An evidence-based guideline for introducing oral feeding to healthy preterm infants

Effects of implementing non-nutritive sucking on oral feeding progression and outcomes in preterm infants: A systematic review and meta-analysis

BACKGROUND

Preterm infants have imperfect neurological development, uncoordinated sucking-swallowing-breathing, which makes it difficult to realize effective oral feeding after birth. How to help preterm infants achieve complete oral feeding as soon as possible has become an important issue in the management of preterm infants. Non-nutritive sucking (NNS), as a useful oral stimulation, can improve the effect of oral feeding in preterm infants. This review aimed to explore the effect of NNS on oral feeding progression through a meta-analysis.

METHODS

We systematically searched PubMed, CINHAL, Web of Science, Embase, Cochrane databases, China's National Knowledge Infrastructure (CNKI), Wanfang and VIP database from inception to January 20, 2024. Search terms included 'non-nutritive sucking' 'oral feeding' and 'premature.' Eligibility criteria involved randomized controlled studies in English or Chinese. Studies were excluded if they were reviews, case reports, or observational studies from which valid data could not be extracted or outcome indicators were poorly defined. The meta-analysis will utilize Review Manager 5.3 software, employing either random-effects or fixed-effects models based on observed heterogeneity. We calculated the mean difference (MD) and 95% confidence interval (CI) for continuous data, and estimated pooled odds ratios (ORs) for dichotomous data. Sensitivity and publication bias analyses were conducted to ensure robust and reliable findings. We evaluated the methodological quality of randomized controlled trials (RCTs) utilizing the assessment tool provided by the Cochrane Collaboration.

RESULTS

A total of 23 randomized controlled trials with 1461 preterm infants were included. The results of the meta-analysis showed that NNS significantly shortened time taken to achieve exclusive oral feeding (MD = -5.37,95%CI = -7.48 to-3.26, p<0.001), length of hospital stay(MD = -4.92, 95% CI = -6.76 to -3.09, p<0.001), time to start oral feeding(MD = -1.41, 95% CI = -2.36 to -0.45, p = 0.004), time to return to birth weight(MD = -1.72, 95% CI = -2.54 to -0.91, p<0.001). Compared to the NNS group, the control group had significant weight gain in preterm infants, including weight of discharge (MD = -61.10, 95% CI = -94.97 to -27.23, p = 0.0004), weight at full oral feeding (MD = -86.21, 95% CI = -134.37 to -38.05, p = 0.0005). In addition, NNS reduced the incidence of feeding intolerance (OR = 0.22, 95% CI = 0.14 to 0.35, p<0.001) in preterm infants.

CONCLUSION

NNS improves oral feeding outcomes in preterm infants and reduces the time to reach full oral feeding and hospitalization length. However, this study was limited by the relatively small sample size of included studies and did not account for potential confounding factors. There was some heterogeneity and bias between studies. More studies are needed in the future to validate the effects on weight gain and growth in preterm infants. Nevertheless, our meta-analysis provides valuable insights, updating existing evidence on NNS for improving oral feeding in preterm infants and promoting evidence-based feeding practices in this population.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Effect of cue-based feeding on time to nipple feed and time to discharge in very low birth weight infants

The objective of this study is to evaluate the effectiveness of a cue-based feeding protocol in improving time to nipple feed and time to discharge in very low birth weight infants in a Level III Neonatal Intensive Care Unit. Demographic, feeding, and discharge data were recorded and compared between the two cohorts. The pre-protocol cohort included infants born from August 2013 through April 2016 and the post-protocol cohort included infants born from January 2017 through December 2019. 272 infants were included in the pre-protocol cohort and 314 infants in the post-protocol cohort. Both cohorts were statistically comparable in gestational age, gender, race, birthweight, prenatal care, antenatal steroid use, and rates of maternal diabetes. There were statistically significant differences between the pre- versus post-protocol cohorts in median post-menstrual age (PMA) in days at first nipple feed (PO) (240 vs 238, p = 0.025), PMA in days at full PO (250 vs 247, p = 0.015), and length of stay in days (55 vs 48, p = 0.0113). Comparing each year in the post-protocol cohort, for each outcome measure, a similar trend was noted in 2017 and 2018, but not in 2019. In conclusion, the cue-based feeding protocol was associated with a decrease in the time to first PO, time to full nipple feeds, and the length of stay in very-low-birthweight infants.

Factors Affecting Oral Feeding Ability in Indonesian Preterm Infants

Most preterm infants exhibit atypical and immature feeding skills. Even though preterm infants have fulfilled the oral feeding readiness criteria, they still do not have optimal oral feeding ability. This study aimed to determine various factors affecting oral feeding ability in Indonesian preterm infants who have fulfilled oral feeding readiness criteria but still have not been able to feed orally. A cross-sectional study included 120 preterm infants admitted to five tertiary hospitals in Jakarta, Indonesia. Participants were preterm infants born at 28-34 weeks gestational age who had fulfilled the oral feeding readiness as the inclusion criteria: (1) stable cardiorespiratory status, (2) have achieved full enteral feeding via orogastric tube (OGT) 120 mL/kg/day without vomiting or bloating, and (3) strong and rhythmic non-nutritive sucking (NNS) through objective measurement. Infants' oral feeding ability and various factors that were assumed to affect oral feeding ability, including physiological flexion postural tone, physiological stability, rooting reflex, self-regulation, behavioral state, and level of morbidity were evaluated. Chi-square and multivariate analysis with Poisson regression were performed. Results indicated that postural tone, rooting reflex, physiological stability, self-regulation, behavioral state, and level of morbidity were significantly related to oral feeding ability in preterm infants. The most influencing factors were self-regulation with a prevalence ratio (PR) of 1.96 (1.16-3.34; CI 95%) and p = 0.012, followed by postural tone, high morbidity, and behavioral state (PR 1.91; 1.59; 1.56; CI 95%, respectively). In conclusion, despite meeting the oral feeding readiness criteria, most preterm infants were still not able to feed orally. There are other factors affecting oral feeding ability in Indonesian preterm infants.

