Multiple factors related to bottle-feeding performance in preterm infants

Factors associated with feeding problems in bottle-fed preterm infants: A descriptive cross-sectional study

BACKGROUND

The feeding problems of preterm infants often persist after neonatal intensive care unit discharge. Further evidence on the feeding problems preterm infants experience after hospital discharge is needed to better serve this vulnerable population. This study aimed to identify infant-related factors associated with bottle-feeding problems in preterm infants before the age of 7 months.

MATERIALS AND METHODS

This descriptive and cross-sectional study included 338 mothers of preterm infants younger than 7 months of corrected age between April 2023 and April 2024. Mothers completed a survey that included infant and mother information form and Turkish version of the NeoEAT-Bottle-feeding assessment tool.

RESULTS

Very and moderately preterm infants exhibited more problematic feeding symptoms according to NeoEAT-Bottle-feeding total scale and all subscale scores compared with late preterm infants (P < 0.05). Gestational age at birth was negatively correlated with NeoEAT-Bottle-feeding total scores (P = 0.001). Additionally, preterm infants with a diagnosed feeding problem had higher NeoEAT-Bottle-feeding total and subscale scores than those without (P < 0.01). In the multivariate regression analysis, very preterm status and presence of gastroesophageal reflux were predictors of higher NeoEAT-Bottle-feeding total and all subscale scores (P < 0.01), and moderately preterm status was associated with higher NeoEAT-Bottle-feeding total (P = 0.036) and infant regulation subscale scores (P = 0.001).

CONCLUSION

Very preterm and moderate preterm birth, gastroesophageal reflux, and diagnosed feeding disorders were associated with problematic feeding. Identifying preterm infants who have difficulty with bottle feeding can guide primary care interventions or referral to specialists to achieve more favorable long-term outcomes.

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.

Knowledge and Use of Paced Bottle-Feeding Among Mothers of Young Infants

OBJECTIVE

To describe mothers' awareness and use of paced bottle-feeding (PBF) and to investigate whether the use of PBF was associated with maternal characteristics and infant feeding practices.

METHODS

Cross-sectional, online survey. Participants were mothers of infants < 12 months of age (n = 197). Participants self-reported their awareness and use of PBF, demographic characteristics, and infant feeding practices.

RESULTS

Of the 41% of participants who indicated they had or maybe had heard of PBF, 23% used PBF and 35% sometimes used PBF. Use of PBF was not associated with mother or infant characteristics. Participants who used PBF were significantly less likely to encourage their infant to finish the bottle (odds ratio, 0.04; 95% confidence interval, 0.01-0.79).

CONCLUSIONS AND IMPLICATIONS

Paced bottle-feeding was associated with lower likelihood of one dimension of pressuring feeding practices, encouraging infant bottle-emptying. More research is needed to determine the effectiveness of PBF in promoting healthy feeding outcomes.

Higher Dose Noninvasive Transcutaneous Auricular Vagus Nerve Stimulation Increases Feeding Volumes and White Matter Microstructural Complexity in Open-Label Study of Infants Slated for Gastrostomy Tube

OBJECTIVE

To determine whether transcutaneous auricular vagus nerve stimulation (taVNS) paired with twice daily bottle feeding increases the volume of oral feeds and white matter neuroplasticity in term-age-equivalent infants failing oral feeds and determined to need a gastrostomy tube.

STUDY DESIGN

In this prospective, open-label study, 21 infants received taVNS paired with 2 bottle feeds for 2 - 3 weeks (2x). We compared 1) increase oral feeding volumes with 2x taVNS and previously reported once daily taVNS (1x) to determine a dose response, 2) number of infants who attained full oral feeding volumes, and 3) diffusional kurtosis imaging and magnetic resonance spectroscopy before and after treatment by paired t tests.

RESULTS

All 2x taVNS treated infants significantly increased their feeding volumes compared with 10 days before treatment. Over 50% of 2x taVNS infants achieved full oral feeds but in a shorter time than 1x cohort (median 7 days [2x], 12.5 days [1x], P < .05). Infants attaining full oral feeds showed greater increase in radial kurtosis in the right corticospinal tract at the cerebellar peduncle and external capsule. Notably, 75% of infants of diabetic mothers failed full oral feeds, and their glutathione concentrations in the basal ganglia, a measure of central nervous system oxidative stress, were significantly associated with feeding outcome.

CONCLUSIONS

In infants with feeding difficulty, increasing the number of daily taVNS-paired feeding sessions to twice-daily significantly accelerates response time but not the overall response rate of treatment. taVNS was associated with white matter motor tract plasticity in infants able to attain full oral feeds.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT04643808).

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.

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.

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.

