Development of the Preterm Infant Breastfeeding Behavior Scale (PIBBS): a study of nurse-mother agreement

Feeding development in healthy infants: A comparative framework for children with Spinal Muscular Atrophy - The DySMAnorm study

OBJECTIVES

Normative data for swallowing parameters in non-dysphagic, healthy children for instrumental and clinical diagnostics are limited. In children with SMA, where due to the degenerative nature a deterioration in swallowing function in the first months of life is possible despite disease-modifying therapy, regular monitoring is required. The DySMA (Dysphagia in Spinal Muscular Atrophy) is a tool available to assess both physiological feeding development and specific abnormalities in children with SMA. We aimed to generate normative data for the DySMA in a sample of healthy infants to facilitate comparisons with children with SMA.

METHODS

Healthy infants and toddlers aged zero to 24 months were recruited and divided into seven age groups. Two speech-language pathologists assessed the children according to the DySMA study protocol. The data were evaluated descriptively and the inter-rater reliability was calculated.

RESULTS

A total of 92 healthy children were included. The DySMA total score ranged from 21 to 35 and showed excellent inter-rater reliability (ICC = .936; 95 % CI .752 to .984). The maximum score of 35 was first reached from 16 months onwards. Categories representing physiological development showed the most significant age-dependent changes, while no age-related development was observed in categories expressing pathology.

CONCLUSION

The DySMA effectively captures physiological feeding development. A higher total score reflects more comprehensive skills in children, while a lower score indicates a reduced range of abilities. By analyzing the normative sample, this tool makes it possible to represent a deviation from the norm for children with SMA.

Effect of an oral stimulation protocol on breastfeeding among preterm infants: a randomised controlled trial

OBJECTIVES

The objectives are to assess the effectiveness of a modified and adapted oral sensorimotor intervention (MA-OSMI) protocol for infants in India on the rate and performance of breastfeeding among preterm (PT) infants at discharge.

DESIGN

Single-centre randomised control trial.

SETTING

Level III B neonatal intensive care unit in a quaternary care hospital in South India.

PATIENTS

A total of 76 PT infants born between 26 and 33+6 weeks of gestational age, stratified into <30 weeks and 30-33+6 weeks, were randomised to intervention group (MA-OSMI) or standard care (SC).

INTERVENTIONS

MA-OSMI in addition to SC versus SC alone. The stimulation included 12 techniques administered by the principal investigator. SC included kangaroo mother care and non-nutritive sucking.

OUTCOME MEASURES

Exclusive breastfeeding (EBF) rate and breastfeeding performance at the time of discharge, assessed using standardised tools by clinician and mothers.

RESULTS

Infants in MA-OSMI group (66%) had significantly higher EBF rate compared with the SC group (16%) (OR: 10.25; 95% CI: 3.41 to 30.80). Improved breastfeeding performance was noted as per the clinician's observation. Significantly lower scores for MA-OSMI groups (63.42±36.43) than SC groups (126.61±60.94) on mothers' ratings suggested better feeding skills.

CONCLUSION

Prefeeding oral stimulation contributed significantly to the achievement of EBF among PT infants at discharge. The present findings may benefit speech-language pathologists, paediatricians/neonatologists and nurses in the intervention of oral feeding among neonates.

Barriers and Facilitators in Lactation Support for the Preterm Mother-Infant Dyad: An Integrated Approach

Breastfeeding offers significant health benefits for both mothers and infants, particularly preterm infants, where it serves as a therapeutic strategy to reduce mortality and morbidities. However, breastfeeding practices are threatened globally by societal norms and systemic barriers at both micro and macro levels. This paper explores the complex interplay of these barriers and facilitators, focusing on the Neonatal Intensive Care Unit (NICU) setting. Preterm infants face specific feeding challenges due to immature physiological functions, yet evidence supports that strategies like cue-based feeding and individualized care can enhance feeding success and health outcomes. For mothers, initiating and maintaining lactation after preterm birth is critical but challenging, with early lactation support and achieving sufficient milk volume being key predictors of success. Partner support significantly influences lactation outcomes, although more inclusive research is needed for diverse family structures. In the NICU, a multidisciplinary approach to lactation care is vital, emphasizing the need for experienced staff and family-centered practices. NICU design, policies promoting parental presence, and adherence to Baby-friendly Hospital Initiative guidelines further support breastfeeding. This paper aims to provide directives for local breastfeeding policies through an integrated approach, considering societal attitudes and healthcare practices. The findings advocate for improved lactation support in NICUs, inclusive language and policies, and further research into diverse familial and gender roles in breastfeeding.

Clinical assessment of breastfeeding in preterm infants

Breastmilk confers empirical benefits for preterm infants, however direct breastfeeding rates in this population remain low. For preterm infants, it may be useful to assess the volume of breastmilk transferred from mother to baby when breastfeeding, particularly during transition to oral feeding when breastfeeding attrition is high. Establishing breastfeeding in preterm infants is complex and without knowledge of milk intake during breastfeeds there is risk of inaccurate feed supplementation with subsequent effects on growth and nutrition. Here we review the evidence for clinical assessments of breastfeeding in preterm infants including test weighing, use of isotope labelled water and clinical observation tools designed to estimate adequacy of breastfeeds. Test weighing is a validated measurement, however requires rigorous protocols and further investigation in small infants. Use of isotope labelled water is a validated technique but, due to sampling requirements, reflects intake over days and weeks instead of individual feeds. Clinical observation tools assessed in preterm infants, have not been shown to reflect volumes of breastmilk intake. While current methods have limitations, the goal is to identify measurement tools to be used as temporary aids to facilitate transition to direct breastfeeding while minimising risk of inaccurate supplementation.

