: A Randomized Controlled Study

BACKGROUND

The use of a pacifier is recommended to support sucking reflex during transition from gavage feeding to oral feeding and ensure readiness for feeding.

PURPOSE

A randomized controlled experimental design was used to determine the effect of a pacifier given before feeding on physiological characteristics and feeding performance in preterm infants initially fed orally.

DESIGN AND METHODS

The data were obtained from preterm infants (N = 72) born before 31st gestational week, who were admitted to Newborn Intensive Care Unit of a training and research hospital affiliated with Ministry of Health between January 2017-July 2018 and met the case selection criteria. Heart rates, oxygen saturation levels and feeding performances of preterm infants in both groups before, during, and after feeding were compared.

RESULTS

Heart rates of preterm infants in the experimental group were statistically significantly lower (Experimental: 139.64 ± 10.16; Control: 149.31 ± 8.40; p < 0.01) and their oxygen saturation levels were higher (Experimental: 97.22 ± 2.22; Control: 96.33 ± 1.93; p < 0.05). Feeding efficiency rates (Experimental: 1.94 ± 1.19; Control: 0.69 ± 0.34; p < 0.01) and the percentage of food intake (Experimental: 89.5 ± 23.93; Control: 70.86 ± 27.41; p < 0.01) of newborns in the experimental group were statistically significantly higher and their feeding duration was shorter (Experimental: 10.58 ± 8.29; Control: 16.14 ± 8.31; p < 0.01).

CONCLUSIONS

It was determined that a pacifier given before feeding is effective on regulating physiological parameters and supporting feeding performance in preterm infants.

PRACTICE IMPLICATIONS

The use of a pacifier in the first transition to oral feeding in preterm infants supports their sucking reflex, calms them down, and ensures the readiness for feeding.

The effects of the Newborn Behavioral Observations (NBO) system in early intervention: A multisite randomized controlled trial

The purpose of this pilot study was to evaluate the effect of an infant mental health intervention, the Newborn Behavioral Observations system (NBO), versus usual care (UC) on infant neurodevelopment and maternal depressive symptoms in early intervention (EI). This multisite randomized trial enrolled newborns into the NBO (n = 16) or UC group (n = 22) and followed them for 6 months. Outcome measures included the Battelle Developmental Inventory (BDI-2), Bayley Scales of Infants Development (BSID-III), and Center for Epidemiologic Studies Depression Scale (CES-D). The CES-D and BSID-III were collected at 3- and 6-months post EI entry and the BDI-2 was collected at EI entry and 6-months post-EI entry. We estimated group differences [95% CI], adjusting for program characteristics. At 6 months, the NBO group had greater gains in Communication (b = 1.0 [0.2, 1.8]), Self-Care (b = 2.0 [0.1, 3.9]), Perception and Concepts (b = 2.0 [0.4, 3.6]), and Attention and Memory (b = 3.0 [0.4, 6.0]) than the UC group. The NBO group also had greater decline in maternal postnatal depressive symptoms (b = -2.0 [-3.7, -0.3]) than the UC group. Infants receiving the NBO infant mental health intervention had greater gains in cognitive and adaptive functions at 6 months than infants receiving UC. Caregivers receiving NBO care had greater improvements in maternal depressive symptoms than caregivers receiving UC.

Reliability and validity of the neonatal feeding assessment scale (NFAS) for the early identification of dysphagia in moderate to late preterm neonates

Background

A clinical feeding assessment instrument to assist with early identification of oropharyngeal dysphagia (OPD) in neonates was developed.

Objective

To investigate the validity and reliability of the Neonatal Feeding Assessment Scale (NFAS) in comparison to the modified barium swallow study (MBSS) as gold standard.

Method

A within-subject design was implemented. A group of 48 late premature neonates (mean gestational age 35.5 weeks) were sampled in the neonatal intensive care unit.