Conceptual Framework Behind the Development of a Level of Confidence Tool: The Pediatric Videofluoroscopic Swallow Study Value Scale

PURPOSE

The videofluoroscopic swallow study (VFSS) is the most commonly used instrumental procedure for evaluating swallowing in pediatric populations suspected of having dysphagia. Assessment and interpretation of a VFSS in pediatric populations is frequently challenged by testing-specific factors that can raise concerns regarding the representativeness of swallow events observed during testing compared to daily feeding/swallowing physiology. When VFSS findings do not represent typical swallowing patterns, treatment recommendations can result in suboptimal outcomes. To address this current challenge to pediatric VFSS interpretation and associated treatment recommendations, the pediatric VFSS Value Scale (pVFSS Value Scale) was developed within a tertiary regional pediatric medical center. This clinical focus article summarizes the initial scale development phases and resulting conceptual framework for rating clinical testing factors that influence a clinician's level of confidence regarding pediatric VFSS findings. Future goals for scientific evaluation and clinical utilization of this new rating scale are also reported.

CONCLUSIONS

The pVFSS Value Scale was developed to assist clinicians with interpretation of pediatric VFSS assessment outcomes and to efficiently communicate factors influencing impressions and treatment recommendations with team members and caregivers. This clinical concept article summarizes potential uses of this tool to inform treatment planning as well as future clinical research to evaluate its psychometrics and clinical utility.

Primary contributors to gastrostomy tube placement in infants with Congenital Diaphragmatic Hernia

OBJECTIVE

To identify factors associated with gastrostomy tube (GT) placement in infants with congenital diaphragmatic hernia (CDH).

METHODS

Retrospective cohort study of 114 surviving infants with CDH at a single tertiary care neonatal intensive care unit from 2010-2019. Prenatal, perinatal and postnatal characteristics were compared between patients who were discharged home with and without a GT. Prenatal imaging was available for 50.9% of the cohort. Logistic regression was used to assess the association between GT placement and pertinent clinical factors. ROC curves were generated, and Youden's J statistic was used to determine optimal predictive cutoffs for continuous variables. Elastic net regularized regression was used to identify variables associated with GT placement in multivariable analysis.

RESULTS

GT was placed in 43.9% of surviving infants with CDH. Prenatal variables predictive of GT placement were percent predicted lung volume (PPLV) <21%, total lung volume (TLV) <30 ml, lung-head ratio (LHR) <1.2 or observed to expected LHR (O/E LHR) <55%. Infants who required a GT were diagnosed earlier prenatally (23.6 ± 3.4 vs. 26.4 ± 5.6 weeks). Patients whose stomach was above the diaphragm on prenatal ultrasound (up) had a higher odds of GT placement compared to those with stomachs below the diaphragm (down) position by a factor of 2.9 (95% CI: 1.25, 7.1); p = 0.0154. Postnatally, infants with GT had lower Apgar scores at 1 and 5 min, longer lengths of stay and higher proportion of flap closures. Infants with a type C or D defect and extracorporeal membrane oxygenation (ECMO) were associated with increased odds of needing a GT. Postnatal association included being NPO for >12 days, need for transpyloric (TP) feeds for >10 days, >14 days to transition to a 30 min bolus feed, presence of gastro-esophageal reflux (GER), chronic lung disease and pulmonary hypertension. In multivariable analysis, duration of NPO, time to TP feeds, transition to 30 min bolus feeds remained significantly associated with GT placement after adjusting for severity of pulmonary hypertension (PH), GER diagnosis and sildenafil treatment.

CONCLUSION

Identification of risk factors associated with need for long-term feeding access may improve timing of GT placement and prevent prolonged hospitalization related to feeding issues.

LEVEL OF EVIDENCE RATING

Level II (Retrospective Study).

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.

Effects of different feeding intervals on the feeding outcomes of infants who underwent surgical repair of ventricular septal defects

OBJECTIVE

The objective of the present study is to explore the effect of different feeding intervals on the feeding outcomes of infants who underwent ventricular septal defect (VSD) closure.

METHODS

This study is a prospective, randomized controlled trial conducted by a provincial hospital in China. According to different feeding intervals, 78 eligible participants were randomly divided into Group A (2-h interval, n = 39) and Group B (3-h interval, n = 39). The basic clinical data, total feeding time, incidence of feeding intolerance, and nurse job satisfaction scores of the two groups were collected.

RESULTS

The total feeding time in Group A was significantly longer than that in Group B (142.5 ± 15.4 vs. 132.0 ± 16.1 min/d, p = .020). The nurse job satisfaction scores in Group A were significantly lower than those in Group B (101.7 ± 9.8 vs. 108.8 ± 10.1, p = .005). There were no significant differences in the duration of mechanical ventilation (3.7 ± 1.1 vs. 3.9 ± 1.0 d, p = .272), length of ICU stay (4.5 ± 1.1 d vs. 4.7 ± 0.9 d, p = .451), or length of hospital stay (13.2 ± 1.4 vs. 13.3 ± 1.0 d, p = .642) between the two groups. Although the incidence of feeding intolerance in Group A was slightly lower than that in Group B, the difference was not statistically significant.

CONCLUSION

Feeding at an interval of 2 or 3 h has no significant effect on the feeding outcomes of infants, and feeding at intervals of 3 h can reduce nurses' workload and improve nursing job satisfaction.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

[Effectiveness of 2 interventions for independent oral feeding in pre-terms]

INTRODUCTION

Oral feeding of pre-term newborns (PTNB) is hampered by their immaturity and intercurrent diseases, which can prolong their hospital stay. The objective of this study was to assess the effectiveness of a program that combines tactile, kinesthetic and oral stimulation (T+K+OS) compared to another intervention based on exclusively oral stimulation (OS), in the time necessary to achieve independent feeding and hospital discharge.

PATIENTS AND METHODS

A clinical study of 2 randomized groups (OS vs. T+K+OS) was carried out on 42 PTNB with gestational age between 27-32 weeks and birth weight>900g. The stimulation programs were carried out in sessions of 15min, for 10 days.

