Good and poor feeding behavior in the neonatal period

Factors contributing to preterm infant engagement during bottle-feeding

BACKGROUND

Preterm infants have difficulty maintaining engagement throughout early oral feedings, which can lead to less efficient feeding and prolonged feeding skill development.

OBJECTIVE

To examine contributions of the infant, mother, and feeding context to infant engagement during bottle-feeding.

METHODS

Bottle-feedings of very-low-birthweight infants (n = 22) by their mothers were observed. Infant and maternal behaviors were coded and synchronized with physiologic measures. At completion of the feeding, the mothers were interviewed, and their working model of feeding coregulation was scored. Feedings were subdivided into feeding episodes (n = 114). Using multilevel linear regression analyses, four dyadic characteristics (working model of the caregiver's role as coregulator, birthweight, postconceptional age, baseline oxygen saturation) and five episode characteristics (readiness at episode onset, episode baseline oxygen saturation, mean oxygen saturation during the episode, maternal feeding behavior, and phase of feeding) were examined as potential predictors of feeding episode engagement.

RESULTS

Conditions observed during the feeding observation explained most of the variation in engagement. Engagement was more likely to occur during the early phase of feeding (p <.05), during feeding episodes that began with infant readiness (p <.05), and during feeding episodes with higher mean oxygen saturation during the episode (p <.05). Feeding episodes with less jiggling of the nipple had a significantly greater amount of engagement (p <.05).

CONCLUSIONS

The ability of the preterm infant to maintain engagement during bottle-feeding cannot be explained by characteristics of the infant or by the prefeeding condition of the infant alone. Rather, engagement is coregulated by the caregiver and the infant throughout the feeding. Strategies to assist infants in maintaining physiologic stability during bottle-feeding and further study of effective and contingent caregiver feeding behaviors are needed.

Oral support measures used in feeding the preterm infant

BACKGROUND

Evidence that bottle-feeding is a stressor for inefficient preterm infant feeders is seen in untoward changes in the physiologic system and nutritive sucking patterns.

OBJECTIVE

To determine whether a therapeutic technique, oral support (cheek and jaw support), would influence the cardiopulmonary functions or nutritive sucking patterns of preterm infants during feeding.

METHODS

A crossover repeated measures design was used with 20 preterm infants for a total of 40 bottle-feeding sessions. The Whitney Mercury Strain Gage and a Nonin Cardiopulmonary monitor were used to observe sucking characteristics and cardiopulmonary functions during feeding.

RESULTS

Infants not receiving support paused longer (F= 6.37, df= 5, p < .001) and more frequently (F= 5.01, df= 5, p < .001) than supported infants. There were no differences between the groups in the number of sucks and bursts, the burst duration, the stability of the total sucking activity, or the rate of sucking. Oxygen saturation (SaO2) values, heart rate, and respiratory rate did not differ between the groups during feeding. Postfeeding SaO2 levels were lower than prefeeding levels for infants not receiving oral support (t= 0.96, df= 19, p= .03).

CONCLUSION

Oral support provided stability for the jaw and fostered the return of the infant's prefeeding SaO2 values, but it did not interfere with cardiopulmonary function during feeding. Further research is needed to determine whether there is a cumulative effect of oral support, and whether it influences state behavior.

Feeding responses to free-flow formula in term and preterm infants

OBJECTIVES

Although introducing freely flowing formula into the infant's mouth is a common feeding practice, its effect on feeding behavior is largely unknown. We evaluated the effects of free flow of formula from the nipple on infant feeding activity (sucking, swallowing, ingestion rate) and documented potential adverse behaviors such as cough, restless behavior, drooling, apnea, and bradycardia.

METHODS

We studied 13 preterm and 7 term infants. During a feeding, bottle pressure was adjusted every 2 to 3 minutes to increase or decrease free flow from the nipple.

RESULTS

Increase in free flow of formula from the nipple caused rapid increases in suck and swallow frequency in term and preterm infants and increased ingestion rate. The response was reversed by decreasing flow and was repeatable throughout the feeding. Peak suck and swallow rates were highest in term infants. Although drooling increased with increased milk flow, no effect of flow on coughing, restless behavior, or apnea was observed.