Results

The NFAS consists of six subsections, including physiological stability, infant state, stress cues, screening of muscle tone and control, oral peripheral examination and feeding/swallowing assessment. 93% of participants (14/15) received confirmatory diagnosis of OPD on MBSS. The NFAS presented with high sensitivity (78.6%) and specificity (88.2%) scores. The positive predictive value was 78.6%. Subsequently the accuracy of the NFAS to identify the presence of OPD accurately was 85.4% when compared to MBSS. Inter-rater reliability was determined on 35% of the sample. The inter-rater agreement on overall instrument outcome was substantial beyond chance.

Conclusion

The NFAS may be of use to clinicians to support the early identification of OPD in this population, especially in resource constrained settings working without access to MBSS and to reach under served neonates.

Neonatal Eating Assessment Tool - Mixed Breastfeeding and Bottle-Feeding (NeoEAT - Mixed Feeding): factor analysis and psychometric properties

Background

Early identification of feeding difficulty in infancy is critical to supporting breastfeeding and ensuring optimal nutrition for brain development. The Neonatal Eating Assessment Tool (NeoEAT) is a parent-report assessment that currently has two versions: NeoEAT – Breastfeeding and NeoEAT – Bottle-feeding for use in breast and bottle-fed infants, respectively. There are currently no valid and reliable parent-report measures to assess feeding through a combination of both breast and bottle delivery. The purpose of this study was to conduct a factor analysis and test the psychometric properties of a new measure, the NeoEAT – Mixed Breastfeeding and Bottle-Feeding (NeoEAT – Mixed Feeding), including internal consistency reliability, test-retest reliability, construct validity and known-groups validity.

Methods

Parents of infants younger than 7 months who had fed by both bottle and breast in the previous 7 days were invited to participate. Internal consistency reliability was tested using Cronbach’s α. Test-retest reliability was tested between scores on the NeoEAT – Mixed Feeding completed 2 weeks apart. Construct validity was tested using correlations between the NeoEAT – Mixed-Feeding, the Infant Gastroesophageal Reflux Questionnaire - Revised (I-GERQ-R), and the Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Known-groups validation was tested between healthy infants and infants with feeding problems.

Results

A total of 608 parents participated. Exploratory factor analysis revealed a 68-item scale with 5 sub-scales. Internal consistency reliability (Cronbach’s α = .88) and test-retest reliability (r = 0.91; p < .001) were both acceptable. Construct validity was demonstrated through correlations with the I-GERQ-R (r = 0.57; p < .001) and IGSQ (r = 0.5; p < .001). Infants with feeding problems scored significantly higher on the NeoEAT – Mixed Feeding, indicating more problematic feeding symptoms, than infants without feeding problems (p < .001), supporting known-groups validity.

Conclusions

The NeoEAT – Mixed Feeding is a 68-item parent-reported measure of breast- and bottle-feeding behavior for infants less than 7 months old that now has evidence of validity and reliability for use in clinical practice and research. The NeoEAT – Mixed Feeding can be used to identify infants with problematic feeding, guide referral decisions, and evaluate response to interventions.

Psychometric Properties of the Early Feeding Skills Assessment Tool

BACKGROUND

Supporting infants as they develop feeding skills is an essential component of neonatal and pediatric care. Selecting appropriate and supportive interventions begins with a thorough assessment of the infant's skills. The Early Feeding Skills (EFS) tool is a clinician-reported instrument developed to assess the emergence of early feeding skills and identify domains in need of intervention.

PURPOSE

The purpose of this study was to identify the factor structure of the EFS and test its psychometric properties, including internal consistency reliability and construct validity.

METHODS

EFS-trained interprofessional clinicians in 3 settings scored 142 feeding observations of infants 33 to 50 weeks' postmenstrual age. Redundant and rarely endorsed items were removed. Factor analysis methods clustered items into subscales. Construct validity was examined through the association of the EFS with (1) concurrently scored Infant-Driven Feeding Scale-Quality (IDFS-Q), (2) infant birth risk (gestational age), and (3) maturity (postmenstrual age).

RESULTS

Principal components analysis with varimax rotation supported a 5-factor structure. The total EFS demonstrated good internal consistency reliability (Cronbach α= 0.81). The total EFS score had construct validity with the IDFS-Q (r =-0.73; P < .01), and with gestational age of a subsample of premature infants (r = 0.22; P < .05).