A swallowing and breastfeeding intervention programme for small and sick neonates embedded in kangaroo mother care

Available evidence of oral sensorimotor interventions for small neonates is not strong. Evidence of interventions for sick term neonates is largely lacking. Studies are limited by risk of bias and inconsistency. Evidence of interventions relying on a single stimulation technique only appears to be low to very low. Ongoing research is required.Contribution: We describe a five-component neonatal swallowing and breastfeeding intervention programme embedded in the practice of kangaroo mother care (KMC). Drawing on oropharyngeal physiology, neonatology, neurodevelopmental care, breastfeeding- and KMC science, the programme is the product of collaboration between a speech-language therapist and a medical doctor, and their team. Its implementation is dependent on coaching mothers and the neonatal care team. Researchers are invited to determine outcomes of the programme.

The Association Between Breastfeeding and Growth Among Infants with Moderately Low Birth Weight: A Prospective Cohort Study

OBJECTIVE

To assess the association between breastfeeding competency, as determined by Latch, Audible swallowing, Type of nipple, Comfort, and Hold (LATCH) and Preterm Infant Breastfeeding Behavior Scale (PIBBS) scores, and exclusive breastfeeding and growth among infants with low birth weight (LBW) in India, Malawi, and Tanzania.

STUDY DESIGN

We conducted LATCH and PIBBS assessments among mother-infant dyads enrolled in the Low Birthweight Infant Feeding Exploration (LIFE) observational study of infants with moderately LBW (1500g-2499 g) in India, Malawi, and Tanzania. We analyzed feeding and growth patterns among this cohort.

RESULTS

We observed 988 infants. We found no association between LATCH or PIBBS scores and rates of exclusive breastfeeding at 4 or 6 months. Higher week 1 LATCH and PIBBS scores were associated with increased likelihood of regaining birth weight by 2 weeks of age [LATCH: aRR 1.42 (95% CI 1.15, 1.76); PIBBS: aRR 1.15 (95% CI 1.07, 1.23); adjusted for maternal age, parity, education, residence, delivery mode, LBW type, number of offspring, and site]. Higher PIBBS scores at 1 week were associated with improved weight gain velocity (weight-for-age z-score change) at 1, 4, and 6 months [adjusted beta coefficient: 1 month 0.04 (95% CI 0.01, 0.06); 4 month 0.04 (95% CI 0.01, 0.06); and 6 month 0.04 (95% CI 0.00, 0.08)].

CONCLUSION

Although week 1 LATCH and PIBBS scores were not associated with rates of exclusive breastfeeding, higher scores were positively associated with growth metrics among infants with LBW, suggesting that these tools may be useful to identify dyads who would benefit from early lactation support.

Developing the Mansoura Early Feeding Skills Assessment Scale for Preterm Infants

Purpose

This study aimed to develop a new bedside scoring system scale that assesses preterm infants' oral feeding skills (OFS) in the neonatal intensive care unit (NICU).

Methods

A literature review and critical appraisal of available oral feeding assessment tools/scores were performed. Subsequently, we developed the "Mansoura Early Feeding Skills Assessment" (MEFSA) scale, an 85-item observational measure of oral feeding skills with three main sections. Forty-one preterm infants who did not receive oral feeding but were clinically stable enough to initiate oral feeding were included in the study. Next, we applied and interpreted the MEFSA to describe and score their feeding skills.

Results

Applying the MEFSA resulted in a smooth feeding transition, early start of oral feeding, full oral feeding, and discharge with a shorter period of tube feeding in preterm infants.

Conclusion

The MEFSA is a successful bedside scoring system that assesses the OFS of preterm infants in the NICU.

Facility-based care for moderately low birthweight infants in India, Malawi, and Tanzania

Globally, increasing rates of facility-based childbirth enable early intervention for small vulnerable newborns. We describe health system-level inputs, current feeding, and discharge practices for moderately low birthweight (MLBW) infants (1500-<2500g) in resource-constrained settings. The Low Birthweight Infant Feeding Exploration study is a mixed methods observational study in 12 secondary- and tertiary-level facilities in India, Malawi, and Tanzania. We analyzed data from baseline facility assessments and a prospective cohort of 148 MLBW infants from birth to discharge. Anthropometric measuring equipment (e.g., head circumference tapes, length boards), key medications (e.g., surfactant, parenteral nutrition), milk expression tools, and human milk alternatives (e.g., donor milk, formula) were not universally available. MLBW infants were preterm appropriate-for-gestational age (38.5%), preterm large-for-gestational age (3.4%), preterm small-for-gestational age (SGA) (11.5%), and term SGA (46.6%). The median length of stay was 3.1 days (IQR: 1.5, 5.7); 32.4% of infants were NICU-admitted and 67.6% were separated from mothers at least once. Exclusive breastfeeding was high (93.2%). Generalized group lactation support was provided; 81.8% of mother-infant dyads received at least one session and 56.1% had 2+ sessions. At the time of discharge, 5.1% of infants weighed >10% less than their birthweight; 18.8% of infants were discharged with weights below facility-specific policy [1800g in India, 1500g in Malawi, and 2000g in Tanzania]. Based on descriptive analysis, we found constraints in health system inputs which have the potential to hinder high quality care for MLBW infants. Targeted LBW-specific lactation support, discharge at appropriate weight, and access to feeding alternatives would position MLBW for successful feeding and growth post-discharge.

Automatic Pasteurized Formula Milk Preparation Machine with Automatic Sterilized Containers

Children are the future of our generation, so reducing child mortality is very critical in developing countries. There are lots of asserting factors of child mortality but malnutrition is one of the prominent factors. Medically, it has been proven that breastfeeding is one of the sources of nutrients and it is being always appreciated to have mothers' milk to a child in the early days. However, with the increasing participation of women in the workforce, the child care load on breastfeeding mothers is very high. This forces many of them to take long career breaks. Here, in this paper, we have an automatic formula milk dispensing unit that will be used in Neonatal Intensive Care Units (NICUs) and for breastfeeding mothers at home. The device has inbuilt sterilization and pasteurization units that would maintain the overall hygiene and sterilization of baby milk bottles. Currently, the device has a few buttons through which we can control the functionality of the device.

