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

Effects of early intervention on the mental wellbeing and caregiving practices of preterm infant caregivers

BACKGROUND

The rising incidence of preterm births worldwide presents a pressing public health challenge, affecting both infants and their preterm caregivers. Early Intervention (EI) programs aim to mitigate the negative impacts associated with preterm births on the physical, cognitive, and psychological health of both infants and their caregivers by providing personalized parental support and developmental monitoring. This study addressed the gap in research evaluating the long-term effects of community-based EI programs on the holistic coping mechanisms of families, encompassing mental wellbeing, caregiving competencies, and the transition process from hospital to home care.

METHODS

This study evaluated the long-term effects of a community-based EI program (in-home only) and the added benefits of earlier Hospital-to-Home (H2H) support, focusing on preterm caregivers' mental wellbeing and caregiving practices.

RESULTS

The findings highlight the extended benefits of EI, demonstrating that program duration and intensity significantly benefit families dealing with neonatal intensive care unit stays. For infants requiring extensive medical intervention, EI support markedly enhances caregiver mental wellbeing. Additionally, interventions initiated earlier yield a more substantial positive effect on preterm caregivers' mental wellbeing after discharge compared to those that commence later.

CONCLUSION

These findings suggest the potential role of community-based EI programs and the benefits of supporting preterm caregivers before transitioning home. The study calls for future research to explore the effects of various EI program components to identify which interventions are most effective for addressing preterm infants' specific developmental challenges.

The effectiveness of oral motor interventions on the weight gain, independent oral feeding, and length of hospital stay in hospitalized preterm infants: A systematic review and meta-analysis

Background and Aims

Oral feeding for preterm infants has been a challenging issue globally. In an effort to enhance the effectiveness of oral feeding in preterm infants, oral motor intervention (OMI) was developed. Present systematic review and meta-analysis study aims to examine the impact of various OMI techniques on key outcomes, including body weight at the time of discharge, the duration required to achieve independent oral feeding, and the length of hospital stay for preterm infants.

Methods

A systematic search of the literature was performed across various databases such as PubMed, Scopus, and Web of Science and Google Scholar up to September 28, 2023. Quality assessment was conducted using the Joanna Briggs Institute (JBI) checklist. The overall effect measure was calculated using a random-effects model and was presented as the standard difference of the mean (SDM), accompanied by the standard error and a 95% confidence interval (CI). We used I 2 statistic for investigating the heterogeneity between studies. Data analysis was performed by CMA software (Version 2).

Results

Finally, 22 articles included in this review. The overall effect for body weight at discharge was found to be statistically significant in the prefeeding oral stimulation (PFOS) (SDM = 7.91, 95% CI: 5.62, 10.2, p = 0.000, I 2 = 86.31) and Premature Infant OMI (PIOMI) (SDM = 3.71, 95% CI: 0.72, 6.69, p = 0.01, I 2 = 96.64) groups versus control group. The overall effect of independent oral feeding was significant for PFOS-only (SDM = -0.64, 95% CI: -1.1, -0.17, p = 0.007, I 2 = 75.45), PIOMI only (SDM = -1.48, 95% CI: -2.49, -0.46, p = 0.004, I 2 = 93.73) and nonnutritive sucking (NNS) only (SDM = -0.53, 95% CI: -0.76, -0.30, p = 0.001, I 2 = 0) groups versus control groups. The overall effect of length of hospital stay was significant for NNS group (SDM = -0.45, 95% CI: -0.67, -0.23, p = 0.067, I 2 = 0) and PIOMI group (SDM = -0.42, 95% CI: -0.69, -0.15, p = 0.002, I 2 = 20.18) versus control group.

Conclusion

Among OMIs, the PIOMI approach generally exhibited a more favorable impact on body weight gain at discharge, the duration required to achieve independent oral feeding, and the length of hospital stay.

The effect of oral motor intervention with different initiation times to improve feeding outcomes in preterm infants: protocol for a single-blind, randomized controlled trial

BACKGROUND

Premature infants commonly encounter difficulties with oral feeding, a complication that extends hospital stays, affects infants' quality of life, and imposes substantial burdens on families and society. Enhancing preterm infants' oral feeding skills and facilitating their transition from parenteral or nasal feeding to full oral feeding pose challenges for neonatal intensive care unit (NICU) healthcare professionals. Research indicates that oral motor interventions (OMIs) can enhance preterm infants' oral feeding capabilities and expedite the transition from feeding initiation to full oral feeding. Nonetheless, the most suitable timing for commencing these interventions remains uncertain.

METHODS

This is a single-blind, randomized controlled trial. Preterm with a gestational age between 29+0 to 34+6 weeks will be eligible for the study. These infants will be randomized and allocated to one of two groups, both of which will receive the OMIs. The intervention commences once the infant begins milk intake during the early OMIs. Additionally, in the late OMIs group, the intervention will initiate 48 h after discontinuing nasal continuous positive airway pressure.

DISCUSSION

OMIs encompass non-nutritive sucking and artificial oral stimulation techniques. These techniques target the lips, jaw, muscles, or tongue of premature infants, aiming to facilitate the shift from tube feeding to oral feeding. The primary objective is to determine the ideal intervention timing that fosters the development of oral feeding skills and ensures a seamless transition from parenteral or nasal feeding to full oral feeding among preterm infants. Furthermore, this study might yield insights into the long-term effects of OMIs on the growth and neurodevelopmental outcomes of preterm infants. Such insights could bear substantial significance for the quality of survival among preterm infants and the societal burden imposed by preterm birth.

TRIAL REGISTRATION

chictr.org.cn ChiCTR2300076721. Registered on October 17, 2023.

Effects of Complete Oral Motor Intervention and Nonnutritive Sucking Alone on the Feeding Performance of Premature Infants: A Systematic Review and Meta-Analysis

We explore the effect of complete oral motor intervention (OMI) and nonnutritive sucking (NNS) alone on oral feeding in preterm infants through a meta-analysis. We searched the Embased, Medline, Cochrane Library, and Web of Science databases for randomized controlled trials up to 8 August 2023, based on established selection criteria. Quality evaluations of the studies were carried out by applying both the Cochrane risk of bias assessment tool and the Jadad scale. The outcome measures of three clinical indicators included transition time to oral feeding, weight gain, and hospitalization duration. We conducted a meta-analysis using a random-effects model to determine the pooled effect sizes, expressed as standardized mean differences (SMDs) and their corresponding confidence intervals (CIs). Additionally, we undertook a subgroup analysis and meta-regression to investigate any potential moderating factors. Eight randomized controlled trials with 419 participants were selected. Meta-analysis revealed that receiving a complete OMI had significantly reduced transition time compared with those receiving NNS alone in preterm newborns (SMD, -1.186; 95% CI, -2.160 to -0.212, p = 0.017). However, complete OMI had no significant effect on shortened hospitalization duration (SMD, -0.394; 95% CI, -0.979 to 0.192, p = 0.188) and increased weight gain (SMD, 0.346; 95% CI, -0.147 to 0.838, p = 0.169) compared with NNS alone. In brief, a complete OMI should not be replaced by NNS alone. However, we were unable to draw decisive conclusions because of the limitations of our meta-analysis. Future well-designed randomized controlled trials are necessary to confirm our conclusion.