Turkish Neonatal Nurses' Knowledge and Practices Regarding the Transition to Oral Feeding in Preterm Infants: A Descriptive, Cross-sectional Study

PURPOSE

Neonatal nurses play an important role in preterm infants' safe and successful transition to oral feeding. Little is known about neonatal nurses' knowledge and practices regarding the transition to oral feeding in preterm infants. The aim of this study was to determine neonatal nurses' knowledge levels and clinical practices related to the process of transitioning preterm infants to oral feeding.

DESIGN AND METHOD

This descriptive cross-sectional study was conducted with 275 neonatal nurses working in the neonatal intensive care units of 9 different hospitals in Istanbul, Turkey. Data were collected using a participant demographic form and a questionnaire about the neonatal nurses' knowledge and practices regarding oral feeding.

RESULTS

The mean knowledge score of the nurses in this study was 64.7 out of 100 (SD = ±8.7; range = 40-87.5). Rates of correct responses were particularly low for items related to cue-based feeding, interventions to promote oral-motor development, non-nutritive sucking, and infant positioning for oral feeding. All of the NICU nurses participating in the study did not use the protocols developed for transitioning preterm infants to oral feeding.

CONCLUSIONS

Nurses need knowledge and practical training on evidence-based therapeutic interventions that promote oral feeding skills in preterm infants during the transition to oral feeding. The use of protocols developed for transitioning preterm infants to oral feeding is limited in NICUs.

PRACTICE IMPLICATIONS

In order to facilitate safe and successful feeding, nurses should improve their knowledge and practical skills regarding the transition to oral feeding and evidence-based therapeutic interventions for preterm infants.

Transcutaneous Auricular Vagus Nerve Stimulation-Paired Rehabilitation for Oromotor Feeding Problems in Newborns: An Open-Label Pilot Study

Neonates born premature or who suffer brain injury at birth often have oral feeding dysfunction and do not meet oral intake requirements needed for discharge. Low oral intake volumes result in extended stays in the hospital (>2 months) and can lead to surgical implant and explant of a gastrostomy tube (G-tube). Prior work suggests pairing vagus nerve stimulation (VNS) with motor activity accelerates functional improvements after stroke, and transcutaneous auricular VNS (taVNS) has emerged as promising noninvasive form of VNS. Pairing taVNS with bottle-feeding rehabilitation may improve oromotor coordination and lead to improved oral intake volumes, ultimately avoiding the need for G-tube placement. We investigated whether taVNS paired with oromotor rehabilitation is tolerable and safe and facilitates motor learning in infants who have failed oral feeding. We enrolled 14 infants [11 premature and 3 hypoxic-ischemic encephalopathy (HIE)] who were slated for G-tube placement in a prospective, open-label study of taVNS-paired rehabilitation to increase feeding volumes. Once-daily taVNS was delivered to the left tragus during bottle feeding for 2 weeks, with optional extension. The primary outcome was attainment of oral feeding volumes and weight gain adequate for discharge without G-tube while also monitoring discomfort and heart rate (HR) as safety outcomes. We observed no adverse events related to stimulation, and stimulation-induced HR reductions were transient and safe and likely confirmed vagal engagement. Eight of 14 participants (57%) achieved adequate feeding volumes for discharge without G-tube (mean treatment length: 16 ± 6 days). We observed significant increases in feeding volume trajectories in responders compared with pre-stimulation (p < 0.05). taVNS-paired feeding rehabilitation appears safe and may improve oral feeding in infants with oromotor dyscoordination, increasing the rate of discharge without G-tube, warranting larger controlled trials.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

Full oral feeding is possible before discharge even in extremely preterm infants

AIM

This study described the steps needed to achieve full oral feeding before discharge in a group of very and extremely preterm (EPT) infants. We analysed the effects of oral feeding skills on discharge timing and on weight gain during their neonatal intensive care unit (NICU) stay.

METHODS

A prospective cross-sectional observational study of 100 infants who were <32 weeks of gestation (GA) was conducted at the Division of Neonatology, Graz, Austria, from March 2014 to February 2015. Patients were stratified into two groups: those who were <28 weeks at birth and those who were 28 weeks and over. Velocity of oral feeding skills attainment and weight gain were analysed.

RESULTS

All infants successfully acquired oral feeding skills during hospitalisation. The median GA at which full oral feeding skills were reached was 37 + 1 weeks in EPT and 34 + 5 weeks in very preterm infants. More immature neonates showed worse feeding performances and lower weight increments during oral feeding steps.

CONCLUSION

Our study confirmed the role of GA in the development of oral feeding skills in the most premature babies. It also raises the question of whether expected daily weight gain should be targeted according to GA.