RESULTS

The PTNBs in the T+K+OS group achieved independent oral feeding earlier, compared to the OS group (24.9±10.1 vs. 34.1±15.6 days, P=.02). An analysis of covariance was performed, which confirmed that the birth weight and gestational age covariates had significant effects on time to reach suction feeding (birth weight: F[1, 38]=5.79; P=.021; gestational age: F[1, 38]=14.12; P=.001) and that once its effect was controlled, the intervention continued to have a significant effect (F[1, 38]=6.07; P=.018). The T+K+OS group, compared to the OS group, achieved an earlier hospital discharge (39±15 vs. 45±18 days), although the differences were not significant (P=.21).

CONCLUSIONS

Combined therapies that include T+K+OS are more effective than OS alone, in order to achieve independent oral feeding in PTNBs.

Abnormal Nutritive Sucking as an Indicator of Neonatal Brain Injury

A term neonate is born with the ability to suck; this neuronal network is already formed and functional by 28 weeks gestational age and continues to evolve into adulthood. Because of the necessity of acquiring nutrition, the complexity of the neuronal network needed to suck, and neuroplasticity in infancy, the skill of sucking has the unique ability to give insight into areas of the brain that may be damaged either during or before birth. Interpretation of the behaviors during sucking shows promise in guiding therapies and how to potentially repair the damage early in life, when neuroplasticity is high. Sucking requires coordinated suck-swallow-breathe actions and is classified into two basic types, nutritive and non-nutritive. Each type of suck has particular characteristics that can be measured and used to learn about the infant's neuronal circuitry. Basic sucking and swallowing are present in embryos and further develop to incorporate breathing ex utero. Due to the rhythmic nature of the suck-swallow-breathe process, these motor functions are controlled by central pattern generators. The coordination of swallowing, breathing, and sucking is an enormously complex sensorimotor process. Because of this complexity, brain injury before birth can have an effect on these sucking patterns. Clinical assessments allow evaluators to score the oral-motor pattern, however, they remain ultimately subjective. Thus, clinicians are in need of objective measures to identify the specific area of deficit in the sucking pattern of each infant to tailor therapies to their specific needs. Therapeutic approaches involve pacifiers, cheek/chin support, tactile, oral kinesthetic, auditory, vestibular, and/or visual sensorimotor inputs. These therapies are performed to train the infant to suck appropriately using these subjective assessments along with the experience of the therapist (usually a speech therapist), but newer, more objective measures are coming along. Recent studies have correlated pathological sucking patterns with neuroimaging data to get a map of the affected brain regions to better inform therapies. The purpose of this review is to provide a broad scope synopsis of the research field of infant nutritive and non-nutritive feeding, their underlying neurophysiology, and relationship of abnormal activity with brain injury in preterm and term infants.

A Delphi survey based construction and validation of test for oropharyngeal dysphagia in Indian neonates

BACKGROUND

SLPs have a crucial need to depend on comprehensive clinical swallowing assessments to determine the presence of dysphagia in neonates. A comprehensive clinical swallowing assessment that is ethnoculturally sensitive may help to identify the presence and severity of swallowing problems in neonates.

OBJECTIVE

The study aimed to construct and validate the contents of a test for oropharyngeal dysphagia in Indian neonates (TOD-IN).

METHOD

The test for oropharyngeal dysphagia in Indian neonates (TOD-IN) was developed using the Delphi process. Five expert panelists served as participants; two rounds of electronic questionnaire-based survey was carried out to develop and validate the contents of TOD-IN.

RESULTS

Round one rendered descriptive data that was analyzed quantitatively and qualitatively. At the end of round one, panelists unequivocally agreed on the need for research to develop a validated assessment tool for dysphagia in Indian neonates. The second round dealt with establishing the face and content validity of the final version of TOD-IN. A unanimous consensus was obtained regarding the format, scoring system, and the construct of the final version of the tool.

CONCLUSION

Practicing clinicians in India are met with several challenges such as resource constraints, limited infrastructure, increasing caseload, and a lack of trained workforce. We believe that inexperienced clinicians will benefit from the structured guidance provided by TOD-IN in a restrained resource context where prioritization of patients is the key. Further studies investigating the psychometric properties of TOD-IN are in progress.

Changes in infant non-nutritive sucking throughout a suck sample at 3-months of age

The goal of this study was to compare how infants’ non-nutritive suck (NNS) changes throughout a suck sample. Fifty-four full-term infants (57% male) completed this study at, on average, 3.03 (SD .31) months of age. These infants sucked on our custom research pacifier for approximately five minutes. Infants produced, on average, 14.50 suck bursts during the sample. NNS data was pooled across subjects and breakpoint analyses were completed to determine if there were changes in their NNS patterning. Breakpoints were evident for NNS cycles per burst at burst numbers 18 and 34, and for amplitude (cmH₂0) at burst numbers 18 and 29. No breakpoints were present for NNS frequency. Infants exhibit changes in their suck physiology across burst number. When assessing suck, developmental specialists should observe more than one suck burst to attain a more valid and appropriate scope of the infant’s suck ability.

Suckling, Feeding, and Swallowing: Behaviors, Circuits, and Targets for Neurodevelopmental Pathology

All mammals must suckle and swallow at birth, and subsequently chew and swallow solid foods, for optimal growth and health. These initially innate behaviors depend critically upon coordinated development of the mouth, tongue, pharynx, and larynx as well as the cranial nerves that control these structures. Disrupted suckling, feeding, and swallowing from birth onward-perinatal dysphagia-is often associated with several neurodevelopmental disorders that subsequently alter complex behaviors. Apparently, a broad range of neurodevelopmental pathologic mechanisms also target oropharyngeal and cranial nerve differentiation. These aberrant mechanisms, including altered patterning, progenitor specification, and neurite growth, prefigure dysphagia and may then compromise circuits for additional behavioral capacities. Thus, perinatal dysphagia may be an early indicator of disrupted genetic and developmental programs that compromise neural circuits and yield a broad range of behavioral deficits in neurodevelopmental disorders.