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.

Psychometric properties of the oral feeding assessment in premature infants scale

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

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 NCT04283682. Registered on 8 February 2020.

Translation and study of the measurement properties of the Early Feeding Skills Assessment tool in premature newborn

INTRODUCTION

With the aim of improving the care of the premature newborn during their hospital stay, and their well-being in the transition from enteral to independent feeding, it is proposed to incorporate an assessment system within a Spanish Neonatal Unit. The translation of the Early Feeding Skills Assessment (EFSA) tool is presented, along with a study of its measurement properties.

PATIENTS AND METHOD

A total of 104 assessments were made on premature babies of less than 34 + 6 weeks of gestational age, admitted to the neonatal unit with total or partial feeding, including a normal neurological examination for their age and with physiological stability.

RESULTS

The EFSA 2010 tool achieved an acceptable value (0.76) as regards its internal consistency. The EFSA 2018 tool maintained an acceptable internal consistency value (0.751). As regards the reliability between two observers, the results showed a satisfactory and excellent reliability in 57.69% of the items in the EFSA 2010 tool, a property that improved in the EFSA 2018 tool (73.68%).

CONCLUSIONS

The Spanish version of the EFSA tool is consistent and reliable for use as a tool for the assessment of oral abilities for feeding premature babies admitted into a Spanish Neonatal Unit.

Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review

Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding 'domains' (baby's behaviour; mother's behaviour; position; latching; effective feeding; breast health; baby's health; mother's view of  feed; number, timing and length of feeds). Results: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form. Conclusions: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.

Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review

Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding 'domains' (baby's behaviour; mother's behaviour; position; latching; effective feeding; breast health; baby's health; mother's view of  feed; number, timing and length of feeds). Results: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form. Conclusions: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.

Estimates of Preterm Infants' Breastfeeding Transfer Volumes Are Not Reliably Accurate

BACKGROUND

Adequate human milk nutrition is critical for infant growth and neurodevelopment; however, low milk transfer volumes are common when establishing preterm breastfeeding. Despite clinical assessments of milk transfer volumes at the breast being inaccurate, measurement of feed volume via test weighing is rarely carried out either routinely or in cases where infant weight gain is inadequate.

PURPOSE

To assess the accuracy of the Preterm Breastfeeding Assessment Tool (PBAT) in determining transfer volumes and examine factors associated with PBAT accuracy.

METHODS

Pre/postfeed weights were performed using electronic scales and PBAT scores recorded for 1186 breastfeeds in 60 preterm infants born less than 33/40 and 33 to 39/40 postmenstrual age. Measured milk intake volumes were converted to percent prescribed feed volume and compared with PBAT estimates of milk transfer.

RESULTS

The PBAT is accurate in identifying when no milk is transferred at the breast but not in estimating transfer of half or the full prescribed volume (accuracy 26% and 47%, respectively). Wide ranges of transfer volumes (11-75 mL) were observed within and between infants, and for 20% of breastfeeds, no milk was transferred. Preterm Breastfeeding Assessment Tool accuracy decreased with each 1-week increase in birth gestation (odds ratio = 0.82; 95% confidence interval, 0.71-0.94; P = .004).

IMPLICATIONS FOR PRACTICE

When establishing breastfeeding, test weighing facilitates adequate nutrition by guiding appropriate complementary feeding. For mothers breastfeeding several times per day in preparation for discharge home, test weighing may offer a useful tool for developing maternal confidence in assessing milk transfer. Preterm Breastfeeding Assessment Tool is inaccurate in assessing preterm infants' milk transfer volumes when breastfeeding.

IMPLICATIONS FOR RESEARCH

While studies have typically focused on medically stable infants, test weighing offers a useful tool to examine breastfeeding efficacy and inform nutritional management of preterm infants with complications such as chronic lung and cardiac disease.

Using the Preterm Infant Breastfeeding Behavior Scale With Late Preterm Infants

Background

Feeding effectiveness of late preterm infants may vary between feedings and over time, creating confusion and frustration for parents and clinicians. An assessment tool for late preterm infants may assist mothers to recognize breastfeeding behavior more clearly. Although tools are available, none have been tested specifically with late preterm infants. We sought to determine the inter-rater reliability of the Preterm Infant Breastfeeding Behavior Scale scores for late preterm infants between mothers and a health professional.

Methods

A one-group observational non-experimental design assessed inter-rater reliability (24 hours [n =23] and 48 hours [n =11] after birth).

Results

The scale's six components were scored independently; agreement ranged from 81.8% to 100% for all components.

Conclusions

The tool was reliable and could be used to help clinicians and parents accurately understand feeding patterns and behaviors assisting with feeding decisions.

Interrater Reliability and Concurrent Validity of the Neonatal Eating Outcome Assessment

IMPORTANCE

Few neonatal feeding assessments are currently available, and the Neonatal Eating Outcome Assessment is the only one that identifies feeding impairment while considering the developmental changes that occur from preterm birth to term-equivalent age.

OBJECTIVE

To determine the interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment.

DESIGN

Prospective, observational study.

SETTING

Level 4 neonatal intensive care unit.

PARTICIPANTS

A convenience sample of 7 neonatal therapists participated in reliability testing. For concurrent validity, a prospective cohort of 52 preterm infants born ≤32 wk gestation had feeding assessed at term-equivalent age.

OUTCOMES AND MEASURES

Intraclass correlations (ICCs) and Fleiss's κ statistics were used to define reliability across therapists, who independently scored five videos of preterm infants orally feeding using the Neonatal Eating Outcome Assessment. Concurrent validity was determined by evaluating relationships between the Neonatal Oral Motor Assessment Scale (NOMAS) and the Neonatal Eating Outcome Assessment using an independent-samples t test and χ² analysis.

RESULTS

The ICC for the Neonatal Eating Outcome Assessment total score was 0.90 (confidence interval [CI] [0.70, 0.99]). Fleiss's κ scores for the 19 scorable items on the Neonatal Eating Outcome Assessment had predominately moderate, fair, and slight agreement, with 3 items having poor agreement. Dysfunctional NOMAS scores were related to lower Neonatal Eating Outcome Assessment scores (t[49.4] = 3.72, mean difference = 12.2, 95% CI [5.60, 18.75], p = .001).

CONCLUSIONS AND RELEVANCE

The Neonatal Eating Outcome Assessment has excellent reliability. Concurrent validity was established.

WHAT THIS ARTICLE ADDS

This article reports that the final version of the Neonatal Eating Outcome Assessment (Version 5.7) has excellent interrater and concurrent validity and is an important tool to assess the occupation of infant feeding in clinical practice.

Oropharyngeal Dysphagia in Breastfeeding Neonates with Hypoxic-Ischemic Encephalopathy on Therapeutic Hypothermia

Purpose: To identify symptoms of oropharyngeal dysphagia (OPD) in breastfeeding neonates with hypoxic-ischemic encephalopathy (HIE) on therapeutic hypothermia (TH). Early identification of feeding problems in neonates with HIE by speech-language therapists (SLTs) may prevent secondary complications of OPD such as aspiration pneumonia and death. Materials and Methods: Twenty-eight full-term neonates with HIE (mean chronological age = 4.5 days) and 30 healthy term controls were prospectively recruited for this case-control study. Participants with HIE (mild [n = 15], moderate [n = 11], severe [n = 2]), diagnosed by pediatricians, received whole-body TH. Feeding was clinically evaluated by an SLT using the Preterm Infant Breastfeeding Behavior Scale. Results: Twenty-five neonates (89.2%) had at least one symptom of OPD. Falling asleep during feeding, noticeable oral secretions, coughing, and flaring nostrils were symptoms of OPD most frequently identified. The HIE group displayed limited arousal during breastfeeding and had less obvious rooting, shallower latching onto the breast, and more single sucks in comparison to term newborns. The HIE group had significantly more closed eyes and minimal movement during breastfeeding, while controls showed the quiet-alert state ideal for breastfeeding. Conclusions: OPD was identified in the majority of infants with HIE. Underlying the appearance of an inactive neonate with HIE may be OPD that could be overlooked if not investigated. Interprofessional collaboration between SLTs, pediatricians and nurses to determine feeding-readiness is imperative. SLTs may assist in decision-making to improve safety of breastfeeding in this population. This study contributes to the small body of research on early breastfeeding of neonates with HIE.

Prediction of nutritive sucking in preterm babies (<34 weeks) and preterm sucking readiness scale

Objective

To determine predictors of nutritive-sucking in babies < 34 weeks and estimate the appropriate preterm sucking readiness (PTSR) score as an indicator of readiness of nutritive-sucking.

Methods

Prospective longitudinal observational study conducted in Neonatal unit of a referral hospital attached to Medical College. Forty-nine inborn babies of 28-34 weeks’ gestation and on full gavage feeds were enrolled.

Results

(a) Nutritive-sucking was achieved at a median age of 14 days (Range 7–50). (b) Low birth weight (LBW) (< 1531.1 ± 142.8) and lesser gestational age (GA) (< 32.8 ± 1) were poor predictors (p < 0.05) and have a significant independent negative association (Correlation birth weight (BW) - 0.0222, GA − 2.2177) with age at which established nutritive-sucking was achieved. (c) PTSR score of ≥9 had the best prediction for achievement of nutritive-sucking at 14-days of life, with a sensitivity of 92.3% and specificity of 100%.

Conclusion

PTSR score is a sensitive and specific tool to predict the readiness for nutritive-sucking in preterm babies < 34 weeks.

Growth and Change in the Journal of Human Lactation: A Content Analysis 1985-2018

BACKGROUND

A professional association journal should reflect the needs of its organization, its readers, and the field it represents. Evaluating the needs that the Journal of Human Lactation has met, and those it has not, is essential if it is to remain relevant to its readers.

AIMS

(1) Describe the characteristics of articles published from 1985 through 2018. (2) Describe content intended to educate lactation support providers and clinicians. (3) Explore the ways the content has illustrated the growth and development of lactation knowledge, and (4) identify the reoccurring content threads consistent throughout the 34 years.

METHODS

A prospective mixed methods approach incorporating a quantitative content analysis and a qualitative thematic analysis was used. Frequency distributions were done on all the variables extracted from published articles (N = 1586). The second level of analysis identified themes using an iterative and consensus approach.

RESULTS

Mirroring the growth in the lactation field, the volume of research articles published each year has increased along with the percent of research articles per issue. Research methods have become more diverse. The international scope and relevance, while always present, has been steadily increasing. Threads identified were; striving for international scope, advancing lactation education, developing a body of knowledge that informs clinical practice in lactation, and creating a centralized place for multidisciplinary research about lactation.

CONCLUSION

The body of work published in the Journal of Human Lactation parallels the development of the lactation specialty. We have highlighted areas for improvement and possible further study.

Breastfeeding skills of full-term newborns and associated factors in a low-and-middle-income setting

BACKGROUND

Normative information on the breastfeeding of term newborns may guide clinicians in early identification of breastfeeding difficulties and oro-pharyngeal dysphagia (OPD), and may support optimal breastfeeding practices.

OBJECTIVE

To describe breastfeeding skills of term newborn infants in a South African hospital, a lower-middle-income setting, and investigate associations between infants' feeding and other factors.

METHOD

One breastfeeding session of each of the 71 healthy newborn full-term infants (mean chronological age=1.9 days; mean gestation=39.1 weeks) was evaluated using the Preterm Infant Breastfeeding Behavior Scale (PIBBS), suitable for use with term newborns.