Predictors and outcomes of the Neonatal Oral Motor Assessment Scale (NOMAS) performance: a systematic review

The NOMAS is by far the most used tool to screen early oral-motor skills in newborns. Here we provide an updated review of scientific literature on the use of the Neonatal Oral Motor Assessment Scale (NOMAS) to screen early oral-motor skills in newborns. An integrative review has been carried out consistent with PRISMA guidelines and standardized qualitative appraisal. Data abstracting and synthesis were executed by two independent co-authors who solved disagreement in conference. Twenty records have been included and reviewed. The efficacy of the NOMAS in screening and identifying precocious oral-motor skills received inconsistent support. Moderate validity and low reliability emerged. Moreover, despite the NOMAS' adequately screen efficient and inefficient feeders, limited evidence emerged for predictive value of NOMAS score on feeding and psychomotor developmental trajectories during the first 2 years of age.

CONCLUSION

The present review highlights benefits and limitations of the NOMAS. Future research is needed to develop observational and clinically-relevant tools to better identify newborns which are at lower- and higher-risk of developing less-than-optimal feeding behaviors and to guide with greater precision the diagnostic and therapeutic journey of these newborns. What is Known: • The assessment of oral-motor skills in newborns and infants is critical for early intervention • The NOMAS is the most adopted tool to assess oral-motor skills in newborns and infants What is New: • The ability of the NOMAS to target newborn at risk for feeding disorders is confirmed • Nonetheless, the capacity to predict long-term developmental outcomes is limited.

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

PURPOSE

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

DESIGN AND METHODS

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

RESULTS

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

PRACTICE IMPLICATIONS

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

The Functional Evaluation of Eating Difficulties Scale: Study Protocol and Validation in Infants with Neurodevelopmental Impairments and Disabilities

INTRODUCTION

A reliable and accurate evaluation of oral-motor skills in newborns at risk for swallowing and feeding disorders is key to set the goals of effective early interventions. Although many tools are available to assess oral-motor skills in newborns, limited evidence exists for what pertains their reliability and their effectivity in predicting short- and long-term developmental outcomes in at-risk infants. The aim of the present study is to develop and provide a preliminary validation of a new clinically grounded tool [i.e., the Functional Evaluation of Eating Difficulties Scale (FEEDS)] specifically designed to be used with at-risk newborns and infants. The paper describes the steps of tool development and information on the reliability of the tool are provided.

METHODS/ANALYSIS

The FEEDS has been developed according to clinical evidence and expertise by a multidisciplinary team of professionals dealing with feeding problems in at-risk infants diagnosed with neurodevelopmental impairments and disabilities. The steps of FEEDS development are reported, together with a detailed description of items, scoring procedure, and clinical cutoff. The FEEDS has been applied to a relatively large sample of 0- to 12-month-old infants (N = 136) with neurodevelopmental disability, enrolled consecutively between 2004 and 2016 at the Scientific Institute IRCCS Eugenio Medea (Bosisio Parini, Italy), which is the main rehabilitation hospital for children with neurodevelopmental disabilities in Italy. Internal consistency (Cronbach's alpha) and reliability (inter-rater agreement) have been assessed.

ETHICS AND DISSEMINATION

All the procedures are consistent with the World Medical Association Declaration of Helsinki (2013) and the FEEDS has been approved by the clinical committee of the Scientific Institute IRCCS Eugenio Medea. Further psychometric characteristics and evidence of the predictive validity of the FEEDS will be obtained on a larger sample and they will be reported in future publications from this group.

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.

Neurodevelopmental Profile, Growth, and Psychosocial Environment of Preterm Infants with Difficult Feeding Behavior at Age 2 Years

OBJECTIVE

To examine the association of difficult feeding behaviors in very preterm infants at age 2 years with growth and neurodevelopmental outcomes and family factors and functioning.

STUDY DESIGN

Eighty children born ≤30 weeks gestation were studied from birth until age 2 years. Feeding difficulties were assessed using the Eating Subscale of the Infant-Toddler Social Emotional Assessment at age 2 years, along with growth measurement and developmental testing. Maternal mental health and family factors were assessed using standardized questionnaires. ANOVA and χ(2) analyses were performed to determine associations between feeding difficulties and growth, neurodevelopmental outcomes, and family characteristics.

RESULTS

Twenty-one children (26%) were at risk for feeding difficulties, and an additional 18 (23%) had definite feeding difficulties at age 2 years. Those with feeding difficulties were more likely to be subject to a range of neurodevelopmental problems, including impaired cognition (P = .02), language (P = .04), motor (P = .01), and socioemotional (P < .007) skills. Compared with the parents of children with fewer feeding difficulties, parents of the children with feeding difficulties had higher parenting stress (P = .02) and reported more difficulty managing their child's behavior (P = .002) and more frequent parent-child interaction problems (P = .002). No associations were found between difficult feeding behaviors and growth, maternal mental health, or family factors.

CONCLUSION

Difficult feeding behaviors in children born very preterm appear to be highly comorbid with other developmental and family challenges, including neurodevelopmental impairment and parent-child interaction difficulties. Focusing on improving feeding skills, in conjunction with supporting positive parent-child interactions, may be beneficial for improving outcomes.