End-stage kidney disease in infancy: an educational review

An increasing number of infants with end-stage kidney disease (ESKD) are surviving and receiving renal replacement therapy (RRT). Unique clinical issues specific to this age group of patients influence their short- and long-term outcomes. This review summarizes current epidemiology, clinical characteristics, ethical dilemmas, management concerns, and outcomes of infants requiring chronic dialysis therapy. Optimal care during infancy requires a multidisciplinary team working closely with the patient's family. Nutritional management, infection prevention, and attention to cardiovascular status are important treatment targets. Although mortality rates remain higher among infants on dialysis compared to older pediatric dialysis patients, outcomes have improved over time. Most importantly, infants who subsequently receive a kidney transplant are now experiencing graft survival rates that are comparable to older pediatric patients.

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

Objective

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

Study design

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

Results

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

Conclusions

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

Trial registration

ClinicalTrials.gov NCT01158391

Non-Nutritive Sucking in the Preterm Infant

OBJECTIVE

To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding.

STUDY DESIGN

Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA with the NTrainer System. Oral feeding was assessed at 38 weeks PMA.

RESULTS

There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; β = -1.4) was related to feeding success at 38 weeks PMA.

CONCLUSION

Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.

Oral Feeding Success: A Concept Analysis

BACKGROUND

The term "oral feeding success" (OFS) is frequently used in clinical practice and research. However, OFS is inconsistently defined, which impacts the ability to adequately evaluate OFS, identify risk factors, and implement interventions in clinical practice and research.

PURPOSE

To develop the defining attributes, antecedents, and consequences for the concept of OFS in preterm infants during their initial hospitalization.

METHODS

PubMed, CINAHL, and PsycINFO databases were searched for English articles containing the key words "oral feeding success" and "preterm infants." The Walker and Avant method for concept analysis was employed.

RESULTS

Sixteen articles revealed the defining attributes, antecedents, and consequences. Defining attributes included (1) physiologic stability; (2) full oral feeding; and (3) combined criteria of feeding proficiency (≥30% of the prescribed volume during the first 5 minutes), feeding efficiency (≥1.5 mL/min over the entire feeding), and intake quantity (≥80% of the prescribed volume).

IMPLICATIONS FOR PRACTICE

The 3 defining attributes may be used in clinical practice to consistently evaluate OFS. The antecedents of OFS provide clinicians with a frame of reference to assess oral feeding readiness, identify risk factors, and implement effective interventions. The consequences of OFS allow clinicians to anticipate challenges when OFS is not achieved and create a care plan to support the infants.

IMPLICATIONS FOR RESEARCH

The empirical referents of OFS provide consistent and clear operational definitions of OFS for use in research. The antecedents and consequences may guide researchers to select specific measures or covariates to evaluate valid measures of OFS.

Impact of Feeding Interval on Time to Achieve Full Oral Feeding in Preterm Infants: A Randomized Trial

BACKGROUND

Preterm infants are scheduled to receive total feeding amount in either 3-hour or 2-hour intervals. A gavage feeding may be required if the scheduled amount is not completed orally. Feedings every 2 hours are one-third smaller than feedings every 3 hours. Thus, if the volume of each feed is reduced by decreasing the feeding interval from 3 to 2 hours, the likelihood that the infant completes each volume orally increases, and the probability of requiring gavage feeding decreases. The impact of feeding with 2-hour or 3-hour intervals on time to achieve full oral feeding in preterm infants was investigated.

METHODS

Infants on full enteral gavage feedings were randomized into 2 groups to receive feedings in either 3-hour or 2-hour intervals. The time to achieve full oral feeding and the duration of feeding transition from gavage to oral feedings were investigated. Data were presented as median (interquartile range).

RESULTS

The study included 100 infants (gestational age: 29 [28-31] weeks, birth weight: 1205 [1040-1380] g) with 50 in each group. The postmenstrual age to achieve full oral feeding was 35 (35-37) weeks in the 3-hour-interval group and 35 (34-36) weeks in the 2-hour-interval group; P = 0.131. The duration of feeding transition was similar between groups.

CONCLUSIONS

Feeding every 2 hours caused no improvement in the time to achieve full oral feeding. The 3-hour-interval feeding is appropriate for the neonatal units, where less handling of preterms and decreased workload of nurses are valuable.

Transition From Nasogastric Tube to Oral Feeding: The Role of Parental Guided Responsive Feeding

Background and Objective: Strategies to transition preterm infants from tube to oral feeding vary greatly and the transition may take days to weeks. The study objective was to evaluate the effect of parental guided responsive feeding (PGRF) on this transition. Methods: We conducted a randomized controlled trial on infants born at <32 weeks gestation. The PGRF intervention was performed by parents, and included feeding intervals and volumes which were guided by the infants' behavioral cues of hunger and satiety. If a minimum volume was not taken orally, an intermediate volume was supplemented via nasogastric tube. The control group was traditionally fed (TF), with pre-planned volumes of intake and at given scheduled intervals. Results: The study comprised 67 infants (PGRF 32, TF 35). PGRF infants reached full oral feeding within less days (median 2 vs. 8 days, p = 0.001), at an earlier age (median 34.28 vs. 35.14 weeks, p < 0.001), returned to baseline weight gain at 35 weeks (1.77 ± 0.70 vs. 1.25 ± 0.63 g/kg/day, p = 0.002), were discharged earlier (36.34 ± 0.6 vs. 36.86 ± 0.9 weeks, p = 0.001), were more likely to be fed by their parents (p < 0.001), and experienced less apnea/bradycardia events at 34 weeks (median 3.5 vs. 9 per week p = 0.047) compared to the TF infants. The regression model demonstrated that independent variables predicted 43.7% of the variance of time to full oral feeding [F _{(9, 65)} = 4.84 p < 0.001]. The only significant variable was feeding group (B = -6.43 p < 0.001); The PGRF infants were more likely to reach full oral feeding earlier. Conclusion: PGRF is safe, and associated with short-term advantages, higher parental engagement, and earlier discharge. Clinical Trial Registration: Identifier: SHEBA-12-9574-IM-CTIL; "Adjusted Individual Oral Feeding for Improving Short and Long Term Outcomes of Preterm Infants."

Clinicians guide for cue-based transition to oral feeding in preterm infants: An easy-to-use clinical guide

RATIONALE, AIMS AND OBJECTIVES

This article aims to provide evidence to guide multidisciplinary clinical practitioners towards successful initiation and long-term maintenance of oral feeding in preterm infants, directed by the individual infant maturity.

