Does the Infant-Driven Feeding Method Positively Impact Preterm Infant Feeding Outcomes?

Effects of Infant Driven Feeding Program on Provision of Breast Milk in Very Low Birth Weight Infants

Background: The ability to complete nipple feedings is one of the discharge criteria for most premature neonates. The Infant Driven Feeding (IDF) program suggests a system of objective promotion of oral feeds in premature infants. There is a lack of studies systematically studying the effects of IDF on the provision of breast milk. Methods: This was a retrospective study of all premature infants born before 33 weeks and birth weight of <1,500 g admitted to a level IV neonatal intensive care unit. Infants on IDF were compared with those not on IDF. Results: A total of 46 infants in the IDF group and 52 in the non-IDF group met the inclusion criteria. A higher number of infants in the IDF group breastfed at first oral attempt (54% versus 12%). Forty-five percent of IDF mothers completed a full 72 hours of protected breastfeeding at the start of oral feeds, and IDF infants had earlier removal of nasogastric (NG) tube. There was no difference in the provision of breast milk and/or breastfeeding on discharge between the two groups. There was no difference in the length of stay between the two groups. Conclusion: The IDF program attempts to streamline the promotion of oral feeds in very low birth weight infants. Higher incidence of breastfeeding at the start of oral feeds and earlier removal of NG tube did not translate into higher provision of breast milk on discharge in very low birth weight infants in the IDF group. Prospective randomized trials are needed to validate cue-based infant driven feeding programs and their effects on the provision of breast milk.

Implementing an Evidence-Based Feeding Protocol: Impact on Nurses' Knowledge, Perceptions, and Feeding Culture in the NICU

BACKGROUND

Evidence-based feeding practices are often variable among neonatal providers due to lack of knowledge and neonatal intensive care unit (NICU) feeding culture norms.

PURPOSE

To evaluate changes in NICU nurses' knowledge, perceptions, feeding practices and culture following education about, and implementation of, an evidence-based Infant-Driven Feeding (IDF) protocol.

METHODS

A pre-/postprospective comparative design was used to survey 120 registered nurses employed in a level 3 NICU about feeding practices, knowledge, and culture prior to IDF education and 1 to 2 months after IDF implementation.

RESULTS

The preeducation survey yielded 59 respondents; of these, 30 responded to the same survey after IDF implementation. Postimplementation responses were significant for fewer nurses making decisions to begin oral feedings ( P = .035), greater use of gestational age to increase frequency of oral feeding attempts ( P = .03), less reliance on weight loss to decrease oral feeding attempts ( P = .018), an increase in use of combination interventions to prepare infants for oral feeding ( P = .001), and greater willingness to allow a rest period or stop the feeding if an infant falls asleep after completing 70% of the feeding ( P = .03).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Trends in several survey categories following the education program and implementation of IDF support the use of evidence-based practices (EBPs) such as IDF. Future research focused on nurses' perceptions of how education influences integration of specific EBPs into practice is needed. Evaluating EBP mentorship combined with education about EBPs can provide insights on how best to integrate EBPs into practice.

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.

Psychometric properties of the oral feeding assessment in premature infants scale

Professionals that work in neonatal units need to identify the strengths and weaknesses of the premature infant who is in the transition process from feeding through a gastric tube to oral feeding. The main aim of this study was to validate the Oral FEeding Assessment in premaTure INfants (OFEATINg) instrument. A psychometric validity and reliability study was conducted in Neonatal Intensive Care Units of two public, metropolitan, university hospitals. The study population were premature infants at a postconceptional age of 31-35 weeks. The study included evaluation of the reliability, convergent, discriminant and construct validity, sensitivity and specificity of the OFEATINg instrument. A total of 621 feedings of 56 preterm infants were evaluated. Confirmatory factor analysis identified 3 factors and 13 indicators with a good fit to the model. Cronbach's alpha coefficient was 0.78. The instrument showed high indices of inter-rater reliability (Pearson 0.9 and intraclass correlation coefficient 0.95). The OFEATINg scale is a valid and reliable instrument for evaluating the readiness for oral feeding of preterm infants. It may enable clinicians to evaluate the physiological and behavioral abilities involved in the oral feeding process and help them make decisions related to the transition to full oral feeding.Clinical trial registration: This study was prospectively registered at the two Institutional review boards.

