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

Development, Psychometric Testing, and Reference Values of the Infant Eating Assessment Tool (InfantEAT)

BACKGROUND

Problematic feeding is common in infancy, particularly in infants with a history of premature birth or medical complexity. A concise, valid, and reliable measure of feeding that can be used across feeding methods is needed for clinical practice and research.

PURPOSE

The purpose of this study was to create an assessment tool to evaluate symptoms of problematic feeding in infants that can be used across all feeding methods (breastfeeding, bottle-feeding, and mixed feeding), then test its psychometric properties and establish reference values.

METHODS

Item response theory (IRT) was used to identify the most important items on the Neonatal Eating Assessment Tool (NeoEAT) related to symptoms of problematic feeding in infants (N = 1054) to create the Infant Eating Assessment Tool (InfantEAT). Reliability of the InfantEAT was tested using Cronbach's α and interitem correlations. Reference values of the InfantEAT were determined from a sample of healthy, full-term infants (n = 561). Percent agreement in identifying problematic feeding between the NeoEAT and the InfantEAT was calculated.

RESULTS

The InfantEAT is comprised of 31 items in 9 subscales. The InfantEAT has evidence of acceptable reliability (α = 0.88). There was 74% agreement between the NeoEAT and the InfantEAT, with the InfantEAT being more sensitive to identifying problematic feeding. References values are presented for infants 0 to 2, 2 to 4, 4 to 6, and 6 to 7 months.

IMPLICATIONS PRACTICE AND RESEARCH

The InfantEAT is a reliable and sensitive tool to evaluate symptoms of problematic feeding across feeding methods for infants younger than 7 months in both practice and research.

Infant Bottle-Feeding: A Prospective Study of Infant Physiology and Parental Report Metrics

The aim of this study was to examine associations between parent reports of bottle-feeding behaviors and infant non-nutritive suck (NNS) on a pacifier as well as oral feeding skills during bottle-feeding. A prospective study was conducted. Full-term infants with no prior diagnosed feeding disorders were recruited at 3-months. Parents reported their infant's bottle-feeding behaviors using the Neonatal Eating Assessment Tool-Bottle-Feeding (NeoEAT-Bottle-Feeding), consisting of five domains: Infant Regulation, Energy and Physiologic Stability, Gastrointestinal Tract Function, Sensory Responsiveness, and Compelling Symptoms of Problematic Feeding. Infant NNS was measured using a custom pacifier, pressure transducer device, which yields the following NNS variables: duration (sec), frequency (Hz), amplitude (cmH20), cycles per burst, cycle amount, and burst amount. The Oral Feeding Skills (OFS) scale was used to measure the initial volume, transfer volume, proficiency, and rate of milk transfer during bottle feeding. Fifty-two infants (58% male) with reported prior bottle experience completed this study. NeoEAT-Bottle-Feeding Total score was significantly positively associated with NNS burst duration and NNS cycles per burst. The NeoEAT-Bottle-Feeding Energy and Physiologic Stability domain was significantly positively correlated with NNS cycles per burst. NeoEAT-Bottle-Feeding Gastrointestinal Tract Function domain score was significantly positively correlated with NNS duration, amplitude, and cycles per burst. There were no significant associations between NeoEAT-Bottle-Feeding domains and the OFS scale. The findings demonstrate that parent reports of problematic feeding at 3 months of age are associated with aspects of infant NNS physiology and not with oral feeding metrics during bottle-feeding. Parent reports of bottle-feeding behaviors, particularly pertaining to gastrointestinal issues, were associated with aspects of infant NNS. These data together will allow for a more nuanced understanding of infant feeding and will be beneficial in determining if infants have a feeding delay.

Establishing Normative Values for Healthy Term Infant Feeding Performance: Neonatal Eating Assessment Tool-Mixed, Oral Feeding Scale, and Early Feeding Skills Assessment

PURPOSE

Infants with perceived feeding problems are frequently referred for assessment of their feeding abilities. However, little is known regarding how healthy nondysphagic infants perform on commonly used assessments, making determination of impairment difficult. The aim of this investigation was to elucidate the characteristics of healthy term infant feeding performance using three commonly employed clinical assessments: Neonatal Eating Assessment Tool-Mixed (NeoEat-Mixed), Oral Feeding Scale, and Early Feeding Skills (EFS).

METHOD

In this prospective case-control study, we recruited 30 infants without feeding impairments to undergo video-monitored bottle feeds under their normal feeding conditions. Caregiver perception of infant feeding was evaluated using the NeoEat-Mixed. Milk ingestion was monitored real time using the Oral Feeding Scale for rate of milk transfer and modified proficiency as characterized by the total volume consumed out of the total volume the caregiver provided. Videos were analyzed by two speech pathologists using the EFS assessment. Descriptive statistics were used to characterize performance.

RESULTS

Participants underwent feeding monitoring at an average chronological age of 4 ± 2 months. Caregivers primarily reported normal, nonconcerning feeding patterns across all of the NeoEAT-Mixed outcomes. Infants consumed milk at an average rate of transfer of 7 ± 3 ml/min, a modified proficiency of 50 ± 21%, and achieved the highest OFS score of 4 (93%, n = 28). The majority of infants scored the best EFS score (mature-3) as it related to the absence of color changes during the feed (97%, n = 29), although commonly scored in the worst EFS score (immature-1) in their presentation of one or more compelling stress cues (63%, n = 19).

CONCLUSION

Establishing healthy term infant normative values for commonly used feeding assessments is critical in accurately distinguishing infants with feeding impairments from those with normal developmental variants.

Assessment and management of feeding difficulties for infants with complex CHD

Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.

Cross-Cultural Adaptation and Psychometric Evaluation of the Neonatal Eating Assessment Tool-Breastfeeding Into Tamil

OBJECTIVE

To adapt the Neonatal Eating Assessment Tool-Breastfeeding (NeoEAT-Breastfeeding) into Tamil, a language spoken in several South Asian countries, to identify the tool's factor structure, and to assess its psychometric properties.

DESIGN

Cross-sectional.

SETTING

Tertiary care hospital in South India.

PARTICIPANTS

A cohort of 323 mothers of infants ages 1 week to 7 months, including infants with and without feeding difficulties.

METHOD

To adapt the English tool to Tamil, we followed standard procedures specified by the tool developers and international guidelines for tool translation and adaptation, including pilot testing and personal interviews with participants who had infants younger than 7 months. Participants completed the NeoEAT-Breastfeeding (Tamil) after assessment of breastfeeding by professionals. The 62-item tool involves rating each item on a 6-point scale, and higher scores indicate increased feeding difficulties.

RESULTS

After exploratory factor analysis, we divided the tool into five subscales in the Tamil version compared to the seven subscales in the original English version. The Tamil version demonstrated high internal consistency reliability (Cronbach's α = 0.97) and test-retest reliability (intraclass correlation = 0.99) for the total scores. Infants with feeding concerns demonstrated significantly higher total and subscale scores on the NeoEAT-Breastfeeding (Tamil) than infants without feeding concerns (p = .000; construct validity).

CONCLUSION

The NeoEAT-Breastfeeding (Tamil) holds promise as a culturally appropriate, clinically useful parent-report tool with evidence for initial reliability and validity for identifying feeding-related concerns among infants younger than 7 months in the Tamil-speaking population.

Effect of Frenotomy on Maternal Breastfeeding Symptoms and the Relationship Between Maternal Symptoms and Problematic Infant Feeding

The relationship between maternal symptoms and problematic infant feeding in the context of tongue-tie is unknown. In a sample of infants with tongue-tie undergoing frenotomy and their mothers, the aims of this study were to: (1) describe changes in maternal symptoms pre- and post-frenotomy, and (2) evaluate the relationships between maternal symptoms and symptoms of problematic feeding pre- and post-frenotomy. Mother-infant dyads were recruited from 1 pediatric dental office between July and November 2020. The sample included 102 mother-infant dyads; 84 completed the follow-up survey. Maternal symptoms of painful and difficult latch, creased/cracked nipples, bleeding, or abraded nipples, chewing of the nipple, and feelings of depression were significantly less common after tongue-tie revision. Poor latch onto the breast was associated with feeding difficulties at both time points. Frenotomy resulted in a decrease of symptoms in breastfeeding mothers. Maternal symptoms and feeding problems persisting post-frenotomy warrant further evaluation.

The Gastrointestinal and Gastroesophageal Reflux (GIGER) Scale for Infants and Toddlers

The purpose of this study was to describe the development of the Gastrointestinal and Gastroesophageal Reflux (GIGER) Scale for Infants and Toddlers, and determine its factor structure and psychometric properties. Items were developed to comprehensively assess gastrointestinal (GI) and gastroesophageal reflux (GER) symptoms observable by a parent. Exploratory factor analysis on 391 responses from parents of children under 2 years old resulted in a 36-item scale with 3 subscales. Internal consistency reliability was acceptable (α = .78-.94). The GIGER total score and all 3 subscales were correlated with the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) (P < .05) and Infant Gastrointestinal Symptoms Questionnaire (IGSQ) (P < .05). GIGER total score was higher in infants with a diagnosis of GER (P < .05) or constipation (P < .05) compared to those without. The GIGER is a parent-report measure of GI and GER symptoms in children under 2 years old with adequate psychometric properties.

Correlates and Trajectories of Preterm Infant Sucking Patterns and Sucking Organization at Term Age

BACKGROUND

Premature infants may experience increased difficulty with nutrition and growth. Successful oral feeding is an important factor associated with discharge readiness. Despite the importance of feeding as a growth-fostering process, little empiric evidence exists to guide recommendations for early interventions.

PURPOSE

Evaluate whether specific elements of sucking, during preterm initiation of oral feeding, predict sucking organization at corrected term age.

METHODS

Sucking performance of 88 preterm infants born between 24 and 34 weeks of post-menstrual age was measured at baseline and term (33-35 and 40 ± 1.5 weeks). Participants were divided into 4 groups (quartiles) based on initial measures of performance including number of sucks, number of bursts, sucks per burst, and maximum pressure. Stability in sucking organization was assessed by comparing changes in infant's quartile location from baseline to term.

RESULTS

A correlation between quartile location was observed for mean maximum pressure (PMAX): infants with PMAX in the lowest quartile (poorest performance) were significantly more likely to remain in the lowest quartile at term (P < .000); infants in the highest quartile (best performance) at baseline were significantly more likely to be in the highest quartile at term (P < .000).

IMPLICATION FOR PRACTICE

Infants with the weakest sucking pressures at 34 weeks of post-menstrual age continue to be at risk for less than optimal feeding skills at 40 weeks of post-menstrual age. Early identification of at-risk infants may allow for effective interventions to potentially decrease long-term feeding problems.

IMPLICATIONS FOR RESEARCH

Future research should focus on the development of personalized interventions to address attributes of problematic feeding such as sucking efficiency.

Prevalence of problematic feeding in young children born prematurely: a meta-analysis

BACKGROUND

Difficulties related to eating are often reported in children born preterm. The objective of this study was to quantitatively synthesize available data on the prevalence of problematic feeding in children under 4 years of age who were born preterm.

METHODS

Literature was identified from PubMed, CINAHL, and PsycInfo. The search was limited to English language and publication years 2000-2020. To be included in the meta-analysis, the article had to report the prevalence of problematic oral feeding within a population of children born prematurely (< 37 weeks' gestation), and the child age at the time of study had to be between full-term corrected age and 48 months. For studies meeting inclusion criteria, the following data were extracted: sample size and subsamples by gestational age and/or child age at time of study; definition of problematic feeding; measures used for assessment of feeding; gestational age at time of birth of sample; child age at time of study; exclusion criteria for the study; and prevalence of problematic feeding. Random-effects meta-analyses were performed to estimate the prevalence of problematic feeding across all studies, by gestational age at birth, and by child age at time of study.

RESULTS

There were 22 studies that met inclusion criteria. Overall prevalence of problematic feeding (N = 4381) was 42% (95% CI 33-51%). Prevalence was neither significantly different across categories of gestational age nor by child age at the time of study. Few studies used psychometrically-sound assessments of feeding.

CONCLUSION

Problematic feeding is highly prevalent in prematurely-born children in the first 4 years of life regardless of degree of prematurity. Healthcare providers of children born preterm should consider screening for problematic feeding throughout early childhood as a potential complication of preterm birth.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Not applicable.

Overlapping Symptoms of Gastroesophageal Reflux and Aspiration Highlight the Limitations of Validated Questionnaires

OBJECTIVES

Infants frequently present with feeding difficulties and respiratory symptoms, which are often attributed to gastroesophageal reflux but may be because of oropharyngeal dysphagia with aspiration. The Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) is a clinical measure of gastroesophageal reflux disease but now there is greater understanding of dysphagia as a reflux mimic. We aimed to determine the degree of overlap between I-GERQ-R and evidence of dysphagia, measured by Pediatric Eating Assessment Tool-10 (Pedi-EAT-10) and videofluoroscopic swallow study (VFSS).

METHODS

We performed a prospective study of subjects <18 months old with feeding difficulties. All parents completed Pedi-EAT-10 and I-GERQ-R as a quality initiative to address parental feeding concerns. I-GERQ-R results were compared with Pedi-EAT-10 and, whenever available, results of prior VFSS. Pearson correlation coefficients were calculated to determine the relationship between scores. Groups were compared with 1-way ANOVA and Fisher exact test. ROC analysis was completed to compare scores with VFSS results.

RESULTS

One hundred eight subjects with mean age 7.1 ± 0.5 months were included. Pedi-EAT-10 and I-GERQ-R were correlated (r = 0.218, P = 0.023) in all subjects and highly correlated in the 77 subjects who had prior VFSS (r = 0.369, P = 0.001). The blue spell questions on I-GERQ-R had relative risk 1.148 (95% confidence interval [CI] 1.043-1.264, P = 0.142) for predicting aspiration/penetration on VFSS, with 100% specificity. Scores on the question regarding crying during/after feedings were also higher in subjects with abnormal VFSS (1.1 ± 0.15 vs 0.53 ± 0.22, P = 0.04).

CONCLUSIONS

I-GERQ-R and the Pedi-EAT-10 are highly correlated. I-GERQ-R results may actually reflect oropharyngeal dysphagia and not just gastroesophageal reflux disease in infants.

Neonatal Eating Assessment Tool-Mixed Breastfeeding and Bottle-feeding: Reference values and factors associated with problematic feeding symptoms in healthy, full-term infants

BACKGROUND

The Neonatal Eating Assessment Tool-Mixed Breastfeeding and Bottle-feeding (NeoEAT-Mixed Feeding) is a parent-report assessment of symptoms of problematic feeding in infants who are feeding by both breast and bottle.

PURPOSE

To establish reference values for the NeoEAT-Mixed Feeding and evaluate factors that contribute to symptoms of problematic feeding in healthy, full-term infants.

METHODS

Parents of 409 infants less than 7 months old completed an online survey. Median and percentile scores are presented for infants aged 0-2, 2-4, 4-6, and 6-7 months old.

RESULTS

Neonatal Eating Assessment Tool-Mixed Feeding total score and scores for the Gastrointestinal Tract Function and Energy & Physiologic Stability subscales decreased with increasing infant age. Infant Regulation and Feeding Flexibility subscale scores remained stable over time, whereas Sensory Responsiveness subscale scores increased with increasing infant age. Infants with more gastrointestinal symptoms had higher NeoEAT-Mixed Feeding total scores.

IMPLICATIONS FOR PRACTICE

The reported reference values may be used to identify infants in need of further assessment, referral, and intervention. In healthy, full-term infants with concurrent gastrointestinal symptoms and problematic feeding, interventions targeted at gastrointestinal symptoms may help to improve symptoms of problematic feeding as well.

Swallowing Screening: Purposefully Different From an Assessment Sensitivity and Specificity Related to Clinical Yield, Interprofessional Roles, and Patient Selection

Purpose The purpose of this clinical focus article is to summarize the goal and process by which identification of individuals at risk for having feeding problems or dysphagia is clinically screened across the life span by speech-language pathologists (SLPs). The topic of this clinical focus article was presented at the Charleston Swallowing Conference in Chicago, Illinois, in July 2018. The contents of this clinical focus article offer an expanded summary of information discussed at this meeting with focus on critical considerations to guide clinical decisions by SLPs regarding the optimal feeding and dysphagia screening approach and process. Conclusion Screening is a critical first step in the identification of individuals at risk for feeding problems and dysphagia across the life span. Understanding the difference between screening and assessment objectives as well as having the knowledge, skills, and clinical competency to implement psychometrically sound screening approaches is a recommended clinical practice standard for SLPs working with these clinical populations. This clinical focus article summarizes critical considerations for identifying individuals at risk for feeding problems and dysphagia across the life span to guide clinicians working with dysphagia populations.