Oral Motor Intervention Improved the Oral Feeding in Preterm Infants: Evidence Based on a Meta-Analysis With Trial Sequential Analysis

Oral feeding for preterm infants has been a thorny problem worldwide. To improve the efficacy of oral feeding in preterm infants, oral motor intervention (OMI), which consists of nonnutritive sucking, oral stimulation, and oral support, was developed. Published studies demonstrated that OMI may be as an alternative treatment to solve this problem; however, these results remain controversial. We conducted a meta-analysis with trial sequential analysis (TSA) to objectively evaluate the potential of OMI for improving the current status of oral feeding in preterm infants.A search of PubMed, EMBASE, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure was performed to capture relevant citations until at the end of October, 2014. Lists of references of eligible studies and reviews were also hand-checked to include any latent studies. Two independent investigators screened literature, extracted data, and assessed the methodology, and then a meta-analysis and TSA was performed by using Reviewer Manager (RevMan) 5.3 and TSA 0.9 beta, respectively.A total of 11 randomized controlled trials (RCTs), which included 855 participants, were incorporated into our meta-analysis. The meta-analyses suggested that OMI is associated with the reduced transition time (ie, the time needed from tube feeding to totally oral feeding) (mean difference [MD], -4.03; 95% confidence interval [CI], -5.22 to -2.84), shorten hospital stays (MD, -3.64; 95% CI, -5.57 to -1.71), increased feeding efficiency (MD, 0.08; 95% CI, 0.36-1.27), and intake of milk (MD, 0.14; 95% CI, 0.06-0.21) rather than weight gain. Results of TSA for each outcomes of interest confirmed these pooled results.With present evidences, OMI can be as an alternative to improve the condition of transition time, length of hospital stays, feeding efficiency, and intake of milk in preterm infants. However, the pooled results may be impaired due to low quality included, and thus, well-designed and large RCTs were needed to further established effects.

Preterm newborn readiness for oral feeding: systematic review and meta-analysis

PURPOSE: To identify and systematize the main studies on the transition from enteral to oral feeding in preterm infants. RESEARCH STRATEGY: Articles that describe the transition from oral to enteral feeding in preterm infants were located in MEDLINE, LILACS, and SciELO databases. SELECTION CRITERIA: Original studies, with available abstract, published in the last 10 years were included. DATA ANALYSIS: Analysis of the methodology and the main results of the studies, and meta-analysis of the effects of sensory-motor-oral stimulation at the time of transition to full oral feeding and duration of hospitalization were conducted. RESULTS: Twenty-nine national and international publications were considered. Most studies were clinical trials (44.8%) and did not use rating scales to start the transition process (82.7%). In the meta-analysis, positive effect of stimulation of the sensory-motor-oral system was observed with respect to the transition time to oral diet (p=0.0000), but not in relation to the length of hospital stay (p=0.09). However, heterogeneity between studies was found both in the analysis of the transition time to full oral feeding (I2=93.98) and in the length of hospital stay (I2=82.30). CONCLUSION: The transition to oral feeding is an important moment, and various physical and clinical characteristics of preterm infants have been used to describe this process. Despite the impossibility of generalizing the results due to the heterogeneity of the studies, we have noted the importance of strategies for stimulation of sensory-motor-oral system to decrease the period of transition to full oral feeding system.

Missed oral feeding opportunities and preterm infants' time to achieve full oral feedings and neonatal intensive care unit discharge

OBJECTIVE

To examine the association of missed oral feeding opportunities among preterm infants with achievement of full oral feedings and length of hospitalization.

STUDY DESIGN

A secondary analysis of clinical trial data was conducted. Study infants included in the analysis (N = 89) were randomized to one of four standardized feeding progression approaches; detailed records on all feedings were maintained. The proportion of oral feeding opportunities reported as missed due to factors unrelated to the infant's clinical condition was calculated for each infant.

RESULTS

The proportion of missed oral feeding opportunities per infant ranged from 0 to 0.12; 30 infants experienced one or more missed oral feeding opportunity. Each 1% increase in the proportion of missed oral feeding opportunities extended the time to achieve full oral feeding by 1.45 days (p = 0.007) and time to discharge by 1.36 days (p = 0.047).

CONCLUSION

Preterm infants' missed oral feeding opportunities may adversely affect feeding outcomes and extend hospitalization.

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.

Factors associated with feeding difficulties in the very preterm infant

AIM

To investigate early medical and family factors associated with later feeding risk in preterm infants.

METHODS

For this longitudinal study, 136 infants born ≤30 weeks gestation were enrolled. Medical and social background factors were assessed at term equivalent age. Infants underwent magnetic resonance imaging, neurobehavioral evaluation and feeding assessment. Parent involvement in the neonatal intensive care unit was tracked, and maternal mental health was assessed at neonatal intensive care unit discharge. At age 2 years, feeding outcome was assessed using the Eating Subscale of the Infant-Toddler Social Emotional Assessment (n = 80). Associations between feeding problems at age 2 years and (i) early medical factors, (ii) neurobehavioral functioning and feeding at term equivalent age, (iii) cerebral structure and (iv) maternal mental health were investigated using regression.