Improving Time to Independent Oral Feeding to Expedite Hospital Discharge in Preterm Infants

BACKGROUND AND OBJECTIVES

Achievement of independent oral feedings remains the most common barrier to discharge in preterm infants. Early oral feeding initiation may be associated with a lower postmenstrual age (PMA) at independent oral feeding and discharge. In preterm infants born between 25 and 32 weeks' gestation, our aim was to decrease the PMA at independent oral feedings and discharge by 1 week between June 2019 and June 2020.

METHODS

Following formation of a multidisciplinary team, the following plan-do-study-act cycles were targeted: (1) oral feeding initiation at <33 weeks' PMA, (2) cue-based feeding, and (3) practitioner-driven feeding in infants who had not yet achieved independent oral feedings by 36 weeks' PMA. Outcome measures included the PMA at independent oral feeding and discharge. Process measures included adherence to cue-based feeding assessments and PMA at oral feeding initiation.

RESULTS

In total, 552 infants with a median gestational age of 30.3 weeks' (interquartile range 28.1-32.0) and birth weight of 1320 g (interquartile range 1019-1620) were included. The PMA at discharge decreased from 38.8 to 37.7 weeks during the first plan-do-study-act cycle, which coincided with an increase in the number of infants initiated on oral feeds at <33 weeks' PMA from 47% to 80%. The age at independent oral feeding decreased from 37.4 to 36.5 weeks' PMA.

CONCLUSIONS

In preterm infants born between 25 and 32 weeks' gestation, earlier oral feeding initiation was associated with a decreased PMA at independent oral feeding and discharge.

Disruptive Therapy Using a Nonsurgical Orthodontic Airway Plate for the Management of Neonatal Robin Sequence: 1-Year Follow-up

We recently published the 3-month follow-up of 2 neonates with Robin sequence whose mandibular hypoplasia and restricted airway were successfully treated with an orthodontic airway plate (OAP) without surgical intervention. Both infants were successfully weaned off the OAP after several months of continuous use. We present the course of OAP treatment in these patients with a focus on breathing, feeding, and facial growth during their first year of life. Both infants demonstrated stable mandibular projection, resolution of obstructive sleep apnea, and normal development.

Developing a Quality Improvement Feeding Program for NICU Patients

Practices in NICUs vary widely, particularly when clinical decisions involve complex tasks and multiple disciplines, which occurs with feeding preterm infants. Neonatal feeding difficulties in preterm infants often lead to prolonged tube feeding and therefore lengthened hospital stays. Education and compliance with evidence-based protocols and guidelines are needed on the initiation of feedings and feeding advancement to transform enteral and oral feeding practices and thus reduce practice variation and improve clinical outcomes.

Positive breastfeeding experiences and facilitators in mothers of preterm and low birthweight infants: a meta-ethnographic review

Background

Most qualitative research on breastfeeding the preterm or low-birthweight (LBW) infant has focused on negative insights; there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences. We aimed to address this knowledge gap by exploring what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants.

Methods

A systematic review using meta-ethnographic methods was conducted. Search strategies involved a comprehensive search strategy on six bibliographic databases, citation tracking and reference checking. The analysis involved a reciprocal level of translation and a line of argument synthesis.

Results

Searches identified 1774 hits and 17 articles from 14 studies were included, representing the views of 697 mothers. A positive breastfeeding experience was identified as being ‘attuned’. Three themes and eight sub-themes were developed to describe what characterizes attuned breastfeeding. ‘Trusting the body and what it can do’, concerned how attuned breastfeeding was facilitated through understanding the bodily responses and capacity and feeling comfortable with holding the infant and to breastfeed. ‘Being emotionally present – in the here and now’ described the importance of feeling relaxed and reassured. ‘Experiencing mutual positive responses’, illuminated how attunement was related to feelings of mutuality - when the mother recognises the infant’s cues, responds to these signals and receives a positive response from the infant. The key factors to facilitate attuned breastfeeding were opportunities for prolonged close physical contact with the infant, positive relationships with and support from staff and peers, and being facilitated to breastfeed when the infant showed feeding cues.