METHOD

A comprehensive review of primary research, explorative work, existing guidelines, and evidence-based opinions regarding the transition to oral feeding in preterm infants was studied to compile this document.

RESULTS

Current clinical hospital practices are described and challenged and the principles of cue-based feeding are explored. "Traditional" feeding regimes use criteria, such as the infant's weight, gestational age and being free of illness, and even caregiver intuition to initiate or delay oral feeding. However, these criteria could compromise the infant and increase anxiety levels and frustration for parents and caregivers. Cue-based feeding, opposed to volume-driven feeding, lead to improved feeding success, including increased weight gain, shorter hospital stay, fewer adverse events, without increasing staff workload while simultaneously improving parents' skills regarding infant feeding. Although research is available on cue-based feeding, an easy-to-use clinical guide for practitioners could not be found. A cue-based infant feeding regime, for clinical decision making on providing opportunities to support feeding success in preterm infants, is provided in this article as a framework for clinical reasoning.

CONCLUSIONS

Cue-based feeding of preterm infants requires care providers who are trained in and sensitive to infant cues, to ensure optimal feeding success. An easy-to-use clinical guideline is presented for implementation by multidisciplinary team members. This evidence-based guideline aims to improve feeding outcomes for the newborn infant and to facilitate the tasks of nurses and caregivers.

Power and sample size calculation for paired recurrent events data based on robust nonparametric tests

The purpose of this paper is to develop a formula for calculating the required sample size for paired recurrent events data. The developed formula is based on robust non-parametric tests for comparing the marginal mean function of events between paired samples. This calculation can accommodate the associations among a sequence of paired recurrent event times with a specification of correlated gamma frailty variables for a proportional intensity model. We evaluate the performance of the proposed method with comprehensive simulations including the impacts of paired correlations, homogeneous or nonhomogeneous processes, marginal hazard rates, censoring rate, accrual and follow-up times, as well as the sensitivity analysis for the assumption of the frailty distribution. The use of the formula is also demonstrated using a premature infant study from the neonatal intensive care unit of a tertiary center in southern Taiwan. Copyright © 2017 John Wiley & Sons, Ltd.

Breastfeeding the late preterm infant: experiences of mothers and perceptions of public health nurses

BACKGROUND

The promotion and maintenance of breastfeeding with late preterm infants (LPIs) remain under examined topics of study. This dearth of research knowledge, especially for this population at-risk for various health complications, requires scientific investigation. In this study, we explore the experiences of mothers and the perceptions of public health nurses (PHNs) about breastfeeding late preterm infants in Calgary, Alberta, Canada.

METHODS

We used an exploratory mixed methods design with a convenience sample of 122 mothers to gather quantitative data about breastfeeding. We collected qualitative data by means of individual face-to-face interviews with 11 mothers and 10 public health nurses. Data were collected from April 2013 to June 2014. We then employed an interpretive thematic analysis to identify central themes and relationships across narratives.

RESULTS

We collected 74 complete data sets about breastfeeding. During the first 6-8 weeks postpartum, 61 mothers breastfed their infants. Of these, 51 partially breastfed and 10 exclusively breastfed. For qualitative purposes, the researchers interviewed 11 mothers with late preterm babies and three themes emerged: significant difficulty with breastfeeding, failing to recognize the infant's feeding distress and disorganized behavior, and the parental stress caused by the multiple feeding issues. The public health nurses' comments reinforced and expanded on what the mothers reported. The themes for the nurses included: challenges with initiating breastfeeding, challenges during breastfeeding, and the need for stimulation during breastfeeding.

CONCLUSION

Mothers face challenges when breastfeeding their late preterm infants and public health nurses can guide them through this experience. Families with a late preterm infant need to be informed about the challenges associated with breastfeeding a late preterm infant. It is necessary for all health care professionals to receive proper training on safe and effective breastfeeding of late preterm infants. It is essential for public health nurses to communicate effectively with families of late preterm infants to provide anticipatory guidance about potential challenges and strategies to resolve any breastfeeding problems.

Responsive versus scheduled feeding for preterm infants

BACKGROUND

Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of a policy of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth rates, levels of parent satisfaction, and time to hospital discharge.

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 17 February 2016), Embase (1980 to 17 February 2016), and CINAHL (1982 to 17 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 controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses. We assessed the quality of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.36, 95% CI -2.44 to -0.29 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.53, 95% CI -6.80 to -4.25 days). GRADE assessments indicated low quality of evidence. The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views.

AUTHORS' CONCLUSIONS

Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some (low quality) evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. This finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.

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.

Caregiving Factors Affecting Breastfeeding Duration Within a Neonatal Intensive Care Unit

BACKGROUND

Increasingly, evidence supports oral feeding of very low birth-weight (VLBW) preterm infants exclusively at breast or with breast milk. Despite known breast milk benefits, outcomes related to exclusive breast milk provision are poor. Identifying factors that promote breast milk provision is critical.

PURPOSE

Breastfeeding practices of mothers of VLBW infants admitted to neonatal intensive care unit were explored to identify factors associated with mode of feeding at discharge.

METHOD

This retrospective study replicates previous work. Subjects were VLBW preterm infants consecutively admitted during a 24-month period. Primary outcomes included receiving any breast milk at discharge. Infant variables included gestational age, postmenstrual age of first direct breastfeeding, and comorbid conditions. Maternal variables included age and ethnicity. Nursing practice variables included first direct-to-breastfeeding, number of times to breast daily, and total direct-to-breastfeeding encounters 24 hours prior to discharge.

RESULTS

A total of 96 VLBW infants (28.7 ± 2.8 weeks' gestational age) met inclusion criteria. Of these, 48% received breast milk at discharge. Controlling for significant effect of length of stay, infants receiving first oral feed at breast were more likely discharged home receiving breast milk (adjusted odds ratio = 8.7; 95% confidence interval, 2.9-32.3; P < .0001). There were both an independent effect of first oral feed at breast and an interaction where infants of nonmarried women also benefited from the first oral feed at breast.