RESULTS

All participants were exclusively breastfed. Thirteen participants (18%) were HIV-exposed. There was no significant difference in the findings of the PIBBS between HIV-exposed and unexposed participants. Most newborns had obvious rooting, latched deeply onto the nipple and some of the areola, had repeated long sucking bursts (mean length=16.82 sucks/burst), and swallowed repeatedly. Most participants were in either the drowsy or quiet-alert state, which are optimal behavioural states for breastfeeding. One to two-hourly on-demand feeds was significantly associated with mothers who had normal births and did not use galactogogues to promote lactation.

CONCLUSION

Results may be used for early identification of OPD in newborns. The findings may be useful to primary care clinicians.

Neonatal Eating Assessment Tool - Mixed Breastfeeding and Bottle-Feeding (NeoEAT - Mixed Feeding): factor analysis and psychometric properties

BACKGROUND

Early identification of feeding difficulty in infancy is critical to supporting breastfeeding and ensuring optimal nutrition for brain development. The Neonatal Eating Assessment Tool (NeoEAT) is a parent-report assessment that currently has two versions: NeoEAT - Breastfeeding and NeoEAT - Bottle-feeding for use in breast and bottle-fed infants, respectively. There are currently no valid and reliable parent-report measures to assess feeding through a combination of both breast and bottle delivery. The purpose of this study was to conduct a factor analysis and test the psychometric properties of a new measure, the NeoEAT - Mixed Breastfeeding and Bottle-Feeding (NeoEAT - Mixed Feeding), including internal consistency reliability, test-retest reliability, construct validity and known-groups validity.

METHODS

Parents of infants younger than 7 months who had fed by both bottle and breast in the previous 7 days were invited to participate. Internal consistency reliability was tested using Cronbach's α. Test-retest reliability was tested between scores on the NeoEAT - Mixed Feeding completed 2 weeks apart. Construct validity was tested using correlations between the NeoEAT - Mixed-Feeding, the Infant Gastroesophageal Reflux Questionnaire - Revised (I-GERQ-R), and the Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Known-groups validation was tested between healthy infants and infants with feeding problems.

RESULTS

A total of 608 parents participated. Exploratory factor analysis revealed a 68-item scale with 5 sub-scales. Internal consistency reliability (Cronbach's α = .88) and test-retest reliability (r = 0.91; p < .001) were both acceptable. Construct validity was demonstrated through correlations with the I-GERQ-R (r = 0.57; p < .001) and IGSQ (r = 0.5; p < .001). Infants with feeding problems scored significantly higher on the NeoEAT - Mixed Feeding, indicating more problematic feeding symptoms, than infants without feeding problems (p < .001), supporting known-groups validity.

CONCLUSIONS

The NeoEAT - Mixed Feeding is a 68-item parent-reported measure of breast- and bottle-feeding behavior for infants less than 7 months old that now has evidence of validity and reliability for use in clinical practice and research. The NeoEAT - Mixed Feeding can be used to identify infants with problematic feeding, guide referral decisions, and evaluate response to interventions.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

IMPLICATIONS FOR PRACTICE

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

IMPLICATIONS FOR RESEARCH

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

Oral Sensorimotor Intervention Enhances Breastfeeding Establishment in Preterm Infants

OBJECTIVE

To assess the efficacy of an oral sensorimotor intervention on breastfeeding establishment and maintenance in preterm infants.

STUDY DESIGN

Thirty-one preterm infants born ≤34 weeks gestation were randomized into an experimental or control group. The experimental group received a 15-minute program consisting of stroking the peri-oral structures for the first 5 minutes, tongue exercises for the next 5 minutes, followed by non-nutritive sucking for the final 5 minutes. The control group received a sham intervention for the same duration. The interventions were administered once daily for 10 days. The outcomes included: time to attainment of full oral feeding, breastfeeding acquisition (i.e., ≥50% of direct breastfeeding at hospital discharge), breastfeeding skill assessment using the Preterm Infant Breastfeeding Behavior Scale (PIBBS), length of hospitalization, and breastfeeding maintenance at 3 and 6 months posthospitalization.

RESULTS

Full oral feeding was attained earlier in the experimental group compared with the control (10.7 ± 2.1 vs. 19.3 ± 3.6 days, p < 0.01). This was associated with a greater number of infants in the intervention group acquiring breastfeeding at hospital discharge compared with the controls (n = 11 vs. 5, p = 0.049). There was no statistical difference in PIBBS score, length of hospitalization, and breastfeeding rates at 3 and 6 months posthospitalization between the two groups (all tests, p > 0.32).

CONCLUSIONS

An oral sensorimotor intervention accelerated the achievement of full oral feeding and enhanced direct breastfeeding rates at hospital discharge only. Provision of an oral sensorimotor intervention is a safe and low-cost intervention that may increase breastfeeding rates in a highly vulnerable population.

A systematic review of clinical and psychometric properties of infant oral motor feeding assessments

PURPOSE

To describe the clinical properties and psychometric soundness of infant oral motor feeding assessments available for practice.

METHODS

A systematic review was conducted using six databases (PubMed, Ovid [Medline], CINHAL, EMBASE, psycINFO, and COCHRANE) to retrieve articles. Assessments were analyzed for their clinical characteristics and psychometric robustness.

RESULTS

Ten assessment tools were identified to meet the inclusion/exclusion criteria. Clinical properties of the tools varied from assessments which assessed oral feeding readiness, oral motor function, and pre-feeding skills for breast and/or bottle feeding. Psychometric evidence was found for seven assessment tools. The Neonatal Oral Motor Assessment Scale was found to be the most widely tested for psychometric soundness. The overall psychometric evidence was inconsistent and/or inadequate for the evaluative tools.

CONCLUSIONS

Findings from this systematic review demonstrate clinical usefulness of the tools based on their assessment properties, however additional studies are needed to further establish their psychometric soundness.

Factor Structure and Psychometric Properties of the Neonatal Eating Assessment Tool-Breastfeeding

The purpose of this study was to identify the factor structure of the Neonatal Eating Assessment Tool-Breastfeeding (NeoEAT-Breastfeeding) and to assess its psychometric properties, including internal consistency reliability, test-retest reliability, and construct validity as measured by concurrent and known-groups validity. Exploratory factor analysis conducted on responses from 402 parents of breastfeeding infants younger than 7 months old showed a 62-item measure with seven subscales and acceptable internal consistency reliability (Cronbach's α = .92). Test-retest reliability was also acceptable (r = .91). The NeoEAT-Breastfeeding has evidence of concurrent validity with the Infant Gastroesophageal Reflux Questionnaire (r = .69) and Infant Gastrointestinal Symptoms Questionnaire (r = .62). The NeoEAT-Breastfeeding total score and all subscale scores were higher in infants with feeding problems than in typically feeding infants (p < .001, known-groups validity). The NeoEAT-Breastfeeding is a parent-report assessment of breastfeeding in infants from birth to 7 months old with good initial evidence of reliability and validity.

Breastfeeding Characteristics of Late-Preterm Infants in a Kangaroo Mother Care Unit

OBJECTIVE

To describe the breastfeeding characteristics of late-preterm infants (LPIs) in a kangaroo mother care (KMC) unit.

MATERIALS AND METHODS

In a 20-bed KMC unit, the breastfeeding of 73 purposively-selected LPIs' (mean gestational age: 34.8 weeks) was observed once-off, using the Preterm Infant Breastfeeding Behavior Scale. Participants' mean age was 9.5 days, mean number of days in the unit was 3.1 days, and mean number of days breastfeeding was 7.5 on observation.

RESULTS

Only 13.7% of participants were directly breastfeeding without supplementary naso- or orogastric feeding/cup-feeding and 86.3% received supplementary cup-feeding of expressed breast milk. Most participants did not exhibit obvious rooting (83.5%) and although most latched-on (97.3%), those who did, latched shallowly (93%). The mean longest sucking burst was 18.8 (standard deviation: 10.5) and approximately half the participants swallowed repeatedly (53.4%). The mean breastfeeding session duration was 17.8 minutes, but most participants breastfed for less than 10 minutes (76.7%). No statistically significant differences in breastfeeding characteristics were detected between participants of different chronological ages. A general trend toward more mature behaviors in participants' breastfeeding for more days was present for many breastfeeding characteristics. More infants exhibited the most mature behavior for each breastfeeding characteristic when the environment was quiet, rather than noisy and disturbing, except for depth of latching (quiet: 0%, disturbance: 15.2%).

CONCLUSION

LPIs in this sample presented with subtle breastfeeding difficulties, highlighting their need for breastfeeding support. Further research is required to examine the effect of KMC on breastfeeding in LPIs.

Psychometric Characteristics of Non-instrumental Swallowing and Feeding Assessments in Pediatrics: A Systematic Review Using COSMIN

As early diagnosis of swallowing and feeding difficulties in infants and children is of utmost importance, there is a need to evaluate the quality of the psychometric properties of pediatric assessments of swallowing and feeding. A systematic review was performed summarizing the psychometric properties of non-instrumental assessments for swallowing and feeding difficulties in pediatrics; no data were identified for the remaining twelve assessments. The COSMIN taxonomy and checklist were used to evaluate the methodological quality of 23 publications on psychometric properties. For each assessment, an overall quality score for each measurement property was determined. As psychometric data proved incomplete, conflicting or indeterminate for all assessments, only preliminary conclusions could be drawn; the most robust assessment based on current data is the dysphagia disorder survey (DDS). However, further research is needed to provide additional information on all psychometric properties for all assessments.

Breastfeeding and swallowing in a neonate with mild hypoxic-ischaemic encephalopathy

BACKGROUND

Specific breastfeeding and swallowing characteristics in neonates with hypoxic-ischaemic encephalopathy (HIE) have not yet been well described in the literature. Considering the relatively high incidence of HIE in resource-poor settings, speech-language therapists should be cognisant of the feeding difficulties in this population during breastfeeding.

OBJECTIVE

To systematically describe the breastfeeding and swallowing of a single case of a neonate diagnosed with mild HIE from admission to discharge.

METHOD

A case study of a 2-day old neonate with mild HIE in a neonatal intensive care unit at an urban teaching hospital, is presented. Data were prospectively collected during four sessions in a 12-day period until the participant's discharge. Feeding and swallowing were assessed clinically, as well as instrumentally using a video-fluoroscopic swallow study.

RESULTS

After parenteral feeding, nasogastric tube feeding commenced. Breastfeeding was introduced on Day 6, as it was considered a safe option, and revealed problematic rooting, shallow latching, short sucking bursts, infrequent swallowing, and a drowsy state of arousal, with coughing and choking. No penetration or aspiration was identified instrumentally. After 13 days, the neonate was breastfeeding safely.

CONCLUSION

Although the pharyngeal stage of swallowing was intact, symptoms of oral stage dysphagia were revealed using a combination of clinical and instrumental measures. Breastfeeding difficulties were identified, exacerbated by poor state regulation, which lead to prolonged hospitalisation. The case study highlights the unexpected long duration of feeding difficulties in an infant with mild HIE and indicates further research.

Measurement of force applied by infant tongue to the nipple during sucking and investigation of the mechanism of tongue movement

In order to clarify the dynamic mechanisms involved in sucking by infants, we developed an artificial nipple with built-in force sensors and have measured the contact force between the tongue and the artificial nipple in infants including healthy, premature and low birth weight. In this study, we measured the force applied by the tongue on the artificial nipple in 10 healthy infants and in 10 infants who were also tube-fed and investigated the differences in dynamic actions between the two groups to extract factors involved in satisfactory sucking. The results showed that differences in the maximum force applied and in the time to reach the maximum force were found between infants with and without established oral feeding. For an infant to suck satisfactorily, 1) the time for the force to propagate from the tongue tip to the tongue root needs to constitute at least 8 % of the sucking period and 2) the force applied at the tongue tip needs to be at least 50% of the force at the tongue root.

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.

Labor Epidural Analgesia and Breastfeeding: A Systematic Review

Despite widespread use of epidural analgesia during labor, no consensus has been reached among obstetric and anesthesia providers regarding its effects on breastfeeding. The purpose of this review was to examine the relationship between labor epidural analgesia and breastfeeding in the immediate postpartum period. PubMed, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature were searched for articles published in 1990 or thereafter, using the search term breastfeeding combined with epidural, labor epidural analgesia, labor analgesia, or epidural analgesia Of 117 articles, 23 described empirical studies specific to labor epidural analgesia and measured a breastfeeding outcome. Results were conflicting: 12 studies showed negative associations between epidural analgesia and breastfeeding success, 10 studies showed no effect, and 1 study showed a positive association. Most studies were observational. Of 3 randomized controlled studies, randomization methods were inadequate in 2 and not evaluable in 1. Other limitations were related to small sample size or inadequate study power; variation and lack of information regarding type and dosage of analgesia or use of other intrapartum interventions; differences in timing, definition, and method of assessing breastfeeding success; or failure to consider factors such as mothers' intention to breastfeed, social support, siblings, or the mother's need to return to work or school. It is also unclear to what extent results are mediated through effects on infant neurobehavior, maternal fever, oxytocin release, duration of labor, and need for instrumental delivery. Clinician awareness of factors affecting breastfeeding can help identify women at risk for breastfeeding difficulties in order to target support and resources effectively.

Assessment Tools for Evaluation of Oral Feeding in Infants Younger Than 6 Months

BACKGROUND

Feeding difficulty is common in infants younger than 6 months. Identification of infants in need of specialized treatment is critical to ensure appropriate nutrition and feeding skill development. Valid and reliable assessment tools help clinicians objectively evaluate feeding.

PURPOSE

To identify and evaluate assessment tools available for clinical assessment of bottle- and breastfeeding in infants younger than 6 months.

METHODS/SEARCH STRATEGY

CINAHL, HaPI, PubMed, and Web of Science were searched for "infant feeding" and "assessment tool." The literature (n = 237) was reviewed for relevant assessment tools. A secondary search was conducted in CINAHL and PubMed for additional literature on identified tools.

FINDINGS/RESULTS

Eighteen assessment tools met inclusion criteria. Of these, 7 were excluded because of limited available literature or because they were intended for use with a specific diagnosis or in research only. There are 11 assessment tools available for clinical practice. Only 2 of these were intended for bottle-feeding. All 11 indicated that they were appropriate for use with breastfeeding. None of the available tools have adequate psychometric development and testing.

IMPLICATIONS FOR PRACTICE

All of the tools should be used with caution. The Early Feeding Skills Assessment and Bristol Breastfeeding Assessment Tool had the most supportive psychometric development and testing.

IMPLICATIONS FOR RESEARCH

Feeding assessment tools need to be developed and tested to guide optimal clinical care of infants from birth through 6 months. A tool that assesses both bottle- and breastfeeding would allow for consistent assessment across feeding methods.

Goniometer Measurements of Oral Labial Angle and Evaluation of Oral Motor Reflexes in Preterm Infants: Comparison to Findings in Term Infants

To date, no study has evaluated changes in oral labial angle as preterm infants mature. The main purpose of this study was to document goniometer measurements of the labial angle of the mouth in preterm infants, to assess changes with development, to compare to findings in healthy term infants, and also evaluate oral motor reflexes in these groups. Seventy-eight preterm infants and 45 healthy term infants were recruited for the prospective study. Labial angle was assessed via goniometer, and oral motor reflexes and the volume of milk ingested were evaluated. There was significant difference between term and preterm infants' labial angles (P < .01). The distribution of preterm infants' angles were similar to term infants' by 36 to 40 weeks' postmenstrual age. Goniometer measurements of the oral labial angle may reveal oral motor performance in preterm infants and may be relevant for feeding skills assessment in this group of infants.

Clinical validation of the Preterm Oral Feeding Readiness Assessment Scale

INTRODUCTION

Health professionals have great difficulties to establish the adequate and safe time to start breast feeding in preterm infants. There is a need to develop a standardized tool to help health professionals to comprehensively evaluate preterm infant readiness to transition preterm infants' feeding from gastric to oral, and encourage breast feeding practice in neonatal units.

AIMS

To clinical validate the accuracy of a Preterm Oral Feeding Readiness Assessment Scale with 60 clinically stable preterm infants.

METHODS

Global accuracy, sensitivity and specificity of Preterm Oral Feeding Readiness Assessment Scale cut-offs, compared to milk intake through translactation, were estimated through ROC curves (Receiver Operating Characteristic Curves).

RESULTS

The global accuracy of Preterm Oral Feeding Readiness Assessment Scale was 74.38%. The highest sensitivity and specificity were obtained for three cut-offs: 28, 29 and 30. Since higher specificity (75.68%) for the Preterm Oral Feeding Readiness Assessment Scale was found at a score cut-off=of 30 showed higher specificity (75.68%), it should be used as a cut-off score to select initiate breastfeeding the preterm newborns' oral feeding readiness.

CONCLUSION

The Preterm Oral Feeding Readiness Assessment Scale is considered valid to assist health professionals to initiate preterm feeding in view of promoting safe and objective breastfeeding.

Effective suckling in relation to naked maternal-infant body contact in the first hour of life: an observation study

BACKGROUND

Best practice guidelines to promote breastfeeding suggest that (i) mothers hold their babies in naked body contact immediately after birth, (ii) babies remain undisturbed for at least one hour and (iii) breastfeeding assistance be offered during this period. Few studies have closely observed the implementation of these guidelines in practice. We sought to evaluate these practices on suckling achievement within the first hour after birth.

METHODS

Observations of seventy-eight mother-baby dyads recorded newborn feeding behaviours, the help received by mothers and birthing room practices each minute, for sixty minutes.

RESULTS

Duration of naked body contact between mothers and their newborn babies varied widely from 1 to 60 minutes, as did commencement of suckling (range = 10 to 60 minutes). Naked maternal-infant body contact immediately after birth, uninterrupted for at least thirty minutes did not predict effective suckling within the first hour of birth. Newborns were four times more likely to sustain deep rhythmical suckling when their chin made contact with their mother's breast as they approached the nipple (OR 3.8; CI 1.03 - 14) and if their mothers had given birth previously (OR 6.7; CI 1.35 - 33). Infants who had any naso-oropharyngeal suctioning administered at birth were six times less likely to suckle effectively (OR .176; CI .04 - .9).

CONCLUSION

Effective suckling within the first hour of life was associated with a collection of practices including infants positioned so their chin can instinctively nudge the underside of their mother's breast as they approach to grasp the nipple and attach to suckle. The best type of assistance provided in the birthing room that enables newborns to sustain an effective latch was paying attention to newborn feeding behaviours and not administering naso-oropharyngeal suction routinely.

Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations

In the World Health Organization/United Nations Children's Fund document Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, neonatal care is mentioned as 1 area that would benefit from expansion of the original Ten Steps to Successful Breastfeeding. The different situations faced by preterm and sick infants and their mothers, compared to healthy infants and their mothers, necessitate a specific breastfeeding policy for neonatal intensive care and require that health care professionals have knowledge and skills in lactation and breastfeeding support, including provision of antenatal information, that are specific to neonatal care. Facilitation of early, continuous, and prolonged skin-to-skin contact (kangaroo mother care), early initiation of breastfeeding, and mothers' access to breastfeeding support during the infants' whole hospital stay are important. Mother's own milk or donor milk (when available) is the optimal nutrition. Efforts should be made to minimize parent-infant separation and facilitate parents' unrestricted presence with their infants. The initiation and continuation of breastfeeding should be guided only by infant competence and stability, using a semi-demand feeding regimen during the transition to exclusive breastfeeding. Pacifiers are appropriate during tube-feeding, for pain relief, and for calming infants. Nipple shields can be used for facilitating establishment of breastfeeding, but only after qualified support and attempts at the breast. Alternatives to bottles should be used until breastfeeding is well established. The discharge program should include adequate preparation of parents, information about access to lactation and breastfeeding support, both professional and peer support, and a plan for continued follow-up.

Revision of the Beginning Breastfeeding Survey: a cumulative assessment of breastfeeding

BACKGROUND AND PURPOSE

Women use their cumulative breastfeeding experiences, in combination with other factors, to make their infant feeding decisions. This pilot study assessed the reliability and predictive validity of the revised Beginning Breastfeeding Survey-Cumulative (BBS-C).

METHODS

25 women were recruited prenatally from a university hospital. The BBS-C was completed before hospital discharge. Infant feeding outcomes were measured at 1 and 3 months postpartum.

RESULTS

Participants were 17-40 years old, mostly married, Whites, and well-educated. Coefficient alpha was .92-.94. The BBS-C predicted an infant not receiving breast milk, not feeding from the breast, and receiving infant formula feedings.

CONCLUSIONS

In this sample, the BBS-C had strong reliability and predictive validity. Further testing should assess reliability and predictive validity in a wider range of populations and settings.

Breastfeeding and human lactation: education and curricular issues for pediatric nurse practitioners

INTRODUCTION

This study explores the breastfeeding and human lactation education offered in pediatric nurse practitioner (PNP) masters-level nursing programs.

METHODS

An online survey about breastfeeding and human lactation education offered in the PNP curriculum was sent to all PNP programs in the United States with viable contact information (N = 84). The response rate was 42.9%.

RESULTS

All of the respondents indicated that their PNP program curriculum includes the promotion of breastfeeding. However, 5.9% of programs do not offer any courses that incorporate these topics, and 73.5% teach this content in only one to two courses. More than three quarters of programs (81.8%) offer opportunities to counsel expectant mothers on infant feeding choices, promote breastfeeding in the clinical setting, and teach breastfeeding techniques. However, 18.2% of programs do not offer any of these opportunities.

DISCUSSION

The breastfeeding and lactation education offered in PNP programs is inconsistent. Formal incorporation of research-based lactation education into PNP curricula will help to standardize knowledge and aid in the PNP clinical role.

Oral-motor function and feeding intervention

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

Physical therapy observation and assessment in the neonatal intensive care unit

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

Oral feeding readiness in the neonatal intensive care unit

Oral feeding is a complex sensorimotor process that is influenced by many variables, making the introduction and management of oral feeding a challenge for many health care providers. Feeding practice guided by tradition or a trial-and-error approach may be inconsistent and has the potential to delay the progression of oral feeding skills. Oral feeding initiation and management should be based on careful, individualized assessment of the NICU infant and requires an understanding of neonatal physiology and neurodevelopment. The purpose of this article is to help the health care provider with this complex process by (a) defining oral feeding readiness, (b) describing the importance of oral feeding in the NICU and the physiology of feeding, and (c) providing a review of the literature regarding the transition from gavage to oral feeding in the NICU.

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 hospitalisation.

SEARCH METHODS

We used the standard methods of the Cochrane Neonatal Review Group, including a search of the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2), MEDLINE via EBSCO (1966 to July 2010), EMBASE (1980 to July 2010), CINAHL via EBSCO (1982 to July 2010), Web of Science via EBSCO (1980 to July 2010) and Health Source (1980 to July 2010). Other sources such as cited references from retrieved articles and databases of clinical trials were also searched. We did not apply any language restriction. We updated this search in March 2012.

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 the Cochrane Neonatal Review Group 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.