Interventions to improve the oral feeding performance of preterm infants

Characterizing Biomarkers of Continuous Peristalsis and Bolus Transit during Oral Feeding in Infants at pH-Impedance Evaluation: Clinical and Research Implications

OBJECTIVE

To examine the biomarkers of pharyngoesophageal swallowing during oral feeding sessions in infants undergoing pH-impedance testing and determine if swallow frequencies are distinct between oral- and partially oral-fed infants.

STUDY DESIGN

One oral feeding session was performed in 40 infants during pH-impedance studies and measurements included swallowing frequency, multiple swallow rate, air and liquid swallow rates, esophageal swallow clearance time (ESCT), and gastroesophageal reflux (GER) characteristics. Linear and mixed statistical models were applied to examine the swallowing markers and outcomes.

RESULTS

Infants (30.2 ± 4.4 weeks birth gestation) were evaluated at 41.2 ± 0.4 weeks postmenstrual age (PMA). Overall, 10,675 swallows were analyzed during the oral feeding sessions (19.3 ± 5.4 min per infant) and GER events were noted (2.5 ± 0.3 per study). Twenty-four-hour acid reflux index (ARI) was 9.5 ± 2.0%. Differences were noted in oral- and partially oral-fed infants for: volume consumption (p<0.01), consumption rate (p<0.01), and length of hospital stay in days (p<0.01). Infants with ARI >7% had greater frequency of swallows (p=0.01). The oral-fed group had greater ARI (12.7 ± 3.3%, p=0.05).

CONCLUSIONS

Oropharyngeal swallowing regulatory characteristics decrease over the feeding duration and were different between ARI >7% vs ≤7%. Although GER is less in infants who are partially oral-fed, the neonates with increased acid exposure achieved greater oral intakes and shorter hospitalizations, despite the presence of comorbidities. Pharyngoesophageal stimulation as during consistent feeding or GER events can activate peristaltic responses and rhythms, which may be contributory to the findings.

Exploration of the Association Between Sucking Measures and Ability to Attain Independent Oral Feeds Among Infants Who Are Born Preterm

IMPORTANCE

Infants who are born preterm often experience difficulty transitioning from full tube to independent oral feeds, which often prolongs their hospital stay. No clinical measures associated with attainment of independent oral feeds are currently available.

OBJECTIVE

To identify specific nutritive sucking measures associated with time to attainment of independent oral feeds among infants who are born preterm.

DESIGN

An observational cohort pilot study was undertaken.

SETTING

A Level 2 to Level 3 neonatal intensive care unit.

PARTICIPANTS

Fourteen infants (7 male, 7 female) born at or less than 34 wk gestation were enrolled.

OUTCOMES AND MEASURES

The monitored suck measures included average suck strength (millimeters of mercury), average sucking burst duration (seconds), average suck count (number of sucks), and average pause duration (seconds). Time to independent oral feeds (days) and baseline characteristics were also monitored. The nutritive sucking measures were recorded once, during the first 5 min of an oral feed, when infants were taking an average of three to four oral feeds per day using a nipple monitoring device.

RESULTS

An inverse relation was found among average suck burst duration (p = .04), gestational age (p = .03), and days to attainment of independent oral feeds.

CONCLUSIONS AND RELEVANCE

Study results suggest that average sucking burst duration, during the first 5 min of an oral feed, is associated with time to attain independent oral feeds. Plain-Language Summary: Sucking burst duration is a simple measure that may be used clinically to identify early on infants who may have trouble transitioning from full tube to independent oral feedings. The results of this study suggest that a suck burst duration in the first 5 min of an oral feeding is inversely associated with the length of time to achieve independent oral feeding. The results highlight the importance of considering an infant's nutritive sucking ability when evaluating their potential to achieve independent oral feedings.

Risk of dysphagia in a population of infants born pre-term: characteristic risk factors in a tertiary NICU

OBJECTIVE

To examine the prevalence and characteristics of dysphagia and suck-swallow-breath incoordination as phenotypes of oral feeding difficulties.

METHOD

A cross-sectional study with secondary data collected consecutively over 2 years from October 2020 to October 2022 to measure the prevalence of swallowing and oral feeding difficulty in preterm infants using Flexible endoscopic evaluation of swallowing examination at the tertiary Integrated Dysphagia Clinic.

RESULTS

The prevalence of swallowing disorders was 25 % and the prevalence of suck-swallow-breath incoordination was 62.5 %. The significant risk factor that may show a possible correlation with oral feeding difficulty was mature post-menstrual age (p = 0.006) and longer length of stay (p = 0.004). The dominant percentage of upper airway abnormality and disorder were retropalatal collapse (40 %), laryngomalacia (42.5 %), paradoxical vocal cord movement (12.5 %), and gastroesophageal reflux disease (60 %). The dominant characteristic of oral motor examination and flexible endoscopic evaluation of swallowing examination was inadequate non-nutritive sucking (45 %), inadequate postural tone (35 %), and inadequate nutritive sucking (65 %).

CONCLUSION

Dysphagia in preterm infants is mostly observed in those with mature post-menstrual age, longer length of stay, and the presence of gastroesophageal reflux disease with inadequate non-nutritive sucking and nutritive sucking abilities. Suck-swallow-breath incoordination is primarily observed in those with immature post-menstrual age, a higher prevalence of cardiopulmonary comorbidity, and a higher prevalence of upper airway pathologies (laryngomalacia, paradoxical vocal cord movement) with inadequate nutritive sucking ability.

Effect of Nonnutritive Sucking on Oral Feeding in Neonates With Perinatal Asphyxia: A Randomized Controlled Trial

AIMS

The effect of nonnutritive sucking (NNS) stimulation is unclear in infants with perinatal asphyxia. Thus, the aim of this study was to assess the effect of NNS stimulation on oral intake, discharge time, and early feeding skills in infants with perinatal asphyxia.

DESIGN

A randomized controlled study was conducted.

METHOD

Of the 94 infants, 47 were included in the experimental group and given NNS stimulation once a day before tube feeding by a speech-language therapist (SLT) in addition to hypothermia treatment. Infants' feeding performances on the days of first oral intake and discharge were evaluated with the Early Feeding Skills Scale (EFS).

RESULTS

The time from tube feeding to oral intake was significantly lower in the experimental group compared to the control group (p < .05). EFS scores at discharge were significantly higher in the experimental group than in the control group (p < .05). There was no significant difference between the experimental and control groups in terms of discharge and weight gain (p > .05).

CONCLUSIONS

The findings indicated that the NNS stimulation positively affected oral intake and early feeding skills in infants with perinatal asphyxia, as in preterms. However, NNS stimulation had no significant effect on discharge and weight gain in infants with asphyxia. This finding may be attributed to other factors. It is recommended to use NNS by an SLT in a neonatal intensive care unit within a multidisciplinary team to accelerate the transition to oral feeding and improve feeding skills in infants with perinatal asphyxia. Further studies on the effect of NNS stimulation in infants with perinatal asphyxia are needed to corroborate its effects on discharge time and weight gain.

Interventions to Enhance Achievement to Independent Oral Feeds in Premature Infants: A Scoping Review

AIM

To assess the effectiveness of interventions aimed at facilitating the transition from full tube to independent oral feeds in premature infants.

METHODS

Scoping review methodology using the Preferred Reporting items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA_ScR). A search of six databases (EMBASE, MEDLINE, CINAHL, Web of Science, COCHRANE, and OT Seeker), using keywords related to oral feeding and premature infants retrieved 11,870 articles. Full-text screening was completed for 36 articles, and 21 articles were included in this review.

RESULTS

Review of the 21 articles revealed five intervention types: oral stimulation (n = 14), swallow/gustatory stimulation (n = 3), olfactory stimulation (n = 2), tactile/kinesthetic stimulation (n = 1), and auditory stimulation (n = 1). Oral stimulation had the most studies with consistent evidence supporting its beneficial effect to facilitate achievement to independent oral feeds, swallow/gustatory stimulation appeared to have some benefit, but evidence for olfactory, tactile/kinesthetic, and auditory stimulation was sparse.

CONCLUSION

Oral stimulation has the most studies with consistent evidence, and thus is suggested as a suitable early intervention strategy that can be used by health providers to facilitate the achievement to independent oral feeds in premature infants. The alternate forms of stimulation have limited evidence and necessitate further studies to confirm their benefits.

Comparison of Effect of Feeding Premature Infants with Either Cup, Bottle, and Syringe on Transition to Breastfeeding, Breastfeeding Success, Weight Gain, and Duration of Hospitalization

Objective: This study was completed with the aim of determining the effect of cup feeding (CF), bottle feeding (BF), and syringe feeding (SF) methods on the transition to breastfeeding, breastfeeding success, physiological parameters, weight gain, and discharge duration for preterm neonates in the neonatal intensive care unit (NICU). Materials and Methods: The study was designed to be randomized, controlled, and single blinded. The study was completed with 102 premature neonates between 29-34 gestational weeks abiding by the case selection criteria receiving treatment and care in the NICU. The 1st group comprised premature neonates receiving CF, the second group received BF, and the third group received SF. For collection of data, the Premature Infant Descriptive Information and Monitoring Form, Bristol Breastfeeding Assessment Tool (BBAT), and Infant-Focused Feeding Scales (IFFS) were used. Results: Comparison of mean peak heart rate in the groups found that the BF group was significantly high (p = 0.047) and comparison of mean SO2 found that the SF group was significantly high (p = 0.000). Infants in the SF group were determined to have significantly higher BBAT scores compared to the infants in the BF and CF groups (p = 0.015). In addition, SF infants were determined to transition to full enteral feeding and breastfeeding in a shorter duration (p < 0.05). There were no significant differences between the groups for weight gain and discharge duration (p > 0.05). Conclusions: The SF method was determined to more positively affect breastfeeding success, transition to full breastfeeding duration, and vital signs compared to the CF and BF methods. In line with the results obtained in the study, the use of the SF method may be recommended to increase breastfeeding success of neonates, to shorten the transition to full breastfeeding and for stable physical parameters.

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.

Pharyngeal biorhythms during oral milk challenge in high-risk infants: Do they predict chronic tube feeding?

BACKGROUND

Eating difficulties are common in high-risk neonatal intensive care unit (NICU) infants; mechanisms remain unclear. Crib-side pharyngo-esophageal motility testing is utilized to assess contiguous swallowing physiology, and cross-system interplay with cardio-respiratory rhythms. Aims were to: (1) identify whether distinct pharyngeal rhythms exist during oral milk challenge (OMC), and (2) develop a chronic tube feeding risk prediction model in high-risk infants.

METHODS

Symptomatic NICU infants (N = 56, 29.7 ± 3.7 weeks birth gestation) underwent pharyngo-esophageal manometry with OMC at 40.9 ± 2.5 weeks postmenstrual age (PMA). Exploratory cluster data analysis (partitioning around k-medoids) was performed to identify patient groups using pharyngeal contractile rhythm data (solitary swallows and swallows within bursts). Subsequently, (a) pharyngeal-esophageal, cardio-respiratory, and eating method characteristics were compared among patient groups using linear mixed models, and (b) chronic tube feeding prediction model was created using linear regression.

RESULTS

Three distinct patient groups were identified with validity score of 0.6, and termed sparse (high frequency of solitary swallows), intermediate, or robust (high swallow rate within bursts). Robust group infants had: lesser pharyngeal and esophageal variability, greater deglutition apnea, pharyngeal activity, and esophageal activity (all p < 0.05), but less frequent heart rate decreases (p < 0.05) with improved clinical outcomes (milk transfer rate, p < 0.001, and independent oral feeding at discharge, p < 0.03). Chronic tube feeding risk = -11.37 + (0.22 × PMA) + (-0.73 × bronchopulmonary dysplasia) + (1.46 × intermediate group) + (2.57 × sparse group).

CONCLUSIONS

Robust pharyngeal rhythm may be an ideal neurosensorimotor biomarker of independent oral feeding. Differential maturation of cranial nerve-mediated excitatory and inhibitory components involving foregut, airway, and cardiac rhythms distinguishes the physiologic and pathophysiologic basis of swallowing and cardio-respiratory adaptation.

Clinical validation of the infant-driven feeding scales© in Turkey

BACKGROUND

Supporting the development of feeding skills among preterm infants is an important component of neonatal care. The selection of appropriate and supportive feeding interventions begins with a comprehensive assessment of the infant's skills.

PURPOSE

This study aimed to adapt the Infant-Driven Feeding Scales© (IDFS) to the Turkish language.

METHODS

This was a methodological, observational, single-center cross-sectional study. The study included 80 infants born at a gestational age ≥ 32 weeks, consecutively admitted to a tertiary Neonatal Intensive Care Unit (NICU). Research data were collected using a premature infant descriptive information form (IDIF), IDFS, and LATCH Score for Breastfeeding Assessment. For the Turkish validity-reliability of the IDF, the translate-back translate method was used with the content validity index (CVI) assessed.

RESULTS

The scale had CVI values between 0.90 and 1.00 with a mean CVI = 0.96. For measures 1 and 2, there were significant positive and high-level correlations between IFDS-R and IFDS-Q correlation values (r = 0.553-0.958; p = 0.001) and significant negative, low-level correlations between IFDS-R and IFDS-Q with the LATCH scale (r = 0.439-0.532; p = 0.001). According to inter-observer compatibility analyses, the kappa value was 0.94-1.00 for the first measure and 0.96-1.00 for the second measure (p = 0.001). There were negative significant correlations between IDFS-R points with gestational age and postmenstrual age (PMA) (p = 0.001), and gestational age and PMA were explanatory factors for 13.8% of IDFS-R points (F = 7.30, p = 0.001).

CONCLUSIONS

The IDFS is recommended for use as a valid and reliable tool to ease the safe and successful development of oral feeding skills in preterm infants and to plan evidence-based interventions.

IMPLICATIONS FOR PRACTICE

The IDFS appears to be a beneficial measurement device for use in assessing the state of readiness of preterm infants for oral feeding and for early determination of risks that may occur due to delayed feeding independence of 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.

Rates and Determinants of Home Nasogastric Tube Feeding in Infants Born Very Preterm

OBJECTIVE

To examine rates and determinants of home nasogastric (NG)-tube feeding at hospital discharge in a cohort of very preterm infants within the Canadian Neonatal Network (CNN).

STUDY DESIGN

This was a population-based cohort study of infants born <33 weeks of gestation and admitted to neonatal intensive care units (NICUs) participating in the CNN between January 1, 2010, and December 31, 2018. We excluded infants who had major congenital anomalies, required gastrostomy-tube, or were discharged to non-CNN facilities. Multivariable logistic regression analysis was used to identify independent determinants of home NG-tube feeding at hospital discharge.

RESULTS

Among the 13 232 infants born very preterm during the study period, 333 (2.5%) were discharged home to receive NG-tube feeding. Rates of home NG-tube feeding varied across Canadian NICUs, from 0% to 12%. Determinants of home NG-tube feeding were gestational age (aOR 0.94 per each gestational week increase, 95% CI 0.88-0.99); duration of mechanical ventilation (aOR 1.02 per each day increase, 95% CI 1.01-1.02); high illness severity at birth (aOR 1.32, 95% CI 1.01-1.74); small for gestational age (aOR 2.06, 95% CI 1.52-2.78); male sex (aOR 0.61, 95% CI 0.49-0.77); severe brain injury (aOR 1.60, 95% CI 1.10-2.32); and bronchopulmonary dysplasia (aOR 2.22, 95% CI 1.67-2.94).

CONCLUSIONS

Rates of home NG-tube feeding varied widely between Canadian NICUs. Higher gestational age and male sex reduced the odds of discharge home to receive NG-tube feeding; and in contrast small for gestational age, severe brain injury, prolonged duration on mechanical ventilation and bronchopulmonary dysplasia increased the odds.

Comparison of the effect of two methods of sucking on pacifier and mother's finger on oral feeding behavior in preterm infants: a randomized clinical trial

BACKGROUND

Oral feeding problems will cause long-term hospitalization of the infant and increase the cost of hospitalization. This study aimed to compare the effect of two methods of sucking on pacifier and mother's finger on oral feeding behavior in preterm infants.

METHODS

This single-blind randomized controlled clinical trial was performed in the neonatal intensive care unit of Babol Rouhani Hospital, Iran. 150 preterm infants with the gestational age of 31 to 33 weeks were selected and were divided into three groups of 50 samples using randomized block method, including non-nutritive sucking on mother's finger (A), pacifier (B) and control (C). Infants in groups A and B were stimulated with mother's finger or pacifier three times a day for five minutes before gavage, for ten days exactly. For data collection, demographic characteristics questionnaire and preterm infant breastfeeding behavior scale were used.

RESULTS

The mean score of breastfeeding behavior in preterm infants in the three groups of A,B,C was 12.34 ± 3.37, 11.00 ± 3.55, 10.40 ± 4.29 respectively, which had a significant difference between the three groups (p = 0.03). The mean rooting score between three groups of A, B, and C was 1.76 ± 0.47, 1.64 ± 0.48, and 1.40 ± 0.90 (p < 0.001) respectively. Also, the mean sucking score in groups of A, B and C was 2.52 ± 0.76, 2.28 ± 0.64 and 2.02 ± 0.74 respectively, which had a significant difference (p = 0.003), but other scales had no significant difference between the three groups (P > 0.05). The mean time to achieve independent oral feeding between the three groups of A, B, C was 22.12 ± 8.15, 22.54 ± 7.54 and 25.86 ± 7.93 days respectively (p = 0.03), and duration of hospitalization was 25.98 ± 6.78, 27.28 ± 6.20, and 29.36 ± 5.97 days (p = 0.02), which had a significant difference. But there was no significant difference between the two groups of A and B in terms of rooting, sucking, the total score of breastfeeding behavior and time of achieving independent oral feeding (P > 0.05).

CONCLUSION

Considering the positive effect of these two methods, especially non-nutritive sucking on mother's finger, on increasing oral feeding behaviors, it is recommended to implement these low-cost methods for preterm infants admitted to neonatal intensive care unit.

TRIAL REGISTRATION

Trial Registration: IRCT, IRCT20191116045460N1 . Registered 11 January 2020- prospective registered.

Direct swallowing training and oral sensorimotor stimulation in preterm infants: a randomised controlled trial

OBJECTIVE

To evaluate the effects of direct swallowing training (DST) alone and combined with oral sensorimotor stimulation (OSMS) on oral feeding ability in very preterm infants.

DESIGN

Blinded, parallel group, randomised controlled trial (1:1:1).

SETTING

Neonatal intensive care unit of a South Korean tertiary hospital.

PARTICIPANTS

Preterm infants born at <32 weeks of gestation who achieved full tube feeding.

INTERVENTIONS

Two sessions per day were provided according to the randomly assigned groups (control: two times per day sham intervention; DST: DST and sham interventions, each once a day; DST+OSMS: DST and OSMS interventions, each once a day).

PRIMARY OUTCOME

Time from start to independent oral feeding (IOF).

RESULTS

Analyses were conducted in 186 participants based on modified intention-to-treat (63 control; 63 DST; 60 DST+OSMS). The mean time from start to IOF differed significantly between the control, DST and DST+OSMS groups (21.1, 17.2 and 14.8 days, respectively, p=0.02). Compared with non-intervention, DST+OSMS significantly shortened the time from start to IOF (effect size: -0.49; 95% CI: -0.86 to -0.14; p=0.02), whereas DST did not. The proportion of feeding volume taken during the initial 5 min, an index of infants' actual feeding ability when fatigue is minimal, increased earlier in the DST+OSMS than in the DST.

CONCLUSIONS

In very preterm infants, DST+OSMS led to the accelerated attainment of IOF compared with non-intervention, whereas DST alone did not. The effect of DST+OSMS on oral feeding ability appeared earlier than that of DST alone.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02508571).

Effects on Growth of Smell and Taste of Milk During Tube Feeding of Preterm Infants: A Randomized Clinical Trial

IMPORTANCE

Smell and taste of food increase food anticipation, activate gut motility, and stimulate digestion and metabolism. Despite poor growth of many preterm infants in neonatal intensive care units, the smell and taste of milk with tube feeding are not generally considered a regular component of care.

OBJECTIVE

To determine the effect of smell and taste of milk with tube feeding on weight z scores at discharge from the hospital.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, controlled, nonblinded, superiority trial was conducted at 2 perinatal centers between May 9, 2017, and February 1, 2020. Eligible infants (n = 659) were born at less than 29 weeks' postmenstrual age (PMA) and/or with a birth weight of less than 1250 g.

INTERVENTIONS

Infants were randomly assigned to receive either the smell and taste of milk with each tube feeding or routine care without the provision of smell and taste of milk.

MAIN OUTCOMES AND MEASURES

The primary outcome was weight z score at discharge from any hospital. Secondary outcomes included anthropometric measures at predefined time points, time to full enteral feeds, and other health outcomes associated with prematurity.

RESULTS

Of the 658 infants, a total of 396 infants were randomized; some parents had not been approached for consent (n = 144) or declined participation (n = 117), and 1 infant with consent was not randomized. Of the 396 infants, 196 were assigned to the treatment group (51% male; mean [SD] PMA at birth, 27.5 [2.2] weeks) and 200 were assigned to the control group (52% male; mean [SD] PMA at birth, 27.6 (2.3) weeks). Mean weight z scores at discharge were -0.87 (95% CI, -1.02 to -0.72) for the treatment group and -0.97 (95% CI, -1.11 to -0.83) for the control group (P = .40). The mean difference in z scores between the treatment and control groups at 36 weeks' PMA was 0.21 (95% CI, 0.01 to 0.4; P = .04) for head circumference and 0.26 (95% CI, 0.05 to 0.51; P = .04) for length. There were no clinically notable differences between the study groups for any other anthropometric, feeding, or health outcomes.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, regular smell and taste of milk included with tube feeding did not improve weight at discharge in preterm infants. Secondary outcomes suggest exposure to smell and taste may improve head circumference and length at 36 weeks' PMA, but not at discharge. Regular exposure to the smell and taste of milk is a simple and inexpensive intervention with potential benefits and no apparent adverse effects.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12617000583347.

Avoidance of bottles during the establishment of breastfeeds in preterm infants

BACKGROUND

Preterm infants often start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women with preterm infants may not always be in hospital to breastfeed their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breastfeeds is detrimental to breastfeeding success is a topic of ongoing debate.

OBJECTIVES

To identify the effects of avoidance of bottle feeds during establishment of breastfeeding on the likelihood of successful breastfeeding, and to assess the safety of alternatives to bottle feeds.

SEARCH METHODS

A new search strategy was developed for this update. Searches were conducted without date or language limits in September 2021 in: MEDLINE, CENTRAL, and CINAHL.  We also searched the ISRCTN trial registry and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.  SELECTION CRITERIA: We included RCTs and quasi-RCTs comparing avoidance of bottles with use of bottles for preterm infants where their mothers planned to breastfeed.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. We used the GRADE approach to assess the certainty of evidence. Outcomes included full breastfeeding and any breastfeeding on discharge home and at three and six months after discharge, as well as length of hospital stay and episodes of infant infection. We synthesised data using risk ratios (RR), risk differences (RD) and mean differences (MD), with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included seven trials with 1152 preterm infants in this updated review. There are three studies awaiting classification. Five included studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breastfeeds were needed. We included the novel teat study in this review as the teat was designed to closely mimic the sucking action of breastfeeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff or parents (or both); the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Avoiding bottles may increase the extent of full breastfeeding on discharge home (RR 1.47, 95% CI 1.19 to 1.80; 6 studies, 1074 infants; low-certainty evidence), and probably increases any breastfeeding (full and partial combined) on discharge (RR 1.11, 95% CI 1.06 to 1.16; studies, 1138 infants; moderate-certainty evidence). Avoiding bottles probably increases the occurrence of full breastfeeding three months after discharge (RR 1.56, 95% CI 1.37 to 1.78; 4 studies, 986 infants; moderate-certainty evidence), and may also increase full breastfeeding six months after discharge (RR 1.64, 95% CI 1.14 to 2.36; 3 studies, 887 infants; low-certainty evidence). Avoiding bottles may increase the occurrence of any breastfeeding (full and partial combined) three months after discharge (RR 1.31, 95% CI 1.01 to 1.71; 5 studies, 1063 infants; low-certainty evidence), and six months after discharge (RR 1.25, 95% CI 1.10 to 1.41; 3 studies, 886 infants; low-certainty evidence). The effects on breastfeeding outcomes were evident at all time points for the tube alone strategy and for all except any breastfeeding three months after discharge for cup feeding, but were not present for the novel teat. There were no other benefits or harms including for length of hospital stay (MD 2.25 days, 95% CI -3.36 to 7.86; 4 studies, 1004 infants; low-certainty evidence) or episodes of infection per infant (RR 0.70, 95% CI 0.35 to 1.42; 3 studies, 500 infants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Avoiding the use of bottles when preterm infants need supplementary feeds probably increases the extent of any breastfeeding at discharge, and may improve any and full breastfeeding (exclusive) up to six months postdischarge. Most of the evidence demonstrating benefit was for cup feeding. Only one study used a tube feeding strategy. We are uncertain whether a tube alone approach to supplementing breastfeeds improves breastfeeding outcomes; further studies of high certainty are needed to determine this.

Early skin contact combined with mother's breastfeeding to shorten the process of premature infants ≤ 30 weeks of gestation to achieve full oral feeding: the study protocol of a randomized controlled trial

Background

Most hospitalized preterm infants experience difficulties in transitioning from tube feeding to full oral feeding. Interventions to promote full oral feeding in preterm infants in the neonatal intensive care unit (NICU) are limited to pacifier use or bottle-feeding exercises. Skin contact has been shown to be beneficial to start and maintain lactation and provide preterm infants with the opportunity to suck on the mother’s breast, which may promote further development of the preterm infant’s suckling patterns. The objective of this study is to compare and evaluate the effects of skin contact combined with breastfeeding (suck on the mother’s empty breast) as compared to the routine pacifier suckling training model in achieving full oral feeding for infants whose gestational age are ≤ 30 weeks.

Methods

This is a single-center, randomized controlled clinical trial conducted in the NICU and designed according to the SPIRIT Statement. The subjects included in the study are premature infants born between April 2020 and July 2021 with a gestational age of ≤30 weeks, birth weight of <1500 g, admission age of <72 h, and absence of congenital malformations. Those with oxygenation indices of >40 and those born to mothers with poor verbal communication skills will be excluded. A sample of 148 infants is needed. The infants will be randomized to the intervention (skin contact combined with mother’s breastfeeding model) or control group (routine pacifier sucking training model). The primary outcome is the time required to achieve full oral feeding. The secondary outcomes are the breastfeeding abilities of preterm infants as assessed by the Preterm Infant Breastfeeding Behavior Scale (PIBBS), breastfeeding rates at 3 and 6 months corrected gestational age, complication rates, duration of oxygen requirement, days of hospital stay, and satisfaction of parents.

Discussion

This paper describes the first single-center, open-label, randomized clinical trial on this topic and will provide crucial information to support the implementation of skin contact combined with the breastfeeding model in the NICU setting.

Trial registration

ClinicalTrials.gov NCT 04283682. Registered on 8 February 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05605-x.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of a pre-feeding oral stimulation program on first feed attempt in preterm infants: Double-blind controlled clinical trial

Objective

To evaluate the effect of an oral stimulation program in preterm on the performance in the first oral feeding, oral feeding skills and transition time from tube to total oral intake.

Study designer

Double-blind randomized clinical trial including very preterm newborns. Congenital malformations, intracranial hemorrhage grade III or IV, bronchopulmonary dysplasia, and necrotizing enterocolitis were excluded. Intervention group (GI) received an oral stimulation program of tactile extra-, peri-, and intraoral tactile manipulation once a day for 15 minutes, during a 10-day period. Control group (GII) received sham procedure with same duration of time. Feeding ability was assessed by a speech-language pathologist blinded to group assignment. The classification of infants’ oral performance was determined by Oral Feeding Skills (OFS). Neonates were monitored until hospital discharge.

Results

Seventy-four (37 in each group) were randomized. Mean gestational ages and birth weights were 30±1.4 and 30±1.5 weeks, and 1,452±330g and 1,457±353g for intervention and control groups, respectively. Infants in the intervention group had significantly better rates than infants in the control group on: mean proficiency (PRO) (41.5%±18.3 vs. 19.9%±11.6 (p<0.001)), transfer rate (RT) (2.3 mL/min and 1.1 mL/min (p<0.001)) and overall transfer (OT) (57.2%±19.7 and 35.0%±15.7 (p<0.001)). Median transition time from tube to oral feeding was 4 (3–11) and 8 (7–13) days in intervention and control groups, respectively (p = 0.003). Intake of breast milk was found to reduce transition time from tube feeds to exclusive oral feeding (p<0.001, HR 1.01, 95%CI 1.005–1.019), but the impact of the study intervention remained significant (p = 0.007, HR 1.97, 95%CI 1.2–3.2).

Conclusion

Infants who were breast-fed and an oral stimulation program proved beneficial in reducing transition time from tube feeding to oral feeding.

Trial registration

ClinicalTrials.gov number NCT03025815.

Feeding Interventions for Infants with Growth Failure in the First Six Months of Life: A Systematic Review

(1) Introduction: Current evidence on managing infants under six months with growth failure or other nutrition-related risk is sparse and low quality. This review aims to inform research priorities to fill this evidence gap, focusing on breastfeeding practices. (2) Methods: We searched PubMed, CINAHL Plus, and Cochrane Library for studies on feeding interventions that aim to restore or improve the volume or quality of breastmilk and breastfeeding when breastfeeding practices are sub-optimal or prematurely stopped. We included studies from both low- and middle-income countries and high-income countries. (3) Results: Forty-seven studies met the inclusion criteria. Most were from high-income countries (n = 35, 74.5%) and included infants who were at risk of growth failure at birth (preterm infants/small for gestational age) and newborns with early growth faltering. Interventions included formula fortification or supplementation (n = 31, 66%), enteral feeds (n = 8, 17%), cup feeding (n = 2, 4.2%), and other (n = 6, 12.8%). Outcomes included anthropometric change (n = 40, 85.1%), reported feeding practices (n = 16, 34%), morbidity (n = 11, 23.4%), and mortality (n = 5, 10.6%). Of 31 studies that assessed formula fortification or supplementation, 30 reported anthropometric changes (n = 17 no effect, n = 9 positive, n = 4 mixed), seven morbidity (n = 3 no effect, n = 2 positive, n = 2 negative), five feeding (n = 2 positive, n = 2 no effect, n = 1 negative), and four mortality (n = 3 no effect, n = 1 negative). Of eight studies that assessed enteral feed interventions, seven reported anthropometric changes (n = 4 positive, n = 3 no effect), five feeding practices (n = 2 positive, n = 2 no effect, n = 1 negative), four morbidity (n = 4 no effect), and one reported mortality (n = 1 no effect). Overall, interventions with positive effects on feeding practices were cup feeding compared to bottle-feeding among preterm; nasogastric tube feed compared to bottle-feeding among low birth weight preterm; and early progressive feeding compared to delayed feeding among extremely low birth weight preterm. Bovine/cow milk feeding and high volume feeding interventions had an unfavourable effect, while electric breast pump and Galactagogue had a mixed effect. Regarding anthropometric outcomes, overall, macronutrient fortified formula, cream supplementation, and fortified human milk formula had a positive effect (weight gain) on preterm infants. Interventions comparing human breastmilk/donor milk with formula had mixed effects. Overall, only human milk compared to formula intervention had a positive effect on morbidity among preterm infants, while none of the interventions had any positive effect on mortality. Bovine/cow milk supplementation had unfavourable effects on both morbidity and mortality. (4) Conclusion: Future research should prioritise low- and middle-income countries, include infants presenting with growth failure in the post-neonatal period and record effects on morbidity and mortality outcomes.

To Individualize the Management Care of High-Risk Infants With Oral Feeding Challenges: What Do We Know? What Can We Do?

The increase in preterm infants' survival over the last 30 years has shed light over their inability to feed by mouth safely and efficiently. With adverse events such as increased risks for oxygen desaturation, bradycardia, penetration/aspiration, infants' hospitalization in neonatal intensive care units (NICUs) are understandably prolonged. Unfortunately, this leads to delayed mother-infant reunion, maternal stress, breastfeeding obstacles, and increased medical costs. Such impediments have stimulated clinicians and researchers to better understand the underlying causes and develop evidence-based solutions to assist these infants. However, it is notable that the research-to-practice translation of this knowledge has been limited as there are still no validated guidelines or protocols as how to best diagnose and care for these infants. This report revisits the immature physiologic functions at the root of these infants' oral feeding difficulties, the current practices, and the recent availability of evidence-based efficacious tools and interventions. Taking advantage of the latter, it presents a renewed perspective of how management strategies can be tailored to the specific needs of individual patients.

Feeding and Swallowing Difficulties in Neonates: Developmental Physiology and Pathophysiology

Development of enteral and oral feeding milestones in infants is intricately linked to physiologic maturation of the gastrointestinal tract and its complex interplay with cardiorespiratory and central nervous system control and coordination. Assessment of an infant's developmental skills and maturation can guide us with targeted management approaches and prediction of feeding outcomes. In this article, we review and summarize the developmental aspects of oral feeding and swallowing physiology, and current understanding of the pathophysiological changes associated with feeding difficulties in infants.

Optimal Timing to Utilize Olfactory Stimulation with Maternal Breast Milk to Improve Oral Feeding Skills in the Premature Newborn

Background: Olfactory maturation is essential for successful oral feeding. Previous studies have suggested that olfactory stimulation with maternal breast milk may expedite oral feeding skills in the premature infant; however, the optimal developmental window to utilize this intervention and sex-specific responses to stimuli are largely unknown. Objectives: To determine individual responses to olfactory stimulation with mother's own milk (MOM) on feeding outcomes in premature newborns. Materials and Methods: Infants born between 28 0/7 and 33 6/7 weeks' gestation (n = 36) were randomized to receive either MOM or water (sham) stimulus during the learning process of oral feeding. Clinical and feeding outcomes were recorded. Statistical analyses examined the effect of stimulation with MOM on feeding outcomes stratified for age and sex. Results: Overall, there was no significant difference between sham infants compared with MOM infants in mean postmenstrual age of full oral feeds (sham: 35 5/7 versus MOM 36 0/7; p = 0.37). However, when stratified by gestational age (GA), infants born <31 weeks' gestation who received MOM stimulation learned to feed sooner than controls (p = 0.06), whereas infants born ≥31 weeks' gestation learned to feed later than controls (p = 0.20) with a significant interaction (p = 0.02) between the stimulus (MOM versus sham) and dichotomized GA (<31 versus ≥31 weeks). There were no sex differences in response to olfactory stimulus. Conclusions: Infants born <31 weeks' GA who received MOM stimulation learned to feed sooner than control infants and the impact of MOM is significantly different between infants born before or after 31 weeks GA. These data suggest there may be an optimal time in development to utilize maternal breast milk to expedite oral feeding maturation in the premature newborn.

Performance on Paladai Feeding of Preterm Infants with Bronchopulmonary Dysplasia

OBJECTIVE

To evaluate the feeding performance of infants with bronchopulmonary dysplasia (BPD) on paladai.

METHODS

This cross-sectional study was performed in a level III neonatal unit in North India from March through August 2012. Nineteen infants (27-32 wk of gestation) were enrolled; 9 in BPD group (oxygen requirement for at least 28 d) and 10 in 'No BPD' group. Paladai feeding (PF) sessions were video recorded for 3 d serially, at first successful (FSF) at postnatal age of ≥28 d and follow up feeding (FUF) at 40 ± 2 wk. Successful feeding was defined as ≥80% intake of volume prescribed. One hundred and four videos were analysed (58 in BPD group and 46 in 'No BPD' group). The outcome variables were: (1) postmenstrual age (PMA) at FSF (2) feeding performance, as assessed by proficiency (mL/min, volume of feed intake during only active feeding), efficiency (mL/min, volume of feed intake during total duration of feeding) and overall feed transfer (OT, % of prescribed feed volume taken), and (3) change in heart rate (∆HR) and oxygen saturation (∆SpO₂) on PF.

RESULTS

PMA (Weeks, 34.2 ± 2.0 vs. 33.6 ± 1.2, p = 0.13), performance on FSF [Median (range), Proficiency: ml/min, 4.2 (1.1, 21.7) vs. 3.4 (1.1, 12.4), efficiency: ml/min, 2.7 (0.4, 6.2) vs. 2.5 (0.9, 10.9)] and OT (%, mean ± SD: 84.9 ± 22.5 vs. 89.1 ± 9.6), and on FUF were comparable between the groups. Changes in SpO₂ and HR were not significantly different.

CONCLUSIONS

Infants with BPD perform comparably well on PF. PF can safely be attempted in them to facilitate transition to oral feeding.

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.

Patterned frequency-modulated oral stimulation in preterm infants: A multicenter randomized controlled trial

Objective

To evaluate the effect of patterned, frequency-modulated oro-somatosensory stimulation on time to full oral feeds in preterm infants born 26–30 weeks gestation.

Study design

This is a multicenter randomized controlled trial. The experimental group (n = 109) received patterned, frequency-modulated oral stimulation via the NTrainer system through a pulsatile pacifier and the control group (n = 101) received a non-pulsatile pacifier. Intent-to-treat analysis (n = 210) was performed to compare the experimental and control groups and the outcomes were analyzed using generalized estimating equations. Time-to-event analyses for time to reach full oral feeds and length of hospital stay were conducted using Cox proportional hazards models.

Results

The experimental group had reduction in time to full oral feeds compared to the control group (-4.1 days, HR 1.37 (1.03, 1.82) p = 0.03). In the 29–30 weeks subgroup, infants in the experimental group had a significant reduction in time to discharge (-10 days, HR 1.87 (1.23, 2.84) p < 0.01). This difference was not observed in the 26–28 weeks subgroup. There was no difference in growth, mortality or morbidities between the two groups.

Conclusions

Patterned, frequency-modulated oro-somatosensory stimulation improves feeding development in premature infants and reduces their length of hospitalization.

Trial registration

ClinicalTrials.gov NCT01158391

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

BACKGROUND

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

PURPOSE

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

SEARCH STRATEGY

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

RESULTS

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

IMPLICATIONS FOR PRACTICE

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

IMPLICATIONS FOR RESEARCH

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

Stress Signals During Sucking Activity Are Associated With Longer Transition Time to Full Oral Feeding in Premature Infants

Several treatments have been proposed to shorten the time to the attainment of full oral feeding (FOF) for premature infants, but there are only a few evaluation methods useful in estimating predictors of this period. We investigated whether specific items within the disorganized sucking patterns described by the Neonatal Oral-Motor Assessment Scale (NOMAS) could estimate the time to FOF in preterm infants with feeding difficulty. Preterm infants diagnosed with a disorganized sucking pattern in the NOMAS evaluation before 50 weeks of postmenstrual age were included. Video recordings of at least 2 min of oral feeding were further analyzed retrospectively by two assessors and the premature infants who exhibited disorganized sucking patterns (n = 109) were divided into three clusters (clusters 2-4). The observational items compatible with disorganization in the original NOMAS were divided into three groups: cluster 2 (disorganized: arrhythmical), cluster 3 (disorganized: arrhythmical + unable to sustain), and cluster 4 (disorganized: arrhythmical + incoordination ± unable to sustain) and further divided into incoordination-positive (cluster 4) and incoordination-negative groups (clusters 2 and 3). Premature infants in the incoordination-positive group (cluster 4, which means stress signals) showed a median transition time of 22 days (range: 4-121 days) which was longer than that in the incoordination-negative group (median 6 days; range: 1-25 days). Univariate linear regression analysis revealed that the presence of incoordination among disorganized sucking patterns (NOMAS cluster 4 vs. clusters 2 and 3), birth weight, total parenteral nutrition (TPN) duration, non-invasive positive pressure ventilation duration, the presence of moderate to severe bronchopulmonary dysplasia, pulmonary hypertension, sepsis, small for gestational age (SGA), and necrotizing enterocolitis are associated with the transition time to FOF. In a multivariate linear regression analysis, the variables revealed to be associated with the transition time were TPN duration, SGA, and the presence of stress signals (incoordination-positive group) among disorganized sucking patterns. When selecting premature infants to be treated with swallowing therapy, it is reasonable to pay more attention to the incoordination-positive group described in the NOMAS, that is, premature infants with stress signals to shorten the time to attain FOF.

Using non-nutritive sucking to support feeding development for premature infants: A commentary on approaches and current practice

Non-nutritive sucking is often used with premature infants by either using a pacifier or an expressed breast nipple to support the introduction and development of early oral feeding. The pattern of non-nutritive sucking is distinct in that it involves two sucks per second in contrast to nutritive sucking which is one suck per second. Although some literature has identified that non-nutritive sucking has some benefit for the premature infant's feeding development, it is not entirely clear why such an approach is helpful as neurologically, activation of non-nutritive and nutritive skills are different. A summary is presented of the main approaches that use non-nutritive sucking with reference to the literature. This paper also considers other factors and beneficial approaches to managing the introduction of infant feeding. These are: the infant's toleration of enteral feeds pre oral trials, overall development and gestational age when introducing oral experiences, developing swallowing skills before sucking, physiological stability, health status, as well as the development and interpretation of infant oral readiness signs and early communication.

Olfactory stimulation may promote oral feeding in immature newborn: a randomized controlled trial

Premature newborns have an increased mortality and morbidity due to respiratory immaturity and inefficient oral feeding performance. Transient assistance with feeding tubes until oral performance improves is required with consequent hospital admission. Based on a controlled and randomized study, we tested whether olfactory stimulation compared to odorless stimulation could accelerate the switch from feeding tube to satisfactory oral feeding. Fifty newborns were included and randomly assigned to either odorless or olfactory stimulation with anise or cinnamon. The main outcome measurement was the duration of the hospital stay. The odor-stimulated group could be discharged from hospital on average 3.4 days earlier than the control group (p = 0.12). When including only more mature newborns into the analysis (n = 39), the difference was statistically significant (p < 0.05). This trend emphasizes that olfaction may have its place in early feeding stimulation.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Avoidance of bottles during the establishment of breast feeds in preterm infants

BACKGROUND

Preterm infants start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women who choose to breast feed their preterm infant are not always able to be in hospital with their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breast feeds is detrimental to breast feeding success is a topic of ongoing debate.

OBJECTIVES

To identify the effects of avoidance of bottle feeds during establishment of breast feeding on the likelihood of successful breast feeding, and to assess the safety of alternatives to bottle feeds.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE via PubMed (1966 to July 2016), Embase (1980 to July 2016) and CINAHL (1982 to July 2016). We also searched databases of clinical trials and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing avoidance of bottles with use of bottles in women who have chosen to breast feed their preterm infant.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. Review authors used standard methods of The Cochrane Collaboration and the Cochrane Neonatal Review Group.

MAIN RESULTS

We included seven trials with 1152 preterm infants. Five studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breast feeds were needed. We included the novel teat study in this review, as the teat was designed to more closely mimic the sucking action of breast feeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff and/or parents; the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Meta-analyses provided evidence of low to moderate quality indicating that avoiding bottles increases the extent of breast feeding on discharge home (full breast feeding typical risk ratio (RR) 1.47, 95% confidence interval (CI) 1.19 to 1.80; any breast feeding RR 1.11, 95% CI 1.06 to 1.16). Limited available evidence for three months and six months post discharge shows that avoiding bottles increases the occurrence of full breast feeding and any breast feeding at discharge and at six months post discharge, and of full (but not any) breast feeding at three months post discharge. This effect was evident at all time points for the tube alone strategy and for all except any breast feeding at three months post discharge for cup feeding. Investigators reported no clear benefit when the novel teat was used. No other benefits or harms were evident, including, in contrast to the previous (2008) review, length of hospital stay.

AUTHORS' CONCLUSIONS

Evidence of low to moderate quality suggests that supplementing breast feeds by cup increases the extent and duration of breast feeding. Current insufficient evidence provides no basis for recommendations for a tube alone approach to supplementing breast feeds.

Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants

BACKGROUND

Non-nutritive sucking (NNS) is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants to improve the development of sucking behavior and the digestion of enteral feedings.

OBJECTIVES

To assess the effects of non-nutritive sucking on physiologic stability and nutrition in preterm infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016), and CINAHL (1982 to 25 February 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials that compared non-nutritive sucking versus no provision of non-nutritive sucking in preterm infants. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported mean differences (MD) for continuous data, with 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses. We did not perform subgroup analyses because of the small number of studies related to the relevant outcomes. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We identified 12 eligible trials enrolling a total of 746 preterm infants. Meta-analysis, though limited by data quality, demonstrated a significant effect of NNS on transition from gavage to full oral feeding (MD -5.51 days, 95% CI -8.20 to -2.82; N = 87), transition from start of oral feeding to full oral feeding (MD -2.15 days, 95% CI -3.12 to -1.17; N = 100), and the length of hospital stay (MD -4.59 days, 95% CI -8.07 to -1.11; N = 501). Meta-analysis revealed no significant effect of NNS on weight gain. One study found that the NNS group had a significantly shorter intestinal transit time during gavage feeding compared to the control group (MD -10.50 h, 95% CI -13.74 to -7.26; N = 30). Other individual studies demonstrated no clear positive effect of NNS on age of infant at full oral feeds, days from birth to full breastfeeding, rates and proportion of infants fully breastfeeding at discharge, episodes of bradycardia, or episodes of oxygen desaturation. None of the studies reported any negative outcomes. These trials were generally small and contained various methodological weaknesses including lack of blinding of intervention and outcome assessors and variability on outcome measures. The quality of the evidence on outcomes assessed according to GRADE was low to very low.

AUTHORS' CONCLUSIONS

Meta-analysis demonstrated a significant effect of NNS on the transition from gavage to full oral feeding, transition from start of oral feeding to full oral feeding, and length of hospital stay. None of the trials reported any adverse effects. Well-designed, adequately powered studies using reliable methods of randomisation, concealment of treatment allocation and blinding of the intervention and outcome assessors are needed. In order to facilitate meta-analysis of these data, future research should involve outcome measures consistent with those used in previous studies.

Avoidance of bottles during the establishment of breast feeds in preterm infants

BACKGROUND

Preterm infants start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women who choose to breast feed their preterm infant are not always able to be in hospital with their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breast feeds is detrimental to breast feeding success is a topic of ongoing debate.

OBJECTIVES

To identify the effects of avoidance of bottle feeds during establishment of breast feeding on the likelihood of successful breast feeding, and to assess the safety of alternatives to bottle feeds.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE via PubMed (1966 to July 2016), Embase (1980 to July 2016) and CINAHL (1982 to July 2016). We also searched databases of clinical trials and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing avoidance of bottles with use of bottles in women who have chosen to breast feed their preterm infant.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. Review authors used standard methods of The Cochrane Collaboration and the Cochrane Neonatal Review Group.

MAIN RESULTS

We included seven trials with 1152 preterm infants. Five studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breast feeds were needed. We included the novel teat study in this review, as the teat was designed to more closely mimic the sucking action of breast feeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff and/or parents; the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Meta-analyses provided evidence of low to moderate quality indicating that avoiding bottles increases the extent of breast feeding on discharge home (full breast feeding typical risk ratio (RR) 1.47, 95% confidence interval (CI) 1.19 to 1.80; any breast feeding RR 1.11, 95% CI 1.06 to 1.16). Limited available evidence for three months and six months post discharge shows that avoiding bottles increases the occurrence of full breast feeding and any breast feeding at discharge and at six months post discharge, and of full (but not any) breast feeding at three months post discharge. This effect was evident at all time points for the tube alone strategy and for all except any breast feeding at three months post discharge for cup feeding. Investigators reported no clear benefit when the novel teat was used. No other benefits or harms were evident, including, in contrast to the previous (2008) review, length of hospital stay.

AUTHORS' CONCLUSIONS

Evidence of low to moderate quality suggests that supplementing breast feeds by cup increases the extent and duration of breast feeding. Current insufficient evidence provides no basis for recommendations for a tube alone approach to supplementing breast feeds.

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.

Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation

BACKGROUND

One of the most challenging milestones for preterm infants is the acquisition of safe and efficient feeding skills. The majority of healthy full term infants are born with skills to coordinate their suck, swallow and respiration. However, this is not the case for preterm infants who develop these skills gradually as they transition from tube feeding to suck feeds. For preterm infants the ability to engage in oral feeding behaviour is dependent on many factors. The complexity of factors influencing feeding readiness has led some researchers to investigate the use of an individualised assessment of an infant's abilities. A limited number of instruments that aim to indicate an individual infant's readiness to commence either breast or bottle feeding have been developed.

OBJECTIVES

To determine the effects of using a feeding readiness instrument when compared to no instrument or another instrument on the outcomes of time to establish full oral feeding and duration of hospitalisations.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 22 February 2016), EMBASE (1980 to 22 February 2016), and CINAHL (1982 to 22 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing a formal instrument to assess a preterm infant's readiness to commence suck feeds with either no instrument (usual practice) or another feeding readiness instrument.

DATA COLLECTION AND ANALYSIS

The standard methods of Cochrane Neonatal were used. Two authors independently screened potential studies for inclusion. No studies were found that met our inclusion criteria.

MAIN RESULTS

No studies met the inclusion criteria.

AUTHORS' CONCLUSIONS

There is currently no evidence to inform clinical practice, with no studies meeting the inclusion criteria for this review. Research is needed in this area to establish an evidence base for the clinical utility of implementing the use of an instrument to assess feeding readiness in the preterm infant population.

Spilled volum, oxygen saturation, and heart rate during feeding of preterm newborns: comparison between two alternative feeding methods

RESUMO Objetivo Comparar o uso da seringa e da técnica sonda-dedo para a oferta de dieta a prematuros, considerando-se volume de dieta oferecido e volume derramado, variação da saturação de oxigênio periférico e frequência cardíaca. Métodos Estudo quasi-experimental, com 30 prematuros, 13 do gênero feminino e 17 do masculino. As médias das idades gestacionais ao nascimento e no momento da avaliação (idade corrigida) foram de 33 4/7±4/7 e 36±4/7, respectivamente. Os pesos médios ao nascimento e na avaliação foram de 1.800±140 e 1.972±88 gramas. Foi avaliado um momento de alimentação com a seringa e outro com a sonda-dedo para a mesma criança, sendo caso e controle de si mesma. Utilizou-se oxímetro de pulso portátil para verificar a variação da saturação de oxigênio e a frequência cardíaca. Uma gaze foi colocada sob o queixo do bebê como anteparo da dieta derramada. Foram utilizados os testes ANOVA, t de Student pareado, Comparação Múltipla de Tukey e Correlação de Pearson, com nível de significância de 5%. Resultados Houve diferença para o volume oferecido e para o volume de leite derramado com os dois valores, sendo maiores quando a seringa foi utilizada. A frequência cardíaca foi diferente: antes/durante e antes/depois para ambas as formas de oferta, mas com valores considerados normais, assim como a saturação de oxigênio, que apontou aumento entre os momentos antes e depois da oferta para a seringa. Conclusão A técnica sonda-dedo proporciona menor derramamento da dieta, sendo as variações da saturação de oxigênio e frequência cardíaca consideradas normais para o neonato.

Effects of pacifier and taste on swallowing, esophageal motility, transit, and respiratory rhythm in human neonates

BACKGROUND

Pacifier use is widely prevalent globally despite hygienic concerns and uncertain mechanistic effects on swallowing or airway safety.

AIMS

The effects of pacifier and taste interventions on pharyngo-esophageal motility, bolus transit, and respiratory rhythms were investigated by determining the upper esophageal sphincter (UES), esophageal body, esophagogastric junction (EGJ) motor patterns and deglutition apnea, respiratory rhythm disturbances, and esophageal bolus clearance.

METHODS

Fifteen infants (six males; median gestation 31 weeks and birth weight 1.4 kg) underwent high-resolution impedance manometry at 43 (41-44) weeks postmenstrual age. Manometric, respiratory, and impedance characteristics of spontaneous swallows, pacifier-associated dry swallowing and taste (pacifier dipped in 3% sucrose)-associated swallowing were analyzed. Linear mixed and generalized estimating equation models were used. Data are presented as mean ± SEM, %, or median (IQR).

KEY RESULTS

Pharyngo-esophageal motility, respiratory, and impedance characteristics of 209 swallows were analyzed (85 spontaneous swallows, 63 pacifier- swallows, 61 taste- swallows). Basal UES and EGJ pressures decreased upon pacifier (p < 0.05) and taste interventions (p < 0.05); however, esophageal motility, respiratory rhythm, and impedance transit characteristics were similar with both interventions.

CONCLUSIONS & INFERENCES

Oral stimulus with pacifier or taste interventions decreases UES and EGJ basal pressure, but has no effects on pharyngo-esophageal motility, airway interactions, or esophageal bolus transit. A decrease in central parasympathetic-cholinergic excitatory drive is likely responsible for the basal effects.

Development of infant oral feeding skills: what do we know?

The hospital discharge of premature infants in neonatal intensive care units is often delayed due to their inability to feed by mouth safely and competently. With immature physiologic functions, infants born prematurely cannot be expected to readily feed by mouth at the equivalent age of a third trimester of gestation as the majority of their term counterparts do. Consequently, it is crucial that health care professionals gain an adequate knowledge of the development of preterm infants' oral feeding skills so as to optimize their safety and competency as they transition to oral feeding. With a greater sensitivity toward their immature skills, we can offer these infants a safer and smoother transition to independent oral feeding than is currently observed. This review article is an overview of the evidence-based research undertaken over the past 2 decades on the development of very-low-birth-weight infants' oral feeding skills. The description of the different functional levels where these infants can encounter hurdles may assist caregivers in identifying a potential cause or causes for their individual patients' oral feeding difficulties.

Premature: growth and its relation to oral skills

OBJECTIVE

To evaluate the influence of oral motor skills of premature infants on their oral feeding performance and growth, during neonatal hospitalization.

METHODS

Fifty-one newborns hospitalized in the neonatal intensive care unit of a hospital in Southern Brazil, between July 2012 and March 2013, were evaluated. The evaluation of oral feeding skills, according to Lau and Smith, was applied after prescription for starting oral feeding. The oral feeding performance was analyzed using the following variables: days taken to start independent oral feeding and hospital discharge. Growth was measured by weight, length, and head circumference, using the curves of Fenton, at birth, first and independent oral feeding, and hospital discharge.

RESULTS

At birth, 71% preterm infants were proper for gestational age, most of them were males (53%), with average of 33.6 (±1.5) weeks of gestational age. The gestational age in the assessment did not influence the oral feeding performance of the premature infant and did not differ between levels. Time of transition from tube feeding to oral feeding and hospital stay was shorter when the oral skills were higher. At birth, there was a tendency of low weight and low oral feeding performance. Level IV premature infants in the release of oral feeding presented higher weights.

CONCLUSION

The level of oral skills of the premature infant interfered positively on time of feeding transition from tube to independent oral feeding and hospital stay. Growth, represented by weight gain, was not affected by the level of oral skill.

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.

Breastfeeding progression in preterm infants is influenced by factors in infants, mothers and clinical practice: the results of a national cohort study with high breastfeeding initiation rates

Background and Aim

Many preterm infants are not capable of exclusive breastfeeding from birth. To guide mothers in breastfeeding, it is important to know when preterm infants can initiate breastfeeding and progress. The aim was to analyse postmenstrual age (PMA) at breastfeeding milestones in different preterm gestational age (GA) groups, to describe rates of breastfeeding duration at pre-defined times, as well as analyse factors associated with PMA at the establishment of exclusive breastfeeding.

Methods

The study was part of a prospective survey of a national Danish cohort of preterm infants based on questionnaires and structured telephone interviews, including 1,221 mothers and their 1,488 preterm infants with GA of 24–36 weeks.

Results

Of the preterm infants, 99% initiated breastfeeding and 68% were discharged exclusively breastfed. Breastfeeding milestones were generally reached at different PMAs for different GA groups, but preterm infants were able to initiate breastfeeding at early times, with some delay in infants less than GA 32 weeks. Very preterm infants had lowest mean PMA (35.5 weeks) at first complete breastfeed, and moderate preterm infants had lowest mean PMA at the establishment of exclusive breastfeeding (36.4 weeks). Admitting mothers to the NICU together with the infant and minimising the use of a pacifier during breastfeeding transition were associated with 1.6 (95% CI 0.4–2.8) and 1.2 days (95% CI 0.1–2.3) earlier establishment of exclusive breastfeeding respectively. Infants that were small for gestational age were associated with 5.6 days (95% CI 4.1–7.0) later establishment of exclusive breastfeeding.

Conclusion

Breastfeeding competence is not developed at a fixed PMA, but is influenced by multiple factors in infants, mothers and clinical practice. Admitting mothers together with their infants to the NICU and minimising the use of pacifiers may contribute to earlier establishment of exclusive breastfeeding.

Preterm infants' orally directed behaviors and behavioral state responses to the integrated H-HOPE intervention

Preterm infants are challenged by immature infant behavioral organization which may negatively influence their ability to oral feed. The purpose of this study was to determine whether the integrated H-HOPE (Hospital to Home: Optimizing the Infant's Environment) intervention would improve infant behavioral organization by increasing the frequency of orally directed behaviors and the proportion of time spent in an alert behavioral state when offered prior to oral feeding. Mother-infant dyads (n=198) were randomly assigned to the H-HOPE intervention or the Attention Control groups. Infants were born at 29-34 weeks gestation and were clinically stable. Mothers had at least two social environmental risk factors such as minority status or less than high school education. H-HOPE is an integrated intervention that included (1) twice-daily infant directed stimulation using the ATVV intervention (auditory, tactile, visual, and vestibular stimuli) and (2) maternal participatory guidance sessions by a nurse-community advocate team. Orally directed behaviors and behavioral states were assessed weekly prior to feeding during hospitalization when infants were able to feed orally. There were no differences between the groups at baseline (Day 0, prior to the initiation of the integrated H-HOPE intervention). We observed a pattern of increased frequency of orally directed behaviors in the H-HOPE intervention group when compared to the Attention Control group, however, the proportion of time spent in an alert behavioral state remained stable in both groups over the course of the study. On Day 7, the H-HOPE intervention group exhibited a significantly higher mean frequency of orally directed behaviors than the Attention Control group (12.6 vs. 7.1 pre-intervention, 51.8 vs. 33.2 during intervention, 4.3 vs. 3.2 immediately after intervention, and 8.9 vs. 5.3 immediately prior to feeding). On Day 7, the H-HOPE intervention group exhibited a significantly higher proportion of time spent in an alert behavioral state only during intervention (0.26 vs. 0.11) and immediately after intervention (0.28 vs. 0.06). These findings are suggestive that the integrated H-HOPE intervention facilitated infant behavioral organization for clinically stable infants born between 29 and 34 weeks gestation. The orally directed behaviors appear to be an important indicator of the infant's preparation for feeding, and when used in conjunction with assessment of behavioral states, are especially valuable to the clinician. Use of this combined assessment approach in practice would strengthen clinician assessment for initiation of (beginning the first oral feeding) and daily preparation for oral feeding in preterm infants.