IMPLICATIONS

Significant associations were found between first oral feeding at breast and infant receiving any breast milk at discharge. Targeting VLBW infants to receive first oral feeding at breast may yield the best outcome even among sickest and smallest infants.

Comparison of Sucking Pattern in Premature Infants With Different Feeding Methods

OBJECTIVE

To compare the sucking pattern of preterm infants on different feeding methods.

METHODS

The sucking behavior on a gloved finger was evaluated for infants receiving breastfeeding, spoon-feeding and tube-feeding.

RESULTS

The mean (SD) numbers of sucks in spoon-fed infants [49 (20) vs. 35 (23); P=0.04] were significantly higher, and the grade of suck was significantly better compared to the tube-fed group. The mean (SD) number of sucks was significantly higher [83 (30) vs. 49 (20), P<0.001] in breastfed infants compared to spoon-fed infants; all infants on breast feeds had grade 2 suction.

CONCLUSION

The sucking behavior varies between tube-fed, spoon-fed, and breastfed preterm infant.

Responsive versus scheduled feeding for preterm infants

BACKGROUND

Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth, duration of hospital stay, and parental satisfaction.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2015), MEDLINE (1966 to September 2015), EMBASE (1980 to September 2015), and CINAHL (1982 to September 2015), conference proceedings, previous reviews, and trial registries.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses.

MAIN RESULTS

We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.4, 95% CI -2.4 to -0.3 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.5, 95% CI -6.8 to -4.2 days). The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views.

AUTHORS' CONCLUSIONS

Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. However, this finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.

Prematuros e prematuros tardios: suas diferenças e o aleitamento materno

Resumo:OBJETIVO:verificar se há diferenças entre recém nascidos prematuros e prematuros tardios no que se refere ao tempo de aleitamento materno e aleitamento materno exclusivo causas e consequências do desmame precoce. Ademais, foi observado o uso de oxigenoterapia e sonda para alimentação, número de sessões de fonoterapia e o tempo de internação.MÉTODOS:pesquisa de campo, de caráter exploratório e longitudinal. Participaram do estudo 82 mães de prematuros. Os dados categóricos foram resumidos através de frequência absoluta e relativa ao total de pacientes em cada grupo estudado. Dados numéricos foram resumidos em média, mediana, desvio padrão, valor mínimo e valor máximo. Os dados quantitativos foram comparados com o teste não paramétrico de Mann-Whitney e as variáveis qualitativas foram comparadas com o teste de igualdade de duas proporções.RESULTADOS:houve significância estatística entre recém-nascidos prematuros e recém-nascidos prematuros tardios para as variáveis Apgar, tempo de internação, tempo de uso da sonda, número de sessões de fonoterapia, tempo de oxigenoterapia e tipo de ventilação mecânica.CONCLUSÃO:a presente pesquisa mostrou que os prematuros tardios apresentaram menor tempo de uso de sonda e oxigenoterapia, menor número de sessões de fonoterapia e menor tempo de internação hospitalar, fazendo-se imprescindível um olhar diferenciado entre os dois grupos de prematuros.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Improving preterm infant outcomes: implementing an evidence-based oral feeding advancement protocol in the neonatal intensive care unit

BACKGROUND

The ability of a preterm infant to exclusively oral feed is a necessary standard for discharge readiness from the neonatal intensive care unit (NICU). Many of the interventions related to oral feeding advancement currently employed for preterm infants in the NICU are based on individual nursing observations and judgment. Studies involving standardized feeding protocols for oral feeding advancement have been shown to decrease variability in feeding practices, facilitate shortened transition times from gavage to oral feedings, improve bottle feeding performance, and significantly decrease the length of stay (LOS) in the NICU.

PURPOSE

This project critically evaluated the implementation of an oral feeding advancement protocol in a 74-bed level III NICU in an attempt to standardize the process of advancing oral feedings in medically stable preterm infants.

METHODS

A comprehensive review of the literature identified key features for successful oral feeding in preterm infants.

RESULTS

Strong levels of evidence suggested an association between both nonnutritive sucking (NNS) opportunities and standardized feeding advancement protocols with successful oral feeding in preterm infants. These findings prompted a pilot practice change using a feeding advancement protocol and consisted of NNS and standardized oral feeding advancement opportunities. Time to exclusive oral feedings and LOS were compared pre- and postprotocol implementation during more than a 2-month evaluation period.

CONCLUSIONS

Infants using NNS and the standardized oral feeding advancement protocol had an observed reduction in time to exclusive oral feedings and LOS, although statistical significance was not achieved.

Influência do estado comportamental nos padrões de sucção de recém-nascidos pré-termo

Objetivo Verificar a influência do estado comportamental na sucção não nutritiva, na sucção nutritiva e na performance alimentar de recém-nascidos pré-termo, no momento da liberação da via oral. Métodos Participaram 32 recém-nascidos pré-termo, clinicamente estáveis, internados em uma unidade de terapia intensiva neonatal. Foram realizadas, por um fonoaudiólogo, as avaliações do estado comportamental, padrão postural, reflexos orais, características dos órgãos fonoarticulatórios, sucção não nutritiva e nutritiva, número de suções por bloco de sucção, taxa de transferência e desempenho alimentar, após a liberação médica para início da alimentação por via oral. Resultados Não foi possível verificar associação do estado comportamental com a sucção não nutritiva. Na sucção nutritiva, verificou-se influência do estado comportamental sobre o número de sucções nos três primeiros blocos, ou seja, o estado de alerta, ao iniciar a mamada, possibilitou aos recém-nascidos apresentarem maior número de sucções, quando comparados aos recém-nascidos em estado de sono. Isto se refletiu na performance alimentar, por meio da maior taxa de transferência e melhor desempenho, embora não tenha sido observada significância estatística quanto a esses aspectos. Conclusão Os achados mostram que o estado comportamental não influenciou os aspectos de sucção não nutritiva, considerados, entretanto, na sucção nutritiva. O estado de alerta apresentou associação com maior número de sucções por bloco, em relação ao estado de sono.