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.

Baby Intensive Early Active Treatment (babiEAT): A Pilot Randomised Controlled Trial of Feeding Therapy for Infants with Cerebral Palsy and Oropharyngeal Dysphagia

Cerebral palsy (CP), results in impairment of muscle function including the face, mouth, and throat, leading to oropharyngeal dysphagia (OPD), which affects 85% of children with CP. OPD increases risk of deficiencies in growth, neurological development, and aspiration pneumonia, a leading cause of death in CP. This pilot randomised controlled trial aimed to (i) assess feasibility and acceptability of a novel neuroplasticity and motor-learning feeding intervention program, Baby Intensive Early Active Treatment (babiEAT), and standard care, and (ii) explore preliminary efficacy of babiEAT on health and caregiver feeding-related quality of life (QoL). A total of 14 infants with both CP and OPD were randomly allocated to 12 weeks of babiEAT or standard care. Results indicate that babiEAT and standard care are equally feasible, and acceptable. Parents in the babiEAT group thought recommendations were significantly more effective than standard care parents, were more likely to recommend the program to a friend and reported higher QoL. babiEAT infants showed significantly greater efficiency in fluid intake, fewer compensatory strategies with cup drinking, consumption of more advanced food textures, and shorter mealtimes without impacting intake, aspiration risk, or weight. This small pilot study shows promise for babiEAT in infants with CP and OPD. Further research is needed to determine strength of its effects.

The use and effects of whole-body exercises on swallowing function: A scoping review

BACKGROUND

Swallowing function can become impaired due to primary medical conditions or age-related presbyphagia, resulting in swallowing disorders, known as dysphagia. Specific manoeuvres that target different musculature have been innovated and researched, but whole-body exercises (WBE) that target multiple large groups of body systems and muscles have been rarely considered in dysphagia management, despite the causes of dysphagia being often systemic.

AIMS

To identify intervention studies that have used or incorporated WBE to target swallowing function in humans, and report on their findings.

METHODS & PROCEDURES

A scoping review was conducted given the paucity and novelty of this topic in research and practice. Key search terms were used to search five major databases on for all human studies published before 28 November 2022. Studies that were not interventional or used animal models were excluded. All swallowing and oromotor-related outcomes were extracted from the studies. Two researchers independently reviewed all search results following the PRISMA-ScR guideline before meeting to resolve any disagreements.

MAIN CONTRIBUTION

Final analysis was conducted on 11 papers that described 10 studies, with 10 papers (9 studies) reporting positive findings for swallowing or oromotor function-related outcomes. Studies ranged from randomised controlled trials to case studies in design. The study design and populations were heterogeneous, with outcome measures for swallowing and oromotor function ranging from subjective questionnaires to instrumental assessments.

CONCLUSIONS & IMPLICATIONS

Dysphagia rehabilitation that incorporates WBE as part of a comprehensive programme appears to be more beneficial than either WBE or swallowing-related interventions alone. This review is an initial attempt to systematically examine the evidence on this topic. There is a need for future research to study how WBE can be used, either alone or combined with traditional swallowing exercises, to influence swallowing function in different healthy and clinical populations.

WHAT THIS PAPER ADDS

What is already known on this subject Dysphagia rehabilitation usually focuses only on the swallowing muscles and structures of the head, neck, and respiratory system. Whole-body exercise (WBE) and fitness are associated with stronger performance of the tongue muscles, there may be transference potential of WBE to swallowing function. What this paper adds to existing knowledge This review found 10 studies conducted in the last decade that investigated the inclusion of WBE in programmes intended to improve swallowing and/or oromotor-related outcomes. The studies varied widely in design and methodology, but most reported evidence in support of the inclusion of WBE to improve or maintain swallowing and/or oromotor-related functions. What are the potential or actual clinical implications of this work? There is potential for WBE to have a synergistic effect on swallowing function when combined with traditional swallowing exercises. Future clinical research should compare different rehabilitation approaches with controls. Clinicians should enlist allied health professionals who can provide whole-body rehabilitation when managing dysphagia.

Prefeeding interventions improve oral feeding in preterm infants

OBJECTIVE

To assess whether oral stimulation (OS), nonnutritive sucking (NNS) and combined tactile/kinesthetic (T/K) interventions can improve the effects of oral feeding in preterm infants.

METHODS

A retrospective review was performed from 2014 to 2016, in which one hundred thirty preterm infants were separated into two intervention groups (the OS + NNS group and the OS + NNS + T/K group) and one control group. Infants in the two intervention groups received 30 min of interventions a day. All interventions started 48 h after stopping nasal continuous positive airway pressure until participants reached complete oral feeding.

RESULTS

The transition times of the OS + NNS, OS + NNS + T/K, and control groups from the introduction of oral feeding to independent oral feeding were 9.03 ± 0.58, 7.20 ± 0.28, and 12.17 ± 0.64 days, respectively (P < 0.05). The infants' weights at full oral feeding in the OS + NNS, OS + NNS + T/K, and control groups were 1834.58 ± 47.96, 1999.17 ± 92.62, and 1725.87 ± 40.34 g, respectively (P = 0.007). Further post hoc analyses indicated that the weight gain at full oral feeding in the OS + NNS and OS + NNS + T/K groups were more significant than the control group (P = 0.012 and P = 0.036, respectively)Conclusion: OS + NNS and OS + NNS + T/K interventions could shorten the transition time from tube feeding to independent oral feeding; OS + NNS and OS + NNS + T/K interventions improved weight gain compared to the control group. Furthermore, the OS + NNS + T/K group was superior to the OS + NNS group regarding transition time and weight gain.

Clinical effects of oral motor intervention combined with non-nutritive sucking on oral feeding in preterm infants with dysphagia

OBJECTIVE

To explore the effectiveness of oral motor intervention combined with non-nutritive sucking in treating premature infants with dysphagia.

METHODS

Sixty preterm infants admitted to the neonatal intensive care unit of the present study's hospital were selected and randomly divided into the control and intervention groups. The control group was given non-nutritive sucking intervention alone, while the intervention group was given oral motor intervention combined with non-nutritive sucking. The oral motor ability, milk sucking amount and sucking rate, feeding efficiency and outcomes, and the occurrence of adverse reactions were measured and compared.

RESULTS

Compared to first-day interventions, preterm infant oral feeding readiness assessment scale-Chinese version (PIOFRAS-CV) scores of the two groups significantly increased after 14 days of intervention, and this score was higher in the intervention group compared to the control group. Similarly, after 14 days of intervention, the intervention group's milk sucking rate and amount were significantly higher than the control group. Also, after the intervention, the intervention group's total oral feeding weeks were considerably lower, while the feeding efficiency and body weight were significantly higher than the control group. Moreover, the overall adverse reaction rate in the intervention group was lower than that in the control group.