IMPLICATIONS FOR PRACTICE

As a valid and reliable tool, the EFS can assist the interprofessional feeding team to organize feeding assessment and plan care.

IMPLICATIONS FOR RESEARCH

The strong psychometric properties of the EFS support its use in future research.

Feeding Infants with Neonatal Abstinence Syndrome: Finding the Sweet Spot

PURPOSE

The purpose of this study is to learn how caregivers who are expert in feeding infants with neonatal abstinence syndrome (NAS) successfully feed these infants during withdrawal.

DESIGN/SAMPLE

Focus group methodology was used to gather information from self-identified experts from three large regional NICUs. Twelve NICU nurses and speech therapists participated in open-ended, recorded discussions. Detailed flip chart notes were taken, reviewed, and verified by the participants before the group ended.

RESULTS

Four major themes emerged verified by the participants: (1) optimal medication management, (2) follow the baby's cues, (3) calm and comfortable, and (4) nurture the relationship. Participants reported using both common and creative techniques. Keeping the infant calm was crucial to being successful, as well as maintaining good control of withdrawal signs. Feeding the infant facing away from them to avoid eye contact was used, as well as vertical rocking, continuous butt patting, bundling, "shhing" sound, and a novel feeding position.

Systematic Review: What Is the Evidence for the Side-Lying Position for Feeding Preterm Infants?

BACKGROUND

Side-lying position is an increasingly common feeding strategy used by parents, nurses, and feeding therapists to support oral feeding in preterm infants. Better understanding of the research evidence on the effect of the side-lying position will help clinicians make informed decisions and guide future research in this important area.

PURPOSE

To identify and summarize the available evidence on the effect of side-lying position on oral feeding outcomes in preterm infants.

METHODS/SEARCH STRATEGY

PubMed, CINAHL, Web of Science and PsycINFO were searched for ("preterm" OR "premature") AND "feed*" AND "position*". The full text of 47 articles was reviewed to identify eligible studies that use a quasi-experimental or experimental design to examine the intervention effectiveness; 4 studies met criteria.

FINDINGS/RESULTS

Four studies compared the effect of the side-lying position with either the semi-upright, cradle-hold, or semi-reclined positions on various feeding outcomes. The findings were conflicting: 2 studies found the side-lying position to be beneficial for supporting physiologic stability during feeding compared with the semi-upright position whereas 2 studies did not find significant differences in any of their outcomes between the side-lying position and other feeding positions. However, this finding should be interpreted cautiously because of various methodological weaknesses and limited generalizability.

IMPLICATIONS FOR PRACTICE

This review does not provide strong or consistent evidence that the side-lying position improves preterm infants' oral feeding outcomes.

IMPLICATIONS FOR RESEARCH

A large randomized controlled trial with a diverse group of preterm infants is needed to determine the effects of the side-lying position and identify infants who would receive the most benefit.Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Effects of two different feeding positions on physiological characteristics and feeding performance of preterm infants: A randomized controlled trial

PURPOSE

The aim of this randomized controlled study was to determine the effect of semielevated side-lying (ESL) and semielevated supine (ESU) positions, which are used to bottle-feed preterm infants, on their physiological characteristics and feeding performance.

DESIGN AND METHODS

The sample consisted of preterm infants who were born in the 31st gestational week and below, and met the inclusion criteria. A randomization was provided in the sample group with a total of 80 infants including 38 infants in the ESL (experimental) group and 42 infants in the ESU (control) group. Both groups were compared in terms of their SpO2 values, heart rates, and feeding performances before, during, and after the feeding. The data were obtained by using a form for infant descriptive characteristics, feeding follow-up form, a Masimo Radical-7 pulse oximeter device, and a video camera.

RESULTS

It was determined that the infants in the ESL group had statistically significantly higher SpO2 values (ESL: 96.77 ± 2.51; ESU: 93.48 ± 5.63) and lower heart rates (ESL: 155.87 ± 11.18; ESU: 164.35 ± 6.00) during the feeding compared to the infants in the ESU group (p < .05). Besides, oxygen saturation levels of the infants in the ESU group decreased more (p < .01) and their heart rates increased more (p < .05) during the feeding than those obtained before the feeding compared to the infants in the ESL group.