Conclusions

This study provides new insights into what characterizes a positive breastfeeding experience and how staff can facilitate and enable mothers to achieve attuned breastfeeding. Improvements in units’ design, such as for rooming-in and having prolonged skin-to-skin contact, and care provided by knowledgeable, supportive and encouraging staff and peers, are crucial. The mother’s physical and emotional states and the infant’s behavioural responses and physiological signals should guide the process towards positive breastfeeding practices.

A cross-sectional analysis of infant-driven and traditional feeding outcomes for neonatal intensive care unit infants

OBJECTIVE

The goal of this study was to assess the impact of infant-driven feeding (IDF) compared to traditional feeding protocols in promoting earlier successful feeding outcomes.

STUDY DESIGN

We performed a cross-sectional analysis of infants admitted to a level three neonatal intensive care unit (NICU) over a 2-year period. We compared infants fed with the traditional protocol to those under the IDF protocol.

RESULTS

Infants in the IDF group were younger at first feed (p < 0.001). There was no difference in age at nasogastric (NG) tube removal or at discharge, length of stay, or percentage breastfeeding at discharge. There were no differences in outcomes within two subgroups born at <35 and <32 weeks gestation, respectively.

CONCLUSION

The IDF program led to earlier initiation of oral feeding. However, this did not lead to earlier NG tube removal or discharge, a shorter length of stay, or increase in the rates of breastfeeding.

Cue-Based Feeding as Intervention to Achieve Full Oral Feeding in Preterm Infants Primarily Managed with Bubble CPAP

OBJECTIVE

 Cue-based feeding aims at matching introduction of per oral (PO) feeding with physiological readiness of preterm infants to facilitate PO intake and avoid oral aversion. It was claimed that cue-based feeding may lead to delay in the initiation or achieving full PO feeding in clinical setting primarily using bubble nasal continuous positive airway pressure (CPAP). The study aimed to examine the association of cue-based feeding with time of introduction and completing oral feeding in infants primarily managed with bubble CPAP.

STUDY DESIGN

 A retrospective analysis where outcomes of preterm infants ≤32 weeks' gestational age (GA) and ≤2,000 g birth weight (BW) were compared after a practice change from volume-based feeding advancement to cue-based feeding. Continuous variables were compared by using t-test and multilinear regression analysis to control for confounding variables.

RESULTS

 Of the 311 preterm infants who met inclusion and exclusion criteria, 194 were in the cue-based feeding group and 117 were in the volume-based advancement historical comparison group. There were no differences between groups regarding demographic or clinical variables. Postmenstrual age (PMA) of initial feeding assessment was less in the cue-based feeding group. Age of first PO feeding and when some PO was achieved every feed was mildly delayed in the cue-based feeding compared with comparison group, 34 (±1.3) versus 33.7 (±1.2) weeks, and 36.2 (±2.3) versus 36.0 (±2.4) weeks, (p < 0.01) respectively. However, the age of achieving full PO did not differ between groups, 36.8 (±2.2) versus 36.4 (±2.4) weeks (p = 0.13). There was no difference between groups regarding growth parameters at 36 weeks' PMA or at discharge. Similar results were obtained when examining subcategories of infants ≤1,000 g and 1,001 to 2,000 g.

CONCLUSION

 Cue-based feeding may not be associated with a delay in achieving full oral feeding or prolongation of the length of stay in preterm infants managed with CPAP.

KEY POINTS

· Cue-based feeding matches introduction of PO feeding with physiological readiness.. · Cue-based feeding may not be associated with a delay in achieving full oral feeding in preterm infants.. · Cue-based feeding is not associated with prolongation of the length of stay in preterm infants.. · Cue based feeding in preterm infants managed with noninvasive bubble CPAP is examined..

Implementation of Cue-Based Feeding to Improve Preterm Infant Feeding Outcomes and Promote Parents' Involvement

OBJECTIVE

To implement cue-based feeding for preterm infants and to assess its effects on time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process.

DESIGN

A quality improvement project with a pre-post evidence-based practice implementation design.

SETTING

Level III NICU in a quaternary hospital in the U.S. Northeast.

PARTICIPANTS

Medical records of preterm infants from 23 0/7 weeks to 31 6/7 weeks gestational age who were eligible for initiation of oral feeding.

INTERVENTION/MEASUREMENTS

We implemented cue-based feeding through staff education and training. We completed a retrospective review of the medical records of 82 preterm infants before implementation and 167 preterm infants after implementation for the outcomes of time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process.

RESULTS

For infants 23 0/7 weeks to 27 6/7 weeks gestation, time to achieve full oral feedings decreased by 7 days, length of stay decreased by 4.4 days, and parents' involvement in the feeding process increased by 80% from before to after implementation. For infants 28 0/7 weeks to 31 6/7 weeks, time to achieve full oral feedings decreased by 6.6 days, length of stay decreased by 2.7 days, and parents' involvement in the feeding process increased by 49% from before to after implementation. The organization saved $103,950 per year by decreasing length of stay.

CONCLUSIONS

Cue-based feeding decreased time to achieve full oral feedings, decreased length of stay, increased parents' involvement in the feeding process, and resulted in cost savings for the institution.

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.

Quantitative assessment of nutritive sucking patterns in preterm infants

OBJECTIVE

To assess patterns of nutritive sucking in very preterm infants ≤32 weeks of gestation.

STUDY DESIGN

Very preterm infants who attained independent oral feeding were prospectively assessed with an instrumented feeding bottle that measures nutritive sucking. The primary outcome measure was nutritive sucking performance at independent oral feeding.

RESULT

We assessed nutritive sucking patterns in 33 very preterm infants. We recorded 63 feeding sessions. The median number of sucks was 784 (IQR: 550-1053), the median sucking rate was 36/min (IQR: 27-55), and the median number of sucking bursts during the first 5 min of oral feeding was 14 (IQR: 12-16). Maximum sucking strength correlated with the number of sucks (r = 0.62; p < 0.01). No safety concerns were identified during the study.

CONCLUSION

The quantitative analysis of nutritive sucking patterns with a newly developed instrumented bottle in stable, very preterm infants is safe and feasible. More research is needed to develop and refine the instrument further.

Management of Oral Feeding Challenges in Neonatal Intensive Care Units (NICUs): A National Survey in China

Objectives: To investigate the current practices of oral feeding difficulties facing high-risk infants in Chinese NICUs. Methods: A questionnaire to survey infant oral feeding practices was distributed to 100 level II and III Chinese neonatal intensive care units (NICUs). Results: Responses were obtained from 88 NICUs. No Units had any structured guidelines regarding the management of infant oral feeding as they transitioned from tube to independent oral feeding. In 54 (61.4%) NICUs, nurses and physicians made shared decisions on when oral feeding were to be initiated. Fifty-four (61.4%) and 22 (25.0%) NICUs used postmenstrual age (PMA) or weight at PMA as a criterion for initiating oral feedings, respectively. The top three criteria to determine introduction of oral feeding were severity of disease, presence of sucking reflex, and trial feeding success. Adverse events were used by 78 Units as indices of oral feeding difficulty. Twenty (22.7%) and 25 (28.4%) Units had access to occupational therapists or nurses who provided oral motor interventions during feeding, i.e., oral support (chin and cheek support, aid to deglutition), non-nutritive sucking with pacifier, and oral stimulation. Conclusions: The management of oral feeding issues in NICUs vary widely in China in relation to the assessment of readiness to oral feeding, daily oral feeding practices and interventions used by staff. It is proposed that an educational program focused on the physiology of infant oral feeding, available evidence-based tools and interventions would assist NICU caregivers develop structured guidelines to improve infants' safe and efficient attainment of independent oral feeding.