CONCLUSIONS

Oral motor intervention combined with non-nutritive sucking can significantly improve the oral motor ability of premature newborns, promote the process of oral feeding, improve the outcome of oral feeding, and reduce the occurrence of adverse effects. The combined intervention seems to have a beneficial effect on oral feeding proficiency in preterm infants.

Non-Pharmacological and Non-Surgical Feeding Interventions for Hospitalized Infants with Pediatric Feeding Disorder: A Scoping Review

Infants born prematurely or with complex medical conditions often require treatment to facilitate safe and efficient feeding. Practice is based on evidence, so frontline clinicians look to the literature to make informed clinical decisions. The aim of this scoping review was to map and describe the literature base for infant feeding and swallowing interventions and to identify areas for further research. Four electronic databases were searched from the sources' inceptions through April 2020 using a search strategy designed by a health sciences research librarian. Thirteen grey literature sources were searched and forward and backward citation chasing was performed. Inclusion criteria were English-language studies reporting non-pharmacological and non-surgical interventions for hospitalized infants. Exclusion criteria included interventions exclusively for infants with cleft lip or palate or for infants being fed exclusively though enteral feeding. Data were extracted using a form created a priori and data were reported descriptively. We reviewed 6654 abstracts: 725 were chosen for full-text review and 136 met inclusion. Most studies explored interventions for infants born prematurely (n = 128). Studies were stratified by intervention domain: bridging (n = 91) and feeding/swallowing (n = 45); intervention approach: direct (n = 72), indirect (n = 31), or combination (n = 33); and outcome: feeding performance (n = 125), physiologic stability (n = 40), and swallowing physiology (n = 12). The body of research in infant feeding has grown; however, a need remains for research focused on populations of infants with various medical complexities and for frequently used interventions that lack supporting evidence.

Spontaneous Orofacial Movements at Writhing and Fidgety General Movements Age in Preterm and Full-Term Infants

Background: As general spontaneous movements at the writhing and fidgety ages have been important for the early identification of neurodevelopmental impairment of both full-term and preterm infants, the knowledge of the spontaneous orofacial movements at these ages also seems to be important for the diagnosis of oral function, particularly in preterm infants. Therefore, we decided to first classify preterm and full-term infants according to general movements ages, and then to record, describe, compare, and discuss their spontaneous orofacial movements. Methods: This cross-sectional study included 51 preterm infants (born between 28 and 36 weeks) and 43 full-term infants who were classified at the writhing and fidgety ages of Prechtl’s method of general movements assessment. Their spontaneous orofacial movements were recorded on video, and The Observer XT software (Noldus) was used to record the quantitative values of the movements. Results: Poor repertoires of writhing movements were more frequent in the preterm infants (90.9%) compared to full-term ones (57.9%). Positive fidgety movements were observed in 100% of both preterm and full-term infants. Oral movements were similar for both preterm and full-term infants, regardless of their movement stage. Conclusion: All spontaneous orofacial movements were present both in preterm and full-term infants, albeit with higher frequency, intensity, and variability at fidgety age.

Study of Orofacial Function in Preschool Children Born Prematurely

Children born prematurely often exhibit orofacial dysfunction. We conducted Nordic Orofacial Test Screening and analyzed chewing and swallowing functions of 243 children aged 3−5 years, consisting of 142 and 101 children born full-term and preterm, respectively, to evaluate the orofacial function of preschool premature children. Categorical variables were analyzed using chi-square test for a comparison. The univariate analysis of variance was used to analyze the effects of birth weight, gestational age, intubation at birth, use of nasal continuous positive airway pressure support after birth, and use of nasogastric tube on the chewing and swallowing functions of children born prematurely. In this survey, term-born children had a higher incidence of bad oral habits, grinding teeth while sleeping, and abnormal gulping compared to preterm-born children. Preterm-born children had a higher incidence of choking, decreased mouth opening (<30 mm), abnormal dental arch form, abnormal palatal vault, and dysarthria compared to term-born children.

Risk Factors for High-Arched Palate and Posterior Crossbite at the Age of 5 in Children Born Very Preterm: EPIPAGE-2 Cohort Study

INTRODUCTION

Children born very preterm have an immature sucking reflex at birth and are exposed to neonatal care that can impede proper palate growth.

OBJECTIVES

We aimed to describe the frequency of high-arched palate and posterior crossbite at the age of 5 in children born very preterm and to identify their respective risk factors.

METHODS

Our study was based on the data from EPIPAGE-2, a French national prospective cohort study, and included 2,594 children born between 24- and 31-week gestation. Outcomes were high-arched palate and posterior crossbite. Multivariable models estimated by generalized estimation equations with multiple imputation were used to study the association between the potential risk factors studied and each outcome.

RESULTS

Overall, 8% of children born very preterm had a high-arched palate and 15% posterior crossbite. The odds of high-arched palate were increased for children with low gestational age (24-29 vs. 30-31 weeks of gestation) [adjusted odds ratio (aOR) 1.76, 95% confidence interval (CI) 1.17, 2.66], thumb-sucking habits at the age of 2 (aOR 1.53, 95% CI 1.03, 2.28), and cerebral palsy (aOR 2.18, 95% CI 1.28, 3.69). The odds of posterior crossbite were increased for children with pacifier-sucking habits at the age of 2 (aOR 1.75, 95% CI 1.30, 2.36).

CONCLUSIONS

Among very preterm children, low gestational age and cerebral palsy are the specific risk factors for a high-arched palate. High-arched palate and posterior crossbite share non-nutritive sucking habits as a common risk factor. The oro-facial growth of these children should be monitored.

Cardio-Respiratory Events and Food Autonomy Responses to Early Uni-Modal Orofacial Stimulation in Very Premature Babies: A Randomized, Controlled Study

Uni-modal orofacial stimulation (OFS) for preventing very preterm infants’ oral disorders is highly controversial. Our study sought to demonstrate that OFS reduced cardio-respiratory events and improved food autonomy in a population of very preterm infants. Our study was randomized, controlled, prospective, and unicentric. The preterm included were born between 26–29 weeks gestational age (GA) with a corrected postnatal age <33 weeks GA. They were randomized into two groups: the experimental group underwent OFS, according to a protocol established, over 10 consecutive days, and the control group underwent no OFS. The primary outcome was the number of cardiorespiratory events: apnea–bradycardia (with or without desaturations) or number of isolated desaturations, which were evaluated at four separate times. Measurements occurred during the first, fourth and eighth independent feedings. Seventeen patients were included in the experimental group and 18 in the control group. The number of cardiorespiratory events for all independent feeding times was significantly reduced in the OFS group (p = 0.003) with univariate analysis, but not with multivariable analysis. The quantity of milk ingested during the first autonomous feeding was higher in the experimental group. The acquisition of food autonomy and the duration of hospitalization were similar in the two groups. While our study does not affirm that an early unimodal OFS improves premature infants’ cardiorespiratory evolution and/or the acquisition of food autonomy, it does indicate an improved food efficiency during their first autonomous feedings.