RESULTS

Eighteen (23%) children had feeding problems at age 2 years. Feeding problems were associated with early hypotonia (p = 0.03; β = 0.29) and lower socio-economic status (p = 0.046; β = -0.22). No associations were observed between early medical factors, early feeding performance, cerebral structure alterations or maternal well-being and feeding outcome.

CONCLUSION

Early hypotonia may disrupt the development of oral-motor skills. Hypotonia and poor feeding also may share a common aetiology. Associations with lower socio-economic status highlight the potential influence of family background factors in feeding problems in the preterm infant.

Evaluating sucking maturation using two pressure thresholds

BACKGROUND

The Medoff-Cooper Nutritive Sucking Apparatus (M-CNSA) has been used to objectively measure sucking maturation in preterm infants. The M-CNSA is able to accurately detect sucking pressures less than 20mmHg, however lower pressure thresholds have not previously been used in research.

AIMS

To determine if differences are observed in the number of sucks and maturation in the number of sucks over time when the minimum pressure threshold used to detect a suck is 7mmHg compared to 20mmHg using the M-CNSA.

STUDY DESIGN

Descriptive.

SUBJECTS

A convenience sample of 171 healthy premature infants born between 29 and 34weeks gestational period who were part of a larger randomized controlled study.

OUTCOME MEASURES

The number of sucks detected during weekly five-minute oral feeding observations using 7mmHg and 20mmHg.

RESULTS

Significantly more sucks were detected using the 7mmHg vs 20mmHg threshold at all time points. At both pressure thresholds, the mean number of sucks detected during the five minute feeding observation increased over time. The difference in the number of sucks detected at 7 and 20mmHg did not change over time (p=0.50).

CONCLUSIONS

Using the lower threshold of 7mmHg compared to 20mmHg resulted in more sucks detected while consistently measuring improvement in sucking over time. Detection of more sucks and sucks at a lower pressure threshold allows clinicians and researchers to more accurately assess oral feeding skills among premature infants.

Exploring factors related to oral feeding progression in premature infants

PURPOSE

To identify infant and maternal characteristics associated with the pace of progression from the first oral feeding to complete oral feeding.

SUBJECTS

One hundred forty-two stable premature infants who were fully or partially gavage feeding immediately after birth (29 to 34 weeks gestational age at birth).

DESIGN

Exploratory secondary analysis.

METHODS

Data are from an ongoing randomized clinical trial of a developmental maternally administered intervention (Hospital to Home Transition-Optimizing Premature Infant's Environment) for mother-infant dyads at high social-environmental risk.

MAIN OUTCOME MEASURES

Oral feeding progression (transition time from the first attempt to complete oral feeding).

SAMPLE CHARACTERISTICS

The convenience sample of preterm infants consisted of 48.6% male infants; the mean gestational age at birth was 32.4 weeks and mean birth weight 1787 g; and African American mothers (47.9%; n = 80) and Latina mothers (52.1%; n = 83).

PRINCIPLE RESULTS

Multivariable linear regression results showed that, on average, the number of days for infants of Latina mothers to achieve complete oral feeding was 2.43 days more than for infants of African American mothers. In addition, lower birth weight and lower postmenstrual age at first oral feeding were associated with longer feeding progression. Higher infant morbidity was correlated with longer feeding progression.

CONCLUSION

Infants with Latina mothers, lower birth weight, lower postmenstrual age at first oral feeding, and higher morbidity scores had a longer transition from first to complete oral feeding. Identification of infants at risk for delayed transition from first to complete oral feeding may allow for the development and testing of appropriate interventions that support the transition from gavage to complete oral feeding.

Lack of feeding progression in a preterm infant: a case study

The purpose of this article was to present the case of a premature infant who displayed immature feeding progression because of nasal occlusion. Two male preterm infants of 33 weeks' gestational age at birth from a larger randomized trial were observed in a comparative case study. Using a prospective design, feeding assessments were conducted weekly from initiation of oral feeding until hospital discharge. Sucking organization was measured using the Medoff-Cooper Nutritive Sucking Apparatus (M-CNSA), which measured negative sucking pressure generated during oral feedings. Oral and nasogastric (NG) intake and vital signs were recorded. At 35 weeks, infant A demonstrated an immature feeding pattern with the M-CNSA NG feedings prevailing over oral feedings. When attempting to feed orally, infant A exhibited labored breathing and an erratic sucking pattern. During the third weekly feeding evaluation, nasal occlusion was discovered, the NG tube was discontinued, and phenylephrine (Neo-Synephrine) and humidified air were administered. Following treatment, infant A's sucking pattern normalized and the infant maintained complete oral feeding. Infant B demonstrated normal feeding progression. Nasal occlusion prevented infant A from achieving successful oral feeding. The M-CNSA has the ability to help clinicians detect inconsistencies in the sucking patterns of infants and objectively measures patterns of nutritive sucking. The M-CNSA has the potential to influence clinical decision making and identify the need for intervention.