PRACTICE IMPLICATIONS

The ESL position has a more positive effect on oxygen saturation and heart rate of infants and it is more effective in providing a physiological stabilization during the feeding, compared to the ESU position. According to these results, the ESL position can be recommended for preterm feeding.

Implementing Co-Regulated Feeding with Mothers of Preterm Infants

PURPOSE

The purpose of this study is to describe implementation of the Co-Regulated Feeding Intervention (CoReg), when provided by mothers and guided by intervention nurses trained in methods of guided participation (GP). Co-regulated feeding intervention aims to prevent stress during feeding and ease the challenge very preterm (VP) infants experience coordinating breathing and swallowing during the early months. Guided participation is a participatory learning method to guide the complex learning required for mothers.

STUDY DESIGN AND METHODS

Sixteen mothers of 17 VP infants participated. Each mother received a median of five intervention sessions during the infant's transition to oral feeding. Intervention field notes, audio recordings of the sessions, and video recordings of the nurse-guided feedings were reviewed, organized, and content analyzed to evaluate implementation.

RESULTS

The co-regulated feeding intervention was well received by mothers; enrollment, participation, and retention rates were high. Most mothers chose to spread out the intervention sessions across the transition period. Scheduling sessions was the greatest barrier. Mothers had competing demands and infant readiness to eat could not be predicted. The top five issues identified as needing attention by the mother or nurse included reading cues, coregulating breathing, providing motoric stability, regulating milk flow, and providing rest periods. Main GP strategies included joint attention with the mother to the dyad's feeding challenges, auditory assessment of breathing and swallowing, and reflection with planning for future feedings using video playback.

CLINICAL IMPLICATIONS

Nurse presence while mothers feed affords rich opportunities to guide coregulated, cue-based feeding. Co-regulated feeding intervention would be enhanced if mothers are guided by the bedside nurse.

Mothers' Psychological Distress and Feeding of Their Preterm Infants

PURPOSE

To examine the change in psychological distress of mothers of preterm infants and its association with maternal feeding behaviors as the infant transitions to full oral feeding.

STUDY DESIGN AND METHODS

This descriptive exploratory study used a subset of data from a study of the effects of a coregulated feeding intervention for 34 mothers and hospitalized preterm infants in a Level-III neonatal intensive care unit (NICU). Maternal psychological distress was measured by maternal worry (Child Health Worry Scale), depression (Center for Epidemiology-Depression Scale), and role stress (Parental Stress Scale: NICU-Role Alteration) at three time points: within 1 week prior to the first oral feeding (T1), and at achievement of half (T2) and full oral feeding (T3). Feedings were videotaped at T2 and T3. An observational coding system measured maternal feeding behaviors. Linear mixed modeling evaluated the change in maternal psychological distress and its association with mothers' feeding behaviors as the infant transitioned to full oral feeding.

RESULTS

Maternal depressive symptoms were highest at T1 and declined over time. Maternal worry and role stress were also highest at T1 but remained stable from T2 to T3. Increased maternal psychological distress, particularly depressive symptoms and role stress, were associated with less use of developmentally supportive feeding behaviors, that is, minimizing tactile stimulation, providing steady touch to contain or stabilize the infant, and regulating milk flow.

CLINICAL IMPLICATIONS

Supporting maternal psychological well-being while infants are learning to feed orally may be an appropriate target for interventions to support mother-infant early feeding interactions.

Clinicians guide for cue-based transition to oral feeding in preterm infants: An easy-to-use clinical guide

RATIONALE, AIMS AND OBJECTIVES

This article aims to provide evidence to guide multidisciplinary clinical practitioners towards successful initiation and long-term maintenance of oral feeding in preterm infants, directed by the individual infant maturity.

METHOD

A comprehensive review of primary research, explorative work, existing guidelines, and evidence-based opinions regarding the transition to oral feeding in preterm infants was studied to compile this document.