The effects of alternative positioning on preterm infants in the neonatal intensive care unit: a randomized clinical trial

There is a paucity of studies that have investigated the developmental benefits of positioning in the neonatal intensive care unit. The purpose of this study was to investigate the effects of a new, alternative positioning device compared to traditional positioning methods used with preterm infants. In this randomized, blinded clinical trial, one hundred preterm infants (born ≤ 32 weeks gestation) from a level III neonatal intensive care unit in the United States were enrolled at birth. Participants were randomized to be positioned in the alternative positioning device or to traditional positioning methods for their length of stay in the neonatal intensive care unit. Infants were assessed using the NICU Network Neurobehavioral Scale between 35-40 weeks postmenstrual age. Clinical and feeding outcomes were also captured. Linear and logistic regressions were used to investigate differences in neurobehavioral outcome, feeding performance, and medical outcomes. Infants in the alternative positioning arm of the study demonstrated less asymmetry of reflex and motor responses on the NICU Network Neurobehavioral Scale (p=0.04; adjusted mean difference=0.90, 95% CI 0.05-1.75) than those positioned using traditional positioning methods. No other significant differences were observed. Reduction in asymmetry among preterm infants is an important benefit of alternative positioning, as symmetrical movement and responses are crucial for early development. However, it will be important to follow this sample of preterm infants to determine the effects of early positioning on neurodevelopmental outcome in childhood.

Setting the stage for successful oral feeding: the impact of implementing the SOFFI feeding program with medically fragile NICU infants

To evaluate the impact of implementing the Supporting Oral Feeding in Fragile Infants (SOFFI) program in a tertiary-level neonatal intensive care unit (NICU) on the oral feeding, growth, and length of stay outcomes of a heterogeneous population of medically fragile infants at discharge and feeding and growth outcomes postdischarge at 3 to 5 months postterm. Data related to feeding, growth, and length of stay from a convenience sample of 81 infants recruited pre-SOFFI training were compared with data for 75 infants recruited post-SOFFI training of the NICU staff. Subjects were not excluded on the basis of level of illness or medical diagnoses. To establish comparability of subject groups, infants were assigned scores using the Neonatal Medical Index. At 3 to 5 months postterm, semistructured parent phone interviews related to feeding and growth at home were conducted (n = 128). Post-SOFFI infants born at less than 37 weeks' gestation achieved full oral feedings in significantly fewer days than pre-SOFFI infants (P = .01). Time to achieve full oral feedings was not significantly different in post-SOFFI infants born at 37 or more weeks' gestation. Growth and length of stay were not significantly different at discharge. At follow-up, parents of post-SOFFI infants reported significantly fewer feeding problems overall (P = .01), less arching (P = .003), less vomiting (P = .006), and fewer infants seeing feeding specialists (P = .03). Results of the study support that NICU implementation of the SOFFI feeding program positively influences feeding outcomes before and following discharge.

Comparison of physiological and behavioral responses to fresh and thawed breastmilk in premature infants--a preliminary study

BACKGROUND

Breastmilk is usually frozen for premature infants when they are unable to feed orally. However, thawed breastmilk may have altered odor and taste from its original form. Few studies have investigated whether premature infants respond differently to fresh and thawed breastmilk. The purpose of this study was to examine the physiological and behavior responses of premature infants alternately fed fresh and thawed breastmilk.

SUBJECTS AND METHODS

An experimental, crossover study using random assignment was conducted. A convenience sample of 18 premature infants less than 37 weeks gestational age at birth with the capability of oral feeding was studied. The premature infants were fed with fresh and thawed breastmilk during two consecutive meals in a random order. Infants' heart rate and oxygen saturation levels were measured baseline and during feeding, as well as observed feeding cues during the feeding period.

RESULTS

Premature infants showed significant differences in heart rate when fed thawed, as opposed to fresh, breastmilk. Premature infants demonstrated more stress cues when fed thawed compared with fresh breastmilk (p=0.007). For infants with postmenstrual ages greater than 36 weeks gestation, feeding with thawed breastmilk showed more stress cues and greater effect on heart rate activity compared with fresh breastmilk (p<0.05).

CONCLUSIONS

Older premature infants demonstrate more stress when fed with thawed breastmilk. Preterm infants should be directly breastfed or fed with nonfrozen breastmilk, when they show stress behaviors in being fed with thawed breastmilk.

Coregulated approach to feeding preterm infants with lung disease: effects during feeding

BACKGROUND

Very preterm (VP) infants are at risk for poor oral feeding endurance, early cessation of eating, poor fluid management with aspiration risk, behavioral distress, and unstable heart rate (HR) and oxygenation during feeding.

OBJECTIVE

The study aims to determine the preliminary effectiveness of a coregulated approach (CoReg) to oral feeding for VP infants at risk for lung disease.

METHODS

A randomized, within-subject, cross-over design was used with 20 VP infants requiring oxygen at the start of oral feeding. Infants were bottle-fed by the Usual Care approach and by the CoReg approach on two consecutive days for an average of four feedings each. Intervention components included coregulation of suck, swallow, and breathe rhythms using enhanced auditory assessment, infant-guided feeding onsets, and infant positioning in a semielevated, side-lying position. Infant physiology metrics (HR and SaO2) were collected continuously before and during the feeding. Behavioral and auditory indicators of regulation were coded continuously from videotape during the feeding.

RESULTS

Up to 75 feedings were analyzed (40 Usual Care and 35 CoReg) using repeated measures modeling. CoReg feedings were characterized by more frequent preparation of the infant for the feeding, were more commonly initiated in response to infant readiness cues, had more rest periods and breath regulation events, and had fewer sucking stimulation events. CoReg feedings had less SaO2 variability, decline, and time spent in a desaturated state; less HR fluctuation and decline; less behavioral disorganization; better fluid management; and less observed effort to breathe.

DISCUSSION

Support is provided for an approach to feeding vulnerable infants. Enhanced auditory assessment of infant feeding rhythms increases the responsiveness of the feeder and improves infant behavioral and physiological responses.

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.

Enteral feeding practices in the NICU: results from a 2009 Neonatal Enteral Feeding Survey

PURPOSE

: The purpose of this study was to examine the current management of the enteral feeding regimens of premature infants cared for in the neonatal intensive care unit (NICU).