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.

Physical therapy observation and assessment in the neonatal intensive care unit

This article presents the elements of the Observation and Assessment section of the Infant Care Path for Physical Therapy in the Neonatal Intensive Care Unit (NICU). The types of physical therapy assessments presented in this path are evidence-based and the suggested timing of these assessments is primarily based on practice knowledge from expert therapists, with supporting evidence cited. Assessment in the NICU begins with a thorough review of the health care record. Assessment proceeds by using the least invasive methods of gathering the behavioral, developmental, physiologic, and musculoskeletal information needed to implement a physical therapy plan of care. As the neonate matures and can better tolerate handling, assessment methods include lengthier standardized tests with the psychometric properties needed for informing diagnosis and intervention planning. Standardized tests and measures for screening, diagnosis, and developmental assessment are appraised and special considerations for assessment of neonates in the NICU are discussed.

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.

[Breast feeding rates and factors influencing breast feeding practice in late preterm infants: comparison with preterm born at less than 34 weeks of gestational age]

PURPOSE

This study was done to compare breast feeding rates and factors influencing feeding practice between late preterm (34 ≤ GA < 37) and preterm infants (GA<34).

METHODS

A survey was done of 207 late preterm and 117 preterm infants in neonatal intensive care units (NICU) of 4 university hospitals in D city. Data were collected from July 2009 to June 2010 from 324 medical records in the NICU. Breast-feeding at home was checked either by telephone survey or questioning during hospital visits.

RESULTS

Rate of breast feeding for late preterm infants was significantly lower than for preterm infants. There was no significant difference in breast-feeding at home. We found differences in factors influencing breast feeding between the two groups. Factors influencing feeding for late preterm infants were type of delivery, mothers' occupation, feeding type during hospitalization, time elapse from hospital discharge, total admission days, infant's body weight at first feeding and length of NPO (nothing by mouth). Factors influencing feeding for preterm infants were birth order, maternal disease and obstetric complications, and one-minute Apgar score.

CONCLUSION

Results of the study show low rates of breast-feeding for late preterm infants indicating a need for breast-feeding education for mothers of these infants.

Feeding Difficulties in Preterm Infants

Preterm infants often display difficulty establishing oral feeding in the weeks following birth. This article aims to provide an overview of the literature investigating the development of feeding skills in preterm infants, as well as of interventions aimed at assisting preterm infants to develop their feeding skills. Available research suggests that preterm infants born at a lower gestational age and/or with a greater degree of morbidity are most at risk of early feeding difficulties. Respiratory disease was identified as a particular risk factor. Mechanisms for feeding difficulty identified in the literature include immature or dysfunctional sucking skills and poor suck–swallow–breath coordination. Available evidence provides some support for therapy interventions aimed at improving feeding skills, as well as the use of restricted milk flow to assist with maintaining appropriate ventilation during feeds. Further research is needed to confirm these findings, as well as to answer remaining clinical questions.

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.

Avaliação de habilidades orais de crianças nascidas pré-termo

OBJETIVO: avaliar as habilidades orais de crianças nascidas pré-termo aos 4 e 6 meses de idade corrigida. MÉTODOS: foram avaliadas 14 crianças, nascidas com idade gestacional entre 29 e 35 semanas, no Ambulatório de Seguimento de Prematuros do Hospital Universitário de Santa Maria, no estado do Rio Grande do Sul. A avaliação aos 4 e 6 meses de idade corrigida compreendeu movimentos de língua, lábios e mandíbula durante a utilização da mamadeira ou seio, sendo que aos 6 meses também foi avaliado a retirada do alimento pastoso da colher, o uso do copo, e a mascagem com bolacha. Todas as avaliações foram filmadas e analisadas por 3 fonoaudiólogas. Um questionário sobre os hábitos alimentares das crianças foi respondido pelos pais. RESULTADOS: aos 4 e 6 meses o vedamento labial adequado foi observado em 71,4% e 85,7%, respectivamente. Aos 6 meses em 78,6% das crianças o lábio superior retirou de forma eficiente o alimento pastoso da colher, 42,9% conseguiram sorver o líquido do copo de forma adequada e 57,1% tiveram dificuldade no uso do copo. CONCLUSÃO: neste estudo, as crianças que nasceram prematuras aos 4 e 6 meses de idade corrigida apresentaram desenvolvimento das habilidades orais em uma seqüência progressiva, no entanto apresentaram comprometimento do vedamento labial durante a sucção e dificuldades no uso da colher e do copo para sua alimentação.