Gene delivery to the hypoglossal motor system: preclinical studies and translational potential

Dysfunction and/or reduced activity in the tongue muscles contributes to conditions such as dysphagia, dysarthria, and sleep disordered breathing. Current treatments are often inadequate, and the tongue is a readily accessible target for therapeutic gene delivery. In this regard, gene therapy specifically targeting the tongue motor system offers two general strategies for treating lingual disorders. First, correcting tongue myofiber and/or hypoglossal (XII) motoneuron pathology in genetic neuromuscular disorders may be readily achieved by intralingual delivery of viral vectors. The retrograde movement of viral vectors such as adeno-associated virus (AAV) enables targeted distribution to XII motoneurons via intralingual viral delivery. Second, conditions with impaired or reduced tongue muscle activation can potentially be treated using viral-driven chemo- or optogenetic approaches to activate or inhibit XII motoneurons and/or tongue myofibers. Further considerations that are highly relevant to lingual gene therapy include (1) the diversity of the motoneurons which control the tongue, (2) the patterns of XII nerve branching, and (3) the complexity of tongue muscle anatomy and biomechanics. Preclinical studies show considerable promise for lingual directed gene therapy in neuromuscular disease, but the potential of such approaches is largely untapped.

Effect of Oral Motor Intervention on Oral Feeding in Preterm Infants: A Systematic Review and Meta-Analysis

Objective This review article aimed to explore the effect of oral motor intervention on oral feeding in preterm infants through a meta-analysis. Method Eligible studies were retrieved from four databases (PubMed, Embase, Cochrane Library, and Web of Science) up to July 2020 and screened based on established selection criteria. Thereafter, relevant data were extracted and heterogeneity tests were conducted to select appropriate effect models according to the chi-square test and I ² statistics. Assessment of risk of bias was performed among the included studies. Finally, a meta-analysis was carried out to evaluate the effect of oral motor intervention in preterm infants according to four clinical indicators: transition time for oral feeding, length of hospital stay, feeding efficiency, and weight gain. Results Eighteen randomized controlled trials with 848 participants were selected to evaluate the effect of oral motor intervention on preterm infants. The meta-analysis results revealed that oral motor intervention could effectively reduce the transition time to full oral feeds and the length of hospital stay as well as increase feeding efficiency and weight gain. Conclusions Oral motor intervention was an effective way to improve oral feeding in preterm infants. It is worthy to be used widely in hospitals to improve the clinical outcomes of preterm infants and reduce the economic burdens of families and society. Future studies should seek to identify detailed intervention processes and intervention durations for clinical application.

The effects of swallowing exercise and non-nutritive sucking exercise on oral feeding readiness in preterm infants: A randomized controlled trial

INTRODUCTION

Preterm infants demonstrate problems with pharyngeal swallowing in addition to sucking problems. Oral motor intervention and nonnutritive sucking (NNS) were introduced for promoting oral feeding skills in preterm infants. NNS cannot cover all the components of oral feeding. In another hand, the swallowing exercise (SE) can accelerate the attainment of independent oral feeding in the preterm infants. The current study sought to examine if a combined program of NNS and SE compared with a program that only involves NNS would be more effective on oral feeding readiness of premature infants.

MATERIAL AND METHODS

This randomized controlled trial was conducted in a neonatal intensive care unit (NICU). 45 preterm infants were recruited in three groups. In the group I, infants were provided with NNS twice a day. The group II received a program that involved 15 min of NNS and 15 min of SE, daily. Both interventions were provided 10 days during two consecutive weeks. The group III, control group, just received the routine NICU care. All infants were assessed by functional oral feeding outcome measures including postmenstrual age (PMA) at the start of oral feeding, PMA at full oral feeding, transition time (days from start to full oral feeding), PMA at discharge time and also the infant's dependency on tube-feeding at discharge time after interventions. Also, all infants were assessed via Preterm Oral Feeding Readiness Scale (POFRAS) before and after intervention.

RESULTS

No significant differences were observed in the PMA mean at start of oral-feeding (P = 0.29), full oral-feeding (P = 0.13), discharge time (P = 0.45) and the mean of transition time (P = 0.14). Compared to the control group, more infants in the group II were discharged without tube-feeding (P = 0.01). The mean of POFRAS was significantly higher in both groups I and II compared to the group III (P = 0.02 and P = 0.01, respectively). This score was, however, not statistically different between the groups I and II (P = 0.98).

CONCLUSIONS

Both studied interventions were superior to routine NICU care in enhancing the oral feeding readiness of preterm infants based on the POFRAS score. The studied combined program of NNS and SE, and not NNS program, could significantly increase the number of discharged infants without tube-feeding compared to control group.

Does birth weight affect neonatal body weight, growth, and physiology in an animal model?

Infant birth weight affects neuromotor and biomechanical swallowing performance in infant pig models. Preterm infants are generally born low birth weight and suffer from delayed development and neuromotor deficits. These deficits include critical life skills such as swallowing and breathing. It is unclear whether these neuromotor and biomechanical deficits are a result of low birth weight or preterm birth. In this study we ask: are preterm infants simply low birth weight infants or do preterm infants differ from term infants in weight gain and swallowing behaviors independent of birth weight? We use a validated infant pig model to show that preterm and term infants gain weight differently and that birth weight is not a strong predictor of functional deficits in preterm infant swallowing. We found that preterm infants gained weight at a faster rate than term infants and with nearly three times the variation. Additionally, we found that the number of sucks per swallow, swallow duration, and the delay of the swallows relative to the suck cycles were not impacted by birth weight. These results suggest that any correlation of developmental or swallowing deficits with reduced birth weight are likely linked to underlying physiological immaturity of the preterm infant.

[Effectiveness of 2 interventions for independent oral feeding in pre-terms]

INTRODUCTION

Oral feeding of pre-term newborns (PTNB) is hampered by their immaturity and intercurrent diseases, which can prolong their hospital stay. The objective of this study was to assess the effectiveness of a program that combines tactile, kinesthetic and oral stimulation (T+K+OS) compared to another intervention based on exclusively oral stimulation (OS), in the time necessary to achieve independent feeding and hospital discharge.

PATIENTS AND METHODS

A clinical study of 2 randomized groups (OS vs. T+K+OS) was carried out on 42 PTNB with gestational age between 27-32 weeks and birth weight>900g. The stimulation programs were carried out in sessions of 15min, for 10 days.

RESULTS

The PTNBs in the T+K+OS group achieved independent oral feeding earlier, compared to the OS group (24.9±10.1 vs. 34.1±15.6 days, P=.02). An analysis of covariance was performed, which confirmed that the birth weight and gestational age covariates had significant effects on time to reach suction feeding (birth weight: F[1, 38]=5.79; P=.021; gestational age: F[1, 38]=14.12; P=.001) and that once its effect was controlled, the intervention continued to have a significant effect (F[1, 38]=6.07; P=.018). The T+K+OS group, compared to the OS group, achieved an earlier hospital discharge (39±15 vs. 45±18 days), although the differences were not significant (P=.21).

CONCLUSIONS

Combined therapies that include T+K+OS are more effective than OS alone, in order to achieve independent oral feeding in PTNBs.