CONCLUSIONS

Free-flow formula is a potent stimulus for feeding activity in both preterm and term infants and is not associated with increased apnea or other adverse behaviors. The ability of the infant to divert excess formula flow by drooling is an efficient airway protective behavior. Reduced maximum suck and swallow frequency may be a primary basis for slow feeding in preterm infants.

Neonatal sucking and maternal feeding practices

This study is the first to demonstrate an association between neonatal and later sucking ability, clinical signs of feeding ability and maternal feeding practices. Of 49 infants followed to a mean age of six weeks, 20 had some feeding problems (compensatory group), based on changes in feeding practices by their mothers, and 29 did not (non-compensatory group). Infants in the compensatory group performed less well on initial and follow-up sucking measures than infants in the non-compensatory group, indicating that they were feeding less efficiently from birth. Also, infants in the compensatory group ingested less during follow-up testing and were reported to be fed more frequently at home by their mothers than infants in the non-compensatory group. These findings strongly suggest that even among healthy infants, there may be more with problematic feeding abilities than have been previously recognized and that mothers are a reliable source of information about their infants' feeding abilities.

Non-organic failure to thrive: growth failure secondary to feeding-skills disorder

In this article the authors propose that non-organic failure to thrive (FTT) is a growth failure secondary to feeding-skills disorder, and that this disorder is neurophysiological in origin. The symptoms of feeding-skills disorder were suggestive of an oral sensorimotor impairment which is usually present from birth or early life, but tends to go unrecognized. Data from 38 infants with non-organic and 22 infants with organic FTT demonstrated that early clinical symptoms of feeding impairment, and observed maternal and infant feeding behaviours and interactions, were similar for both groups, suggesting a need to redefine the term 'non-organic'.

The analysis of sucking behaviour in newborn infants

A special video camera devised by the author and a fiberscope were used to film the neonatal sucking response of 50 low-risk full-term newborn infants on the 5th day after birth. Analysis of the sucking behaviour showed that the sucking movements consist mainly of a peristaltic tongue movement and two kinds of negative pressure; that the peristaltic tongue movements are synchronized with the jaw movements; that infants actively adapt to a varying environment; and that the sucking movements change to minimize the energy required.

Sucking behaviors of normal 3-day-old female neonates during a 24-hr period

Feeding behaviors were measured during six feeding sessions distributed throughout a 24-hr period in 10 normal 3-day-old female infants. Infants were individually videotaped during feeding sessions at 13:00, 17:00, 21:00, 01:00, 05:00, and 09:00 hours. Total mealtime, nutritive sucking time, pause time, number of nutritive sucks, and amount of nutrient consumed were measured. None of these feeding variables were affected by the time of day an infant was fed. Maternal interactions with their infants such as auditory stimulation, caretaking touches or tender touches were unaffected by the time of a feed. These maternal behaviors did not correlate with any of the feeding variables. These findings suggest that 3-day-old infants experiencing routine nursery care do not express specific day-night feeding differences and that certain maternal behaviors do not influence the infants' feeding pattern.

Feeding behaviour in preterm neonates

In 100 bottle-fed preterm infants feeding efficiency was studied by quantifying the volume of milk intake per minute and the number of teat insertions per 10 ml of milk intake. These variables were related to gestational age and to number of weeks of feeding experience. Feeding efficiency was greater in infants above 34 weeks gestational age than in those below this age. There was a significant correlation between feeding efficiency and the duration of feeding experience at most gestational ages between 32 and 37 weeks. A characteristic adducted and flexed arm posture was observed during feeding: it changed along with feeding experience. A neonatal feeding score was devised that allowed the quantification of the early oral feeding behavior. The feeding score correlated well with some aspects of perinatal assessment, with some aspects of the neonatal neurological evaluation and with developmental assessment at 7 months of age. These findings are a stimulus to continue our study into the relationships between feeding behaviour and other aspects of early development, especially of neurological development.