RESULTS

Current clinical hospital practices are described and challenged and the principles of cue-based feeding are explored. "Traditional" feeding regimes use criteria, such as the infant's weight, gestational age and being free of illness, and even caregiver intuition to initiate or delay oral feeding. However, these criteria could compromise the infant and increase anxiety levels and frustration for parents and caregivers. Cue-based feeding, opposed to volume-driven feeding, lead to improved feeding success, including increased weight gain, shorter hospital stay, fewer adverse events, without increasing staff workload while simultaneously improving parents' skills regarding infant feeding. Although research is available on cue-based feeding, an easy-to-use clinical guide for practitioners could not be found. A cue-based infant feeding regime, for clinical decision making on providing opportunities to support feeding success in preterm infants, is provided in this article as a framework for clinical reasoning.

CONCLUSIONS

Cue-based feeding of preterm infants requires care providers who are trained in and sensitive to infant cues, to ensure optimal feeding success. An easy-to-use clinical guideline is presented for implementation by multidisciplinary team members. This evidence-based guideline aims to improve feeding outcomes for the newborn infant and to facilitate the tasks of nurses and caregivers.

Preliminary psychometric performance of the Neonatal Feeding Assessment Scale

Objective

The objective was to determine the preliminary psychometric performance of a new clinical feeding scale to diagnose oropharyngeal dysphagia (OPD) in neonates.

Methods

Twenty neonates with a median gestational age of 35 weeks were evaluated using the Neonatal Feeding Assessment Scale (NFAS) and modified barium swallow studies (MBSS). The results were compared.

Results

Nine of the 20 participants presented with OPD on the NFAS. Comparison of the scale’s results with instrumental MBSS indicated that all participants without OPD were correctly excluded (100% sensitivity). The specificity was 78.6%, indicating that three participants were falsely identified with OPD on the scale. Inter-rater reliability was determined on 50% (n = 10) of the sample. Substantial agreement (80%) was obtained between two raters in five of the six sections of the scale and on the diagnostic outcome.

Conclusion

The preliminary performance of the scale appears to be promising. A further validation study will take place.

Development of a clinical feeding assessment scale for very young infants in South Africa

Background

There is a need for validated neonatal feeding assessment instruments in South Africa. A locally developed instrument may contribute to standardised evaluation procedures of high-risk neonates and address needs in resource constrained developing settings.

Objective

The aim of the study was to develop and validate the content of a clinical feeding assessment scale to diagnose oropharyngeal dysphagia (OPD) in neonates.

Method

The Neonatal Feeding Assessment Scale (NFAS) was developed using the Delphi method. Five international and South African speech-language therapists (SLTs) formed the expert panel, participating in two rounds of electronic questionnaires to develop and validate the content of the NFAS.

Results

All participants agreed on the need for the development of a valid clinical feeding assessment instrument to use with the neonatal population. The initial NFAS consisted of 240 items across 8 sections, and after the Delphi process was implemented, the final format was reduced to 211 items across 6 sections. The final format of the NFAS is scored using a binary scoring system guiding the clinician to diagnose the presence or absence of OPD. All members agreed on the format, the scoring system and the feeding constructs addressed in the revised final format of the NFAS.

Conclusion

The Delphi method and the diverse clinical and research experience of participants could be integrated to develop the NFAS which may be used in clinical practice in South Africa or similar developing contexts. Because of demographically different work settings marked by developed versus developing contexts, participants did not have the same expectations of a clinical dysphagia assessment. The international participants contributed to evidence-based content development. Local participants considered the contextual challenges of South African SLTs entering the field with basic competencies in neonatal dysphagia management, thereby justifying a comprehensive clinical instrument. The NFAS is aimed at clinicians working in Neonatal Intensive Care Units where they manage large caseloads of high-risk neonates. Further validation of the NFAS is recommended to determine its criterion validity in comparison with a widely accepted standard such as the modified barium swallow study.

Cue-Based Feeding in the NICU

In NICU settings, caring for neonates born as early as 23 weeks gestation presents unique challenges for caregivers. Traditionally, preterm infants who are learning to orally feed take a predetermined volume of breast milk or formula at scheduled intervals, regardless of their individual ability to coordinate each feeding. Evidence suggests that this volume-driven feeding model should be replaced with a more individualized, developmentally appropriate practice. Evidence from the literature suggests that preterm infants fed via cue-based feeding reach full oral feeding status faster than their volume-feeding counterparts and have shorter lengths of stay in the hospital. Changing practice to infant-driven or cue-based feedings in the hospital setting requires staff education, documentation, and team-based communication.

Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation

BACKGROUND

One of the most challenging milestones for preterm infants is the acquisition of safe and efficient feeding skills. The majority of healthy full term infants are born with skills to coordinate their suck, swallow and respiration. However, this is not the case for preterm infants who develop these skills gradually as they transition from tube feeding to suck feeds. For preterm infants the ability to engage in oral feeding behaviour is dependent on many factors. The complexity of factors influencing feeding readiness has led some researchers to investigate the use of an individualised assessment of an infant's abilities. A limited number of instruments that aim to indicate an individual infant's readiness to commence either breast or bottle feeding have been developed.

OBJECTIVES

To determine the effects of using a feeding readiness instrument when compared to no instrument or another instrument on the outcomes of time to establish full oral feeding and duration of hospitalisations.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 22 February 2016), EMBASE (1980 to 22 February 2016), and CINAHL (1982 to 22 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing a formal instrument to assess a preterm infant's readiness to commence suck feeds with either no instrument (usual practice) or another feeding readiness instrument.

DATA COLLECTION AND ANALYSIS

The standard methods of Cochrane Neonatal were used. Two authors independently screened potential studies for inclusion. No studies were found that met our inclusion criteria.

MAIN RESULTS

No studies met the inclusion criteria.

AUTHORS' CONCLUSIONS

There is currently no evidence to inform clinical practice, with no studies meeting the inclusion criteria for this review. Research is needed in this area to establish an evidence base for the clinical utility of implementing the use of an instrument to assess feeding readiness in the preterm infant population.

Preterm infants' orally directed behaviors and behavioral state responses to the integrated H-HOPE intervention

Preterm infants are challenged by immature infant behavioral organization which may negatively influence their ability to oral feed. The purpose of this study was to determine whether the integrated H-HOPE (Hospital to Home: Optimizing the Infant's Environment) intervention would improve infant behavioral organization by increasing the frequency of orally directed behaviors and the proportion of time spent in an alert behavioral state when offered prior to oral feeding. Mother-infant dyads (n=198) were randomly assigned to the H-HOPE intervention or the Attention Control groups. Infants were born at 29-34 weeks gestation and were clinically stable. Mothers had at least two social environmental risk factors such as minority status or less than high school education. H-HOPE is an integrated intervention that included (1) twice-daily infant directed stimulation using the ATVV intervention (auditory, tactile, visual, and vestibular stimuli) and (2) maternal participatory guidance sessions by a nurse-community advocate team. Orally directed behaviors and behavioral states were assessed weekly prior to feeding during hospitalization when infants were able to feed orally. There were no differences between the groups at baseline (Day 0, prior to the initiation of the integrated H-HOPE intervention). We observed a pattern of increased frequency of orally directed behaviors in the H-HOPE intervention group when compared to the Attention Control group, however, the proportion of time spent in an alert behavioral state remained stable in both groups over the course of the study. On Day 7, the H-HOPE intervention group exhibited a significantly higher mean frequency of orally directed behaviors than the Attention Control group (12.6 vs. 7.1 pre-intervention, 51.8 vs. 33.2 during intervention, 4.3 vs. 3.2 immediately after intervention, and 8.9 vs. 5.3 immediately prior to feeding). On Day 7, the H-HOPE intervention group exhibited a significantly higher proportion of time spent in an alert behavioral state only during intervention (0.26 vs. 0.11) and immediately after intervention (0.28 vs. 0.06). These findings are suggestive that the integrated H-HOPE intervention facilitated infant behavioral organization for clinically stable infants born between 29 and 34 weeks gestation. The orally directed behaviors appear to be an important indicator of the infant's preparation for feeding, and when used in conjunction with assessment of behavioral states, are especially valuable to the clinician. Use of this combined assessment approach in practice would strengthen clinician assessment for initiation of (beginning the first oral feeding) and daily preparation for oral feeding in preterm infants.