SUBJECTS

: The study included responses from 70 neonatal nurses who participated in a 2009 Neonatal Enteral Feeding Survey distributed electronically to the National Association of Neonatal Nurses membership. These respondents were representative of both the United States and Canada, with 29 US states represented. The majority of respondents (95.7%) reported current nursing employment in a level III NICU.

DESIGN

: Survey research was used in this exploratory study. The survey, Enteral Tube Feeding Practices in the Neonatal Intensive Care Unit, was developed in collaboration with expert neonatal nurses and nutritionists, pilot tested, and distributed via electronic means.

METHODS

: Survey research was conducted according to the Dillman methodology. Data analysis included descriptive statistics and univariate analysis of variance assessing for significant differences in specific neonatal feeding practices reported. Thematic analysis was used to analyze the qualitative data reported.

OUTCOME MEASURES

: The outcome measures included the survey responses to the questions asked about the implementation of an enteral feeding protocol and various aspects of enteral feeding practices in the NICU.

RESULTS

: The majority of participants (60.9%) reported that an enteral feeding protocol was implemented in practice, but that it was inconsistently followed because of individual physician or nurse practice patterns, or highly individualized feeding plans required of specific clinical care needs of the patient. Respondents indicated that gestational age was the leading criteria used to initiate feedings, and patent ductus arteriosis treatment was the primary contraindication to enteral feedings. The leading factor reported to delay or alter enteral feedings was the presence of gastric residuals. Survey data indicated that other contraindicating factors to enteral feeding are variable across NICUs and, as reported, are often inconsistent with the current research published to date.

CONCLUSIONS

: Research is needed to provide a foundation on which to develop effective enteral feeding protocols that are appropriate for the diversity of infants cared for in the NICU. Such research findings will culminate in the development and implementation of enteral feeding protocols in the NICU, which will result in improved nutrition, growth, and development outcomes for premature infants.

The SOFFI Reference Guide: text, algorithms, and appendices: a manualized method for quality bottle-feedings

The Support of Oral Feeding for Fragile Infants (SOFFI) method of bottle-feeding rests on quality evidence along with implementation details drawn from clinical experience. To be clear, the SOFFI Method is not focused on the amount of food taken in but on the conduct of the feeding and the development of competent infant feeding behavior that, consequently, assures the intake of food necessary for growth. The unique contribution of the SOFFI method is the systematic organization of scientific findings into clinically valid and reliable, easily followed algorithms, and a manualized Reference Guide for the assessments, decisions, and actions of a quality feeding.A quality feeding is recognized by a stable, self-regulated infant and a caregiver who sensitively (responsively) adjusts to the infant's physiology and behavior to realize an individualized feeding experience in which the infant remains comfortable and competent using his nascent abilities to ingest a comfortable amount of milk/formula. The SOFFI Reference Guide and Algorithms begin with prefeeding adjustments of the environment and follow step by step through a feeding with observations of specific infant behavior, decisions based on that behavior, and specific actions to safeguard emerging abilities and the quality of the experience. An important aspect the SOFFI Reference Guide and Algorithms is the clarity about pausing and stopping the feeding on the basis of the infant's physiology and behavior rather than on the basis of the amount ingested. The specificity of each observation, decision, and action enables nurses at all levels of experience to provide quality, highly individualized, holistic feedings. Throughout the course of feeding in the NICU, the nurse conveys to parents the integrated details (observations, decisions, and actions) particular to their infant, thus passing on the means for parents to become competent in quality feeding, to enjoy feeding time into the future, and to gain in confidence as they watch their infants grow.

Supporting oral feeding in fragile infants: an evidence-based method for quality bottle-feedings of preterm, ill, and fragile infants

Successful oral feeding of preterm and other ill and fragile infants is an interactive process that requires (1) sensitive, ongoing assessment of an infant's physiology and behavior, (2) knowledgeable decisions that support immediate and long-term enjoyment of food, and (3) competent skill in feeding. Caregivers can support feeding success by using the infant's biological and behavioral channels of communication to inform their feeding decisions and actions. The Supporting Oral Feeding in Fragile Infants (SOFFI) Method is described here with text, algorithms, and reference guides. Two of the algorithms and the reference guides are published separately as Philbin, Ross. SOFFI Reference Guides: Text, Algorithms, and Appendices (in review). The information in all of these materials is drawn from sound research findings and, rarely, when such findings are not available, from expert, commonly accepted clinical practice. If the quality of a feeding takes priority over the quantity ingested, feeding skill develops pleasurably and at the infant's own pace. Once physiologic organization and behavioral skills are established, an affinity for feeding and the ingestion of sufficient quantity occur naturally, often rapidly, and at approximately the same postmenstrual age as volume-focused feedings. Nurses, therapists, and parents alike can use the SOFFI Method to increase the likelihood of feeding success in the population of infants at risk for feeding problems that emerge in infancy and extend into the preschool years.

Developmental considerations in working with newborn infants of mothers with diabetes

Infants of diabetic mothers (IDMs) are at risk for an altered developmental course beginning with physiologic alterations in utero. This article describes physiologic and behavioral factors that impact the fetus and newborn infant and may have long-term developmental consequences. A clinical reasoning process to support development optimizes the outcomes of IDMs while in the NICU. Specific interventions are suggested.

A novel approach to assess oral feeding skills of preterm infants

BACKGROUND

There is no well-defined means to identify the level of oral feeding skills (OFS) in preterm infants.

OBJECTIVE

To determine whether OFS as reflected by the combination of proficiency (PRO, %ml taken during the first 5 min/ml prescribed) and rate of milk transfer (RT, ml/min) correlates with gestational age (GA), oral feeding performance (OT, %ml taken during a feeding/ml prescribed) and days from start to independent oral feeding (SOF-IOF). Our working premises are that PRO is reflective of infants' actual feeding skills when fatigue is minimal and RT, monitored over an entire feeding session, reflects their overall skills when fatigue comes into play.

METHODS

Infants (26-36 weeks GA) with prematurity as their principal diagnosis were recruited and monitored at their first oral feeding. GA was divided into 3 strