The Effects of Nonnutritive Sucking and Oral Support on the Feeding Efficiency of 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.

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.

Early Intervention to Improve Sucking in Preterm Newborns: A Systematic Review of Quantitative Studies

BACKGROUND

Premature birth is associated with feeding difficulties due to inadequate coordination of sucking, swallowing, and breathing. Nonnutritive sucking (NNS) and oral stimulation interventions may be effective for oral feeding promotion, but the mechanisms of the intervention effects need further clarifications.

PURPOSE

We reviewed preterm infant intervention studies with quantitative outcomes of sucking performance to summarize the evidence of the effect of interventions on specific components of sucking.

METHODS

PubMed, CINAHL, MEDLINE, EMBASE, and PSYCOLIST databases were searched for English language publications through August 2017. Studies were selected if they involved preterm infants, tested experimental interventions to improve sucking or oral feeding skills, and included outcome as an objective measure of sucking performance. Specific Medical Subject Headings (MeSH) terms were utilized.

RESULTS

Nineteen studies were included in this review: 15 randomized, 1 quasi-randomized, and 3 crossover randomized controlled trials. Intervention types were grouped into 6 categories (i) NNS, (ii) NNS with auditory reinforcement, (iii) sensorimotor stimulation, (iv) oral support, (v) combined training, and (vi) nutritive sucking. Efficiency parameters were positively influenced by most types of interventions, though appear to be less affected by trainings based on NNS alone.

IMPLICATIONS FOR PRACTICE

These findings may be useful in the clinical care of infants requiring support to achieve efficient sucking skills through NNS and oral stimulation interventions.

IMPLICATIONS FOR RESEARCH

Further studies including quantitative measures of sucking performance outcome measures are needed in order to best understand the needs and provide more tailored interventions to preterm infants.

Managing eating and drinking difficulties (dysphagia) with children who have learning disabilities: What is effective?

People who work with children who have neurological and learning disabilities frequently need to manage the health and emotional risks associated with eating, drinking and swallowing (dysphagia). Some approaches can support children to develop oral feeding competence or to maximise their ability to maintain some oral intake supplemented with tube feeding. However, some clinicians feel that oral-motor exercises can support eating and drinking skills as well as speech and language development, whereas there is little evidence to support this.The implied "beneficial" association between oral-motor exercises, speech and swallowing skills gives a false impression in terms of future outcomes for parents and carers of children with learning disabilities. This paper considers oral-motor approaches in the remediation of dysphagia and the need for a cultural shift away from this view. Realistic and useful outcomes for people with learning disabilities need to be an essential part of therapeutic intervention.

Effect of nonnutritive sucking and oral stimulation on feeding performance in preterm infants: a randomized controlled trial

OBJECTIVES

To evaluate the effectiveness of nonnutritive sucking (NNS) and oral stimulation (OS), either applied alone or in combination, to reduce the transition time from tube feeding to independent oral feeding.

DESIGN

Randomized controlled trial.

SETTING

A 40-bed neonatal ICU in a university hospital in the People's Republic of China.

PATIENTS

A total of 120 preterm infants were admitted to the neonatal ICU from December 2012 to July 2013.

INTERVENTIONS

Oral motor interventions.

MEASUREMENTS AND MAIN RESULTS

One hundred twelve preterm infants were assigned to three intervention groups (NNS, OS, and combined NNS + OS) and one control group. Primary outcome was the number of days needed from introduction of oral feeding to autonomous oral feeding (transition time). Secondary outcome measures were the rate of milk transfer (mL/min), proficiency (intake first 5 min/volume ordered), volume transfer (volume transferred during entire feeding/volume prescribed), weight, and hospital length of stay. Transition time was reduced in the three intervention groups compared with the control group (p < 0.001). The milk transfer rate in the three intervention groups was greater than in the control group (F3,363 = 15.37; p < 0.001). Proficiency in the NNS and OS groups did not exceed that in the control group while the proficiency in the NNS + OS group was greater than that in the control group at the stage when the infants initiated the oral feeding (p = 0.035). Among all groups, no significant difference was found on weight gain and length of stay.

CONCLUSIONS

The combined NNS + OS intervention reduced the transition time from introduction to independent oral feeding and enhanced the milk transfer rate. The combined intervention seems to have a beneficial effect on oral feeding proficiency in preterm infants.

State of the science: a contemporary review of feeding readiness in the preterm infant

Oral feeding readiness has been described by researchers in the neonatal intensive care unit, and research has continued on this topic for many years. The purpose of this narrative review is to identify research and practice guidelines related to oral feeding readiness in preterm infants that have occurred during the last decade. The introduction and mastery of oral feeding is a major developmental task for the preterm infant that is often a prerequisite for discharge from the neonatal intensive care unit. Having a better understanding of the evidence supporting the development of this skill will help the practicing nurse choose appropriate interventions and the researcher to develop trajectories of research that continue to increase our knowledge in this important practice area.

Oral-motor function and feeding intervention

This article presents the elements of the Oral Motor Intervention section of the Infant Care Path for Physical Therapy in the Neonatal Intensive Care Unit (NICU). The types of physical therapy interventions presented in this path are evidence based as well as infant driven and family focused. In the context of anticipated maturation of suck-swallow-breathe coordination, the timing and methods for initiation of oral feedings and transition from gavage to full breast or bottle-feedings are presented with supporting evidence.

Transition from gavage to nipple feeding for preterm infants with bronchopulmonary dysplasia

BACKGROUND

The transition from gavage to nipple feeding is difficult for preterm infants with bronchopulmonary dysplasia because of tachypnea and hypoxemia from chronic respiratory distress.

OBJECTIVE

The aim of this study was to test the hypothesis that preterm infants with bronchopulmonary dysplasia who transitioned from gavage to nipple feeding with the semidemand method would achieve nipple feeding sooner and be discharged from hospital sooner than control infants who received standard care.

METHODS

Forty-two infants were randomized to the control condition and 44 to the experimental protocol. Mean gestational ages and birth weights were 25 ± 1.5 weeks and 784 g for controls and 25 ± 1.4 weeks and 787 g for experimental infants. Control infants received standard care that included gradual increases in the number of nipple to gavage feedings per day. Experimental infants received the semidemand method that used infant behavioral and cardiorespiratory signs to regulate frequency, length, and volume of nipple feedings. General linear model procedures were used to compare study groups.

RESULTS

Experimental infants achieved nipple feeding at M = 5.9 ± 0.7 days compared with control infants, M = 12.3 ± 0.8 (p < .0001). Length of hospitalization was not significantly different between groups.

DISCUSSION

The semidemand method significantly shortened the time for infants to attain nipple feeding in a manner taking their respiratory distress into consideration.

The effect of oral training on vital signs of premature infants

AIMS AND OBJECTIVES

This study aimed to develop an applicable oral training protocol and test its effects on vital sign stabilisation in premature infants.

BACKGROUND

Oral training improves the feeding behaviour of premature infants. However, the inconsistencies of oral training procedures in previous studies obscure the interventional effect of oral training on vital sign stabilisation in premature infants.

DESIGN

True experimental design.

METHODS

Sixty premature infants with a gestational age <33 weeks were recruited and randomly assigned to the oral training or control group.

RESULTS

Heart rate, respiratory rate and oxygen saturation tended to improve in the oral training group compared to those in the control group. However, the intergroup differences with respect to vital signs before and after feeding were not statistically significant.

CONCLUSIONS

Further studies comparing protocols with different measurement points and durations are suggested.

Making the literature palatable at the bedside: Reference poster promotes oral feeding best practice

Neonatal nurses often draw upon prior experiences and intuition to feed neonates. Such experience and skill vary from nurse to nurse and may not be based on recent research, nor tailored to each neonate's feeding skill. An evidence-based neonatal oral feeding guideline was produced to improve oral feeding practices among nurses and parents. The implementation was initially less than ideal, resulting in poor compliance. A bedside reference poster was designed to serve as a visual succinct reminder of the oral feeding guideline.

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

PURPOSE

To conduct an evidence-based systematic review and provide an estimate of the effects of oral motor interventions (OMIs) on feeding/swallowing outcomes (both physiological and functional) and pulmonary health in preterm infants.

METHOD

A systematic search of the literature published from 1960 to 2007 was conducted. Articles meeting the selection criteria were appraised by 2 reviewers and vetted by a 3rd for methodological quality.

RESULTS

Twelve studies were included and focused on 3 OMIs-nonnutritive sucking (NNS), oral/perioral stimulation, and NNS plus oral/perioral stimulation. Six studies addressed the effects of OMI on the feeding/swallowing physiology outcomes of feeding efficiency or sucking pressures. Ten studies addressed the functional feeding/swallowing outcomes of oral feeding or weight gain/growth. No studies reported data on pulmonary health. Methodological quality varied greatly. NNS alone and with oral/perioral stimulation showed strong positive findings for improvement in some feeding/swallowing physiology variables and for reducing transition time to oral feeding. Prefeeding stimulation showed equivocal results across the targeted outcomes. None of the OMIs provided consistent positive results on weight gain/growth.

CONCLUSIONS

Although some OMIs show promise for enhancing feeding/swallowing in preterm infants, methodological limitations and variations in results across studies warrant careful consideration of their clinical use.

Guidelines for bottle feeding your premature baby

Prolonged use of gavage feedings is common in premature infants who have not yet acquired suck, swallow, and breathing coordination. Preterm infants must be developmentally mature to orally feed successfully. Als' Synactive Theory of Development offers a conceptual framework to facilitate understanding of how premature infants dynamically differentiate to attain developmental milestones such as oral feeding. Key clinical implications for neonatal nurses are contingent upon incorporating evidence-based research into practice and providing consistent quality care to improve feeding outcomes.