The effect of non-nutritive sucking combined with oral motor stimulation and oral support on feeding performance in premature infants: A single-blind randomized-clinical trial

PURPOSE

Feeding problems are common in premature infants (PIs) and may lead to negative consequences such as malnutrition, dehydration, excessive weight loss, as well as developmental and psychological deficits. Moreover, they are associated with increased length of hospital stay/cost. There is not enough evidence on how feeding problems should be treated in PIs. The goal of this study was to investigate the effects of non-nutritive sucking combined with oral motor stimulation and oral support on feeding performance in PIs.

METHODS

A single-blind randomized clinical trial was performed on 44 PIs with feeding problems. Patients were randomly categorized into two groups: (1) combined intervention (CI) and (2) non-nutritive sucking (NNS). The CI group received NNS, oral motor stimulation and oral support simultaneously. Infants in both groups received 14 treatment sessions for 14 consecutive days. The Preterm Oral Feeding Readiness Assessment Scale (POFRAS) was used as the primary outcome measure. Weight, volume of milk intake, time to achieve full oral feeding, and length of hospital stay were secondary outcome measures. All measures were assessed before treatment, after the 7th session, after the 14th session, and after 7 days after the end of treatment.

RESULTS

Both groups improved in all outcome measures across time (P < 0.001). The improvements in the POFRAS, volume of milk intake, and time to achieve full oral feeding were significantly greater in the CI group than the NNS group (P < 0.001). The improvements attained in weight and length of hospital stay were not significantly different between the CI and NNS groups (P > 0.05). Large effect sizes were found for POFRAS score in both CI (d = 3.98) and NNS (d = 2.19) groups.

CONCLUSION

The current study showed that the combined intervention including NNS, oral motor stimulation, and oral support significantly improved the feeding performance in PIs.

Oral-feeding guidelines for preterm neonates in the NICU: a scoping review

OBJECTIVE

This scoping review describes the nature and evidence base of internationally available guidelines for the introduction of oral feeding for preterm infants in neonatal units.

STUDY DESIGN

Thirty-nine current infant oral feeding introduction guidelines were obtained, and their recommendations contrasted with available scientific literature.

RESULT

Documents were primarily from the USA, UK, Canada, and Australia, from hospitals, regional health authorities, and journal articles. Specifics of nonnutritive sucking, gestational age at first feed, exclusions to oral feeding, suggested interventions, and the definition of full oral feeding varied between documents. There was variable use of scientific evidence to back up recommendations.

CONCLUSION

Guidelines for oral feeding, whether written by clinicians or researchers, vary greatly in their recommendations and details of interventions. Areas more widely researched were more commonly discussed. Recommendations varied more when evidence was not available or weak. Guideline developers need to synthesize evidence and local variability to create appropriate guidelines.

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.

Inadequate oral feeding as a barrier to discharge in moderately preterm infants

OBJECTIVES

The objectives describe the frequency that inadequate oral feeding (IOF) is the reason why moderately preterm (MPT) infants remain hospitalized and its association with neonatal morbidities.

STUDY DESIGN

Prospective study using the NICHD Neonatal Research Network MPT Registry. Multivariable logistic regression was used to describe associations between IOF and continued hospitalization at 36 weeks postmenstrual age (PMA).

RESULT

A total of 6017 MPT infants from 18 centers were included. Three-thousand three-seventy-six (56%) remained hospitalized at 36 weeks PMA, of whom 1262 (37%) remained hospitalized due to IOF. IOF was associated with RDS (OR 2.02, 1.66-2.46), PDA (OR 1.86, 1.37-2.52), sepsis (OR 2.36, 95% 1.48-3.78), NEC (OR 16.14, 7.27-35.90), and BPD (OR 3.65, 2.56-5.21) compared to infants discharged and was associated with medical NEC (OR 2.06, 1.19-3.56) and BPD (OR 0.46, 0.34-0.61) compared to infants remaining hospitalized for an alternative reason.

CONCLUSION

IOF is the most common barrier to discharge in MPT infants, especially among those with neonatal morbidities.

Nonnutritive Sucking at the Mother's Breast Facilitates Oral Feeding Skills in Premature Infants: A Pilot Study

BACKGROUND

Premature infants have difficulties in transitioning from gavage to breastfeeding. Targeted interventions to support breastfeeding in premature infants in the neonatal intensive care unit are scarce.

PURPOSE

This pilot study evaluates the effectiveness of nonnutritive sucking at the mother's breast in premature infants to facilitate breastfeeding performance and exclusive breastfeeding.

METHODS

The study design constituted a single-blinded randomized control trial, with 9 participants randomly allocated into experimental (n = 4) and control (n = 5) groups. The intervention, nonnutritive sucking at the mother's breast thrice a day for 5 minutes, till nutritive breastfeeding was started, was done in addition to standard care, which was nonnutritive sucking on a finger during gavage feeds. The control group received only standard care. Nonnutritive sucking was assessed using "Stages of Nonnutritive Sucking Scale," and breastfeeding performance was assessed using the "Preterm Infant Breastfeeding Behavior Scale" by a blinded assessor unaware of the infants' allocation.

RESULTS

Five infants in the control arm and 4 in the intervention arm completed the study. The infants in the intervention group showed faster transition to mature stages of nonnutritive sucking (P = .05) and had longer sucking bursts during breastfeeding (P = .06) than those in the control group. There was no difference in the rates of exclusive breastfeeding at 6 months in the intervention and control groups.

IMPLICATIONS FOR PRACTICE

Early initiation of nonnutritive sucking at the mother's breast in very preterm infants is a safe and effective intervention to facilitate maturation of oral feeding and breastfeeding behavior.

IMPLICATIONS FOR RESEARCH

Nonnutritive sucking at the mother's breast can be explored as an intervention, with a larger sample, to facilitate exclusive breastfeeding and to establish intervention fidelity.

Effect of Unimodal and Multimodal Sensorimotor Interventions on Oral Feeding Outcomes in Preterm Infants: An Evidence-Based Systematic Review

BACKGROUND

Preterm infants often experience difficulty with the transition from tube to oral feeding. While many unimodal and multimodal sensorimotor interventions have been generated to optimize oral feeding skills, there has been little cohesion between interventions.

PURPOSE

The aims of this systematic review were to examine the effect of sensorimotor interventions on oral feeding outcomes and to determine whether multimodal interventions lead to better oral feeding performances than unimodal interventions.

SEARCH STRATEGY

A systematic search of CINAHL, Embase, MEDLINE, and PsycINFO databases was conducted. Studies were reviewed to assess the types of interventions used to improve transition to full oral feeding, volume intake, weight gain, and length of hospital stay.

RESULTS

The search identified 35 articles. Twenty-six studies examined a unimodal intervention, with the majority focusing on oral sensorimotor input and the others on tactile, auditory, and olfactory input. Nine studies assessed multimodal interventions, with the combination of tactile and kinesthetic stimulation being most common. Results varied across studies due to large differences in methodology, and caution is warranted when interpreting results across studies. The heterogeneity in the studies made it difficult to make any firm conclusions about the effects of sensorimotor interventions on feeding outcomes. Overall, evidence on whether multimodal approaches can lead to better oral feeding outcomes than a unimodal approach was insufficient.

IMPLICATIONS FOR PRACTICE

The use of sensorimotor interventions to optimize feeding outcomes in preterm infants varies based on methods used and modalities. These factors warrant caution by clinicians who use sensorimotor interventions in the neonatal intensive care unit.

IMPLICATIONS FOR RESEARCH

Large randomized clinical trials using a standardized approach for the administration of sensorimotor input are needed to further establish the effects on feeding outcomes in preterm infants.

Effect of oral stimulation on feeding performance and weight gain in preterm neonates: a randomised controlled trial

BACKGROUND

In preterm infants, oral stimulation enhances muscle tone and movement which facilitates normal oral motor developmental patterns improving oral feeding performance.

AIM

To study the effects on feeding performance, transition to independent oral feeding, weight gain and length of hospital stay of an oral stimulation programme in preterm neonates.

STUDY DESIGN

This randomised controlled trial was conducted in a tertiary care teaching hospital over a period of 10 months. Altogether, 102 preterm neonates (30-34 weeks gestation) were randomised into the intervention group (oro-motor stimulation for 5 min twice a day, n = 51) or the control group (routine care only, n = 51). The primary outcome measures were feeding performance, and transition period to reach independent oral feeding.

RESULTS

There was better feeding performance (overall intake and rate of milk transfer), shorter transition to independent oral feeding, better weight gain and shorter length of hospital stay in the intervention group (p < 0.001).

CONCLUSIONS

Oral stimulation improves feeding performance, weight gain rate and reduces hospital stay in preterm neonates born between 30 and 34 weeks of gestation. [Trial registration number: CTRI/2017/05/008630].

Preterm Birth, Pacifier use and Breastfeeding: is there a Relationship?

Abstract The immaturity of born to preterm infants may predispose to sucking difficulties. This research aimed to evaluate if pacifier use is associated with preterm birth and influenced in type of infant feeding. This comparative cross-sectional study was conducted in Belo Horizonte, Brazil and evaluated 250 children aged 3 to 5 years. As a sample, two groups were established: the normal term children group (n=125) was selected at a day-care centre and the group of preterm children (125) was identified at a public university hospital with a preterm care project from birth to seven years of age. To collect data, a pre-tested questionnaire regarding information on gestational age, infant development, infant feeding and non-nutritive sucking habits was used for both groups. Bivariate and multivariate Poisson regression was used for the statistical analysis. Pacifier use was more prevalent in the preterm group (PR=1.20, 95% CI=1.02-1.42) who used the bottle (PR=1.38, 95% CI=1.15-1.64) and were breastfed for less than six months (PR=1.19, 95% CI=1.01-1.41). The majority of breastfed infants were of normal term birth (PR=1.14, 95% CI=1.04-1.20) and had monthly family income greater than USD 450.28 (RP= 1.10, 95% CI=1.01-1.20). In this study, pacifier use was more prevalent among preterm infants and associated with less than six months of breastfeeding and used of bottle. Monthly family income was associated with a prevalence of breastfeeding.

Exploration des dilemmes éthiques entourant le traitement de la dysphagie à l’enfance et leurs solutions : perceptions d’intervenants

Une recension des écrits révèle qu’il existe peu de connaissances sur les dilemmes éthiques (et leurs solutions) entourant le traitement de la dysphagie à l’enfance. Le but de cette étude était d’explorer, voire de décrire les dilemmes éthiques rencontrés par des intervenants lors du traitement des problèmes d’alimentation chez des enfants souffrant de dysphagie et les façons dont ceux-ci procèdent pour les résoudre. Des entrevues semi-dirigées ont été réalisées auprès de huit intervenantes travaillant dans un Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Québec. Toutes les intervenantes mentionnent avoir rencontré des dilemmes éthiques, et ce, en moyenne deux fois par année et ceux-ci leur ont fait vivre une certaine détresse. Ces dilemmes ont trois causes principales, soit les refus de traitement de certains parents, les suivis partiels des recommandations professionnelles et les divergences d’opinions avec des partenaires externes. Pour résoudre ces dilemmes, les intervenantes affirment recourir à des discussions en équipe et à de l’aide de supérieurs, de partenaires externes ou de parents. La majorité des intervenantes mentionnent avoir besoin de moyens supplémentaires pour résoudre ces dilemmes et proposent certaines avenues en ce sens. Les résultats de la recherche rejoignent en général ceux documentés dans les écrits. Plus d’attention devrait être portée à ces dilemmes étant donné le peu de ressources éthiques, actuellement disponibles, adaptées à ces situations pour les résoudre et la détresse que ceux-ci occasionnent.

Motility disorders in infants

Gastrointestinal motility disorders are common in the pediatric population and may affect the entire gastrointestinal tract and can vary from mild to severe conditions. They may clinically manifest as gastro-esophageal reflux symptoms, feeding difficulties and failure to thrive, constipation and diarrhea amongst others. This review first highlights the embryologic development of the gastrointestinal tract, after which the prenatal and neonatal development of gastrointestinal motility is discussed. Normal motility patterns as seen in (preterm) infants are described as a background for the discussion of the most common congenital and acquired motility disorders in infancy. This review specifically focuses on the role of preterm birth on the development of these disorders.

Readiness for oral feeding and oral motor function in preterm infants

ABSTRACT Objective: this study aimed at investigating the Schedule Oral Motor Assessment (SOMA) tool to be used with preterm infants and to compare its results with the Preterm Oral Feeding Readiness Assessment Scale (POFRAS) to start oral feeding. Methods: a cross-sectional and quantitative study, consisting in a sample of 45 healthy and clinically stable preterm infants, assessed at their first oral feeding with two tools: the Schedule Oral Motor Assessment and Preterm Oral Feeding Readiness Assessment Scale. Stata 10.0 software was used for data analysis. Results: 10 preterm infants with readiness for oral feeding showed normal oral motor function, and 16, presented with oral motor dysfunction, did not show readiness for feeding (p <0.05). The time of transition for full oral feeding was 13.5 (± 8.1) days for preterm infants with better results in both assessment tools, and 17.7 (± 10.9) days for those who did not show readiness for oral feeding and had oral motor dysfunction to initiate oral feeding, resulting in a given clinical relevance, even showing no significance (p> 0.05). Conclusion: these results suggest that the Schedule Oral Motor Assessment can be an adjunctive method for evaluation of the oral motor function at the first oral feeding in preterm infants.

Feeding Disorders

Feeding disorders often present in children with complex medical histories as well as those with neurodevelopmental disabilities. If untreated, feeding problems will likely persist and may lead to additional developmental and medical complications. Treatment of pediatric feeding disorders should involve an interdisciplinary team, but the core intervention should include behavioral feeding techniques as they are the only empirically supported therapy for feeding disorders.

Development of a Dysphagia Screening Test for Preterm Infants (DST-PI)

OBJECTIVE

To explore both the early prediction and diagnosis of dysphagia in preterm infants as an important developmental aspect as well as the prevention of respiratory complications, we developed the simple and-easy-to-apply Dysphagia Screening Test for Preterm Infants (DST-PI) to predict supraglottic penetration and subglottic aspiration.

METHODS

Fifty-two infants were enrolled in a videofluoroscopic swallowing study (VFSS) due to clinical suspicions of dysphagia. Thirteen items related to supraglottic penetration or subglottic aspiration were initially selected from previous studies for the DST-PI. Finally, 7 items were determined by linear logistic regression analysis. Cutoff values, sensitivity, specificity, and the area under the ROC curve (AUC) of the DST-PI for predicting supraglottic penetration or subglottic aspiration were calculated using a ROC curve. For inter-rater reliability, the kappa coefficient was calculated.

RESULTS

Seven items were selected: 'gestational age,' 'history of apnea,' 'history of cyanosis during feeding,' 'swallowing pattern,' 'coughs during or after feeding,' 'decreased oxygen saturation within 3 minutes of feeding,' and 'voice change after feeding.' The Spearman correlation coefficient between the DST-PI and the penetration-aspiration scale (PAS) was 0.807 (p<0.001). The sensitivity and specificity at different cutoff values for detecting supraglottic penetration and subglottic aspiration were 96.6% and 76.9% at 3.25, and 88.9% and 75.8% at 6.25, respectively.

CONCLUSION

The DST-PI is a valid and reliable dysphagia screening test for supraglottic penetration or subglottic aspiration in preterm infants that is easy to apply in a clinical context.

Evidence to support treatment options for children with swallowing and feeding disorders: A systematic review

PURPOSE

A rise in pediatric patients with swallowing and feeding problems has resulted in increased interest in multidisciplinary treatments to address these issues. This evidence based systematic review (EBSR) examined the published evidence for the use of common strategies used by clinicians across disciplines to treat pediatric swallowing and feeding problems.

METHODS

A systematic search of 10 electronic databases was completed to identify relevant, peer reviewed literature published in English prior to December 2015 reporting original data that addressed at least one of the five identified clinical questions.

RESULTS

Sixty-one studies of varying methodological quality were included. The majority of the included studies (60/61) focused on the use of behavioral therapies to remediate swallowing and feeding disorders in children and reported mixed findings across all of the targeted outcomes.

CONCLUSION

There is insufficient quantity of evidence to determine the effects of oral motor, sensory, and pharmaceutical therapies on functional feeding outcomes in pediatric populations. A larger body of phase 1 evidence is available that establishes the efficacy of behavioral strategies to treat some swallowing and feeding difficulties in small cohort and single subject studies. This analysis identified limited high quality (phase 4) research articles that establish the efficacy and benefit of joint nutrition and behavior intervention programs and systematic desensitization and operant conditioning behavioral therapy approaches to improve functional feeding and swallowing outcomes in children.

Pediatric feeding and swallowing rehabilitation: An overview

Children with neurological disabilities frequently have problems with feeding and swallowing. Such problems have a significant impact on the health and well-being of these children and their families. The primary aims in the rehabilitation of pediatric feeding and swallowing disorders are focused on supporting growth, nutrition and hydration, the development of feeding activities, and ensuring safe swallowing with the aim of preventing choking and aspiration pneumonia. Pediatric feeding and swallowing disorders can be divided into four groups: transient, developmental, chronic or progressive.This article provides an overview of the available literature about the rehabilitation of feeding and swallowing disorders in infants and children. Principles of motor control, motor learning and neuroplasticity are discussed for the four groups of children with feeding and swallowing disorders.

Are There Sensitive Periods for Food Acceptance in Infancy?

PURPOSE OF REVIEW

A sensitive period in development is one in which it is easier for learning to take place; the behaviour can however still be learned at a later stage, but with more difficulty. This is in contrast to a critical period, a time at which a behaviour must be learned, and if this window of opportunity is missed, then the behaviour can never be acquired. Both might determine food acceptance in childhood.

RECENT FINDINGS

There is evidence to support the idea of a sensitive period for the introduction of tastes, a critical period for the introduction of textures and for the development of oral motor function, and a possible critical period for the introduction of new foods but only in children where there is an innate disposition to develop early and extreme disgust responses.

SUMMARY

There are both sensitive and critical periods in the acquisition of food preferences.

Relationship between oxygen saturation, gestational age, and level of oral feeding skills in preterm infants

Purpose

To correlate the peripheral oxygen saturation with gestational age and the level of oral feeding skills in the introduction of oral feeding in preterm infants.

Methods

This is a cross-sectional, quantitative study whose sample was composed of 169 clinically stable preterm infants. Peripheral oxygen saturation was assessed before and after introduction of oral feeding. The preterm infants were stratified into three groups based on their gestational age at birth: 26-29, 30-33, and 34-36 weeks. The preterm infants were classified into four levels according to their oral feeding skill and resistance.

Results

No differences in oxygen saturation were observed between the strata of gestational age and between the levels of oral feeding skill. Differences were observed in the groups of preterm infants aged 30-33 weeks (p=0.04) and 34-36 weeks (p=0.02) and on the level I of oral feeding skills (p=0.04) when oxygen saturation was compared at pre- and post-first oral feeding. Significant correlations (p<0.001) were found between gestational age and the levels of oral feeding skills (r=0.38); in Group A, between gestational age and oxygen saturation before the first oral feeding (r=0.83); in Group B, between the level of oral feeding skill and oxygen saturation before the first oral feeding (r=0.26) and between level of oral feeding skill and gestational age (r=0.26).

Conclusion

Correlation was found for peripheral oxygen saturation when compared with gestational age and with the level of oral feeding skills.

Why do clinicians choose the therapies and techniques they do? Exploring clinical decision-making via treatment selections in dysphagia practice

PURPOSE

Speech-language pathologists (SLPs) are assumed to use evidence-based practice to inform treatment decisions. However, the reasoning underpinning treatment selections is not well known. Understanding why SLPs choose the treatments they do may be clarified by exploring the reasoning tied to specific treatments such as dysphagia interventions.

METHOD

An electronic survey methodology was utilised. Participants were accessed via the gatekeepers of two national dysphagia special interest groups representing adult and paediatric populations. Information was elicited on the dysphagia therapies and techniques used and on the reasoning for using/not using therapies. Data was analysed using descriptive and non-parametric statistics.

RESULT

The survey had a 74.8% response rate (n = 116). Consensus in both treatment selections and reasoning supporting treatment decisions was evident. Three favoured interventions (texture modification, thickening liquids, positioning changes) were identified. The reasoning supporting treatment choices centred primarily on client suitability and clinician knowledge. Knowledge reflected both absent knowledge (e.g. training) and accumulated knowledge (clinical experience).

CONCLUSION

Dysphagia practice appears highly-defined, being characterised by group consensus regarding both preferred treatments and the reasoning underpinning treatment selections. Treatment selections are based on two core criteria: client suitability and the SLPs experience/knowledge. Explicit scientific reasoning is less influential than practice-centric influences.