Análise da produção científica acerca da atenção ao recém-nascido de baixo peso em UTI

O objetivo deste estudo foi analisar a natureza e tendência dos artigos na temática saúde do recém nascido de baixo peso. Trata-se de uma revisão integrativa desenvolvida em agosto de 2009, a partir dos descritores: "recém-nascido de baixo peso" or "recém-nascido de muito baixo peso" and "unidades de terapia intensiva neonatal", no recorte temporal 1990-2008. A amostra de 608 resumos foi submetida à análise de conteúdo temática. Nos resultados, os estudos de natureza clínico-epidemiológica contemplam os fatores de risco do baixo peso e morbimortalidade neonatal e os de tendência assistencial contribuem com as rotinas e cuidados prestados. Evidenciam-se os avanços na atenção a saúde do recém-nascido, a complexidade clínica e as implicações para sua assistência. Destaca-se a lacuna de pesquisas que aponte a subjetividade, o apoio e a inclusão das famílias nos cuidados e no enfrentamento dessa situação.

Impact of prematurity and co-morbidities on feeding milestones in neonates: a retrospective study

OBJECTIVE

Feeding problems are an important area of neonatal morbidity that requires attention. We defined the feeding milestones related to transition to per oral feeding among premature infants based on gestational (GA) and postmenstrual ages (PMA), and elucidated the co-morbidity variables affecting with these skills.

STUDY DESIGN

Feeding progress was tracked during the first hospitalization in a retrospective study involving 186 infants. We measured the age at acquisition of first feedings, maximum gavage feedings and maximum oral feedings. Resource usage measures included the total length of hospital stay (LOS), duration of gavage tube and duration of respiratory support. Effects of perinatal and co-morbidity factors on the acquisition of feeding milestones were evaluated. ANOVA, t-test, Wilcoxon rank sum test, chi(2) test, univariate and multivariate analysis, stepwise linear regression analysis and logistic regression analysis were applied as appropriate. Data were presented as mean+/-s.d., or as stated. P<0.05 was considered significant.

RESULT

We stratified the data into three groups based on GA at birth: <28.0 weeks (group-1), 28.0 to 32.0 weeks (group-2) and 32.0 to 35.0 weeks (group-3). Compared with group-3, group-1 needed four-fold more ventilation and five-fold more continuous positive airway pressure (CPAP) duration (all P<0.001); whereas group-2 needed two-fold more CPAP duration. Age at first feed correlated with age at full gavage feedings and age at full oral feedings (r=0.53 and r=0.71, both P<0.0001). Age at full gavage feedings correlated with age at full oral feedings (r=0.81, P<0.0001). Univariate analysis was significant for GA age, hypotension, the effects of gastroesophageal reflux, and duration of ventilation and CPAP on the PMA at maximal oral feedings (all P<0.05); multivariate analysis for these variables was also significant (R (2)=0.58, P<0.0001). The success rate for oral feedings at discharge accelerated with GA maturation and caffeine use; on the other hand, the need for respiratory support and management of positive blood culture were associated with failure rates (P<0.05).

CONCLUSION

Infants < 28 weeks GA have significant feeding delays with respect to initiation and progression to maximal gavage and oral feedings, as well as prolonged LOS. Infants >28 weeks GA attained successful feeding milestones by similar PMA. Specific aero-digestive co-morbidities significantly affected maximal oral feeding milestone. Delays in achieving maximum gavage and maximum oral feeding milestones suggest delays with the development of control and regulation of foregut motility.

Os efeitos da estimulação sensório motora oral na sucção nutritiva na mamadeira de recém-nascidos pré-termo

OBJETIVO: verificar o desempenho da sucção nutritiva, na mamadeira, em recém-nascidos pré-termo submetidos à estimulação sensório-motora-oral. MÉTODOS: pesquisa do tipo ensaio clínico controlado de intervenção. 20 recém-nascidos pré-termo foram distribuídos em grupo estimulado e grupo controle. Estes grupos foram submetidos à avaliação fonoaudiológica em dois diferentes momentos: na liberação da alimentação por via oral; e quando atingiam alimentação plena por via oral num período de 24 horas. As avaliações foram filmadas, e os resultados foram analisados pela pesquisadora. Para análise dos dados utilizou-se o Teste exato de Fishe r e o Teste "T" de Studen t do software estatístico STATA 10.0. Considerou-se p < 0,05. RESULTADOS: recém-nascidos do grupo estimulado, na segunda avaliação, apresentaram resultados com diferença estatística significante quanto a força de sucção forte (p=0,003), presença dos três reflexos adaptativos (p=0,001), coordenação da sucção/deglutição/respiração (p=0,003), no tempo total de sucções (p=0,01) e na frequência de sucção (p<0,01). O número total de sucções apresentou diferença estatística significante (p<0,05) entre as avaliações do grupo controle. Quanto ao ritmo e a relação entre o volume de leite prescrito e ingerido não apresentou resultados com diferença estatística significante. CONCLUSÃO: a estimulação sensório-motora oral parece favorecer o desempenho nas funções de sucção nutritiva de recém-nascidos pré-termo.

Avaliação da estimulação sensório-motora-oral na transição da alimentação enteral para a via oral plena em recém-nascidos pré-termo

OBJETIVOS: avaliar a influência da estimulação sensório-motora-oral (SMO) sobre o ganho de peso, tempo para realizar a transição da sonda para a via oral e, indiretamente, sobre a alta hospitalar de pré-termos. MÉTODOS: estudo de intervenção, do tipo ensaio clínico controlado, que incluiu 24 pré-termos, internados na UTI Neonatal do Hospital Universitário de Santa Maria, Rio Grande do Sul, Brasil, entre maio de 2007 e março de 2008, alocados, por sorteio, em grupo estimulado (GE) e controle (GC). A análise das diferenças entre os grupos foi testada utilizando o teste t-Student independente e exato de Fisher (valor de p<0,05). RESULTADOS: não houve diferença estatística para as medidas antropométricas, embora o incremento diário de peso tenha sido maior no GE (p=0,16). O GE realizou a transição completa da sonda para a via oral em média 1,6 dias antes que o GC, sendo que 83,3% das crianças do GE fizeram essa transição em até sete dias, enquanto apenas 38,9% do GC alcançaram esse prazo. Não houve diferença no tempo de permanência hospitalar entre os grupos (p=0,48). CONCLUSÕES: a estimulação SMO favoreceu uma transição mais rápida da sonda para a via oral, não comprometendo o ganho de peso de recém-nascidos pré-termo. Não foi possível observar sua influência sobre o tempo de permanência hospitalar.

Outcomes From an Oral Feeding Protocol Implemented in the NICU

The purpose of this study was to compare the clinical outcomes of 2 different oral feeding protocols. The old protocol advanced oral feedings based on established feeding times, whereas the new evidenced-based protocol advanced oral feedings using infant cues. This retrospective study, conducted by reviewing the charts of premature infants born less than or at 34 weeks' gestation, documented the differences between the 2 oral feeding protocols. The medical records were reviewed for 200 premature infants admitted to the neonatal intensive care unit at Children's Hospital of Illinois, Peoria, Illinois. The main outcome variables this study compared were when infants started oral feedings, time to achieve 50% and 100% feedings orally, weight at time of oral feeding, day of life, and postmenstrual age. The percentage of feedings when oral stimulation was ordered, frequency of feeding therapy consultations, length of stay, weight at the time of discharge, and postmenstrual age at the time of discharge were also compared. Infants participating in the new feeding protocol began oral feedings at an earlier postmenstrual age as compared to infants using the old feeding protocol. Participants enrolled in this new protocol did not experience adverse events. They were also able to progress to full oral feedings while maintaining adequate weight, had less need for feeding therapy consultations, and length of stay was not prolonged.

Psychometric characteristics of the Neonatal Oral-Motor Assessment Scale in healthy preterm infants

We examined the reliability, validity, and responsiveness of the Neonatal Oral-Motor Assessment Scale (NOMAS) in healthy preterm infants. Feeding records of 147 infants (71 males, 76 females; gestational age [GA] <or= 36 wks), taken from the day bottle-feeding was initiated to the day the infants were discharged, were used to examine the psychometric properties of the normal and disorganized categories of the NOMAS. The infants, with or without experience of breastfeeding, were all fed by bottle, with either formula and/or breast milk. GA ranged from 24 to 35.9 weeks (mean 29.7 wks, SD 2.7) and birthweight ranged from 470 g to 2570 g (mean 1251.1g, SD 425.9). Postmenstrual age (PMA) at the starting point of bottle-feeding ranged from 29.4 to 40.1 weeks (mean 33.8 wks, SD 1.7). We found that the NOMAS had satisfactory internal consistency (Cronbach's alpha >0.70) in the normal category for 32 to 35 weeks'PMA. Moderate correlations were found between scores on the NOMAS and feeding performance for all age groups except for PMA of >or= 36 weeks (absolute Spearman's r(s)=0.51-0.69), indicating acceptable convergent validity. The NOMAS demonstrated moderate responsiveness to changes in oral-motor skills in every 2-week period, ranging from 32 to 36 weeks'PMA (standard response mean greater than 0.5). This study demonstrated that the normal and disorganized categories of the NOMAS are useful, with acceptable psychometric properties, in assessing oral-motor function in preterm infants aged 32 to 35 weeks'PMA. Future research on infants with abnormal oral-motor skills is needed to further validate psychometric properties of the dysfunction category of the NOMAS.