Cardiorespiratory parameters and their relation with gestational age and level of oral feeding skills in preterm infants

Purpose

To correlate cardiorespiratory parameters with gestational age and level of oral feeding skills in the first oral feeding in preterm infants.

Methods

Study participants were 37 clinically stable preterm infants. Cardiorespiratory rate was assessed before and after introduction of oral feeding. The newborns were divided into three strata according to gestational age at birth. Oral skill was classified into four levels: I - low oral skill and low resistance to feeding; II - low oral skill and high resistance to feeding; III - high oral skill and low resistance to feeding; IV - high oral skill and high resistance to feeding.

Results

No difference was observed in heart and respiratory rate between the strata of gestational age at birth and between the levels of oral skill. Comparison between pre- and post-cardiorespiratory rates within each level of oral skill and stratum of gestational age showed difference between heart rate in the strata of gestational ages of 30 to 33 weeks and of 34 to 36 weeks, as well as between oral skill of levels I, II, and IV. With regard to the comparison between pre- and post- respiratory rates, difference was found in the oral skill of level I.

Conclusion

Differences were observed between pre- and post-prandial cardiorespiratory rates regarding the first oral feeding, as well as between strata of gestational age at birth and levels of oral feeding skills.

Effects of pacifier use on transition to full breastfeeding and sucking skills in preterm infants: a randomised controlled trial

AIMS AND OBJECTIVES

To determine the effects of pacifier use on transition to full breastfeeding and sucking skills in preterm infants.

BACKGROUND

Feeding problems in preterm infants cause delays in hospital discharge, extend mother-infant reunification and increase medical cost. Nutritive sucking skills of preterm infants may develop by improving non-nutritive sucking skills and increasing sucking experiences.

DESIGN

A prospective, randomised controlled trial conducted in the Eastern Turkey.

METHODS

Seventy infants were randomised into two groups: a pacifier group (n = 34) and a control group (n = 36). Pacifier use was applied in the preterm infants in the pacifier group, up to switching to full breastfeeding. The infants in the control group did not use pacifiers. Data were collected by a researcher using the Preterm Infant Introductory Information Form, the Preterm Infant Monitoring Form and the LATCH Breastfeeding Assessment Tool. For the study, ethics committee approval, official permission and written informed consents of the families were obtained.

RESULTS

The time to transition to full breastfeeding (123·06 ± 66·56 hours) and the time to discharge (434·50 ± 133·29 hours) in the pacifier group were significantly shorter compared to the control group (167·78 ± 91·77 and 593·63 ± 385·32 hours, respectively) (p < 0·05). The weight at transition to full breastfeeding (1944·12 ± 275·67 g) and the weight of discharge (1956·45 ± 268·04 g) in the pacifier group were significantly lower compared to the control group (2155·58 ± 345·57 and 2159·75 ± 341·22 g, respectively) (p < 0·05). Sucking skills of the infants in the pacifier group at 48 hours after transition to oral feeding and before the discharge was better than in the control group (p < 0·05).

CONCLUSION

Pacifier use improved the sucking skills and shortened the time to transition to full breastfeeding and to discharge in preterm infants receiving complementary feeding.

RELEVANCE TO CLINICAL PRACTICE

Pacifier use may be recommended to accelerate transition to full breastfeeding and to improve the sucking skills in preterm infants who were fed by both oral route and complementary feeding in the neonatal intensive care units.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' postmenstrual age) 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.

OBJECTIVES

To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' postmenstrual age (PMA).To conduct subgroup analyses for the following prespecified subgroups.• Extremely preterm infants born at < 28 weeks' PMA.• Very preterm infants born from 28 to < 32 weeks' PMA.• Infants breast-fed exclusively.• Infants bottle-fed exclusively.• Infants who were both breast-fed and bottle-fed.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 25 February 2016). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles.

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 in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

One review author searched the databases and identified studies for screening. Two review authors screened the abstracts of these studies and full-text copies when needed to identify trials for inclusion in the review. All review authors independently extracted the data and analysed each study for risk of bias across the five domains of bias. All review authors discussed and analysed the data and used the GRADE system to rate the quality of the evidence. Review authors divided studies 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

This review included 19 randomised trials with a total of 823 participants. Almost all included trials had several methodological weaknesses. Meta-analysis showed that oral stimulation reduced the time to transition to oral feeding compared with standard care (mean difference (MD) -4.81, 95% confidence interval (CI) -5.56 to -4.06 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days), as well as the duration of initial hospitalisation compared with standard care (MD -5.26, 95% CI -7.34 to -3.19 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days).Investigators reported shorter duration of parenteral nutrition for infants compared with standard care (MD -5.30, 95% CI -9.73 to -0.87 days) and compared with another non-oral intervention (MD -8.70, 95% CI -15.46 to -1.94 days). They could identify no effect on breast-feeding outcomes nor on weight gain.

AUTHORS' CONCLUSIONS

Although the included studies suggest that oral stimulation shortens hospital stay, days to exclusive oral feeding and duration of parenteral nutrition, one must interpret results of these studies with caution, as risk of bias and poor methodological quality are high overall. Well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should use reliable methods of randomisation while concealing treatment allocation, blinding caregivers to treatment when possible and paying particular attention to blinding of outcome assessors.

Sensorimotor therapy and time to full oral feeding in <33weeks infants

BACKGROUND

Previous research has shown that oral stimulation improves feeding skills in preterm infants. However, it remains unclear whether other sensorimotor therapies have similar effect.

OBJECTIVE

To investigate the effect of sensorimotor therapy on the time to reach full oral feeding (FOF) in infants <33weeks.

METHODS

Retrospective review compared two time periods between 2009 and 2014, before (PRE TX) and after (POST TX) initiation of sensorimotor therapy to infants <33weeks. Type and number of sensorimotor therapy, time to FOF and length of stay (LOS) were collected. Statistical analysis used SPSS 22 for descriptive, non-parametric testing, chi-square and multivariate linear regression computation.

RESULTS

Of 245 records, 137 were excluded due to death, record unavailability/incompleteness or transfer. The remaining 55 in PRE TX and 53 in POST TX infants differed by small for gestational age (SGA) (36.4% vs. 28.3%, p=0.02); sepsis (81.8% vs. 54.7%, p=0.002); patent ductus arteriosus (PDA) (5.5% vs. 22.6%, p=0.01) and bradycardia (47.3% vs. 83%, p<0.0001). Infants in (POST TX) achieved FOF in 6.3±4.3days vs. 8.8±6.6days in (PRE TX) (p=0.02); their LOS was 56.8±26.4 vs. 52.2±25.1 (p=0.36). Predictors of days to FOF were any number of therapy sessions (β=-4.31; 95% CI: -6.47:-2.15), LOS (β=0.05; 95% CI: 0.004:0.09), PDA (β=3.23; 95% CI: 0.27:6.19) and bradycardia (β=2.94; 95% CI: 0.62:5.26).

CONCLUSION

Providing any type of sensorimotor therapy decreased time to reach FOF in infants <33weeks. Structured guidelines may help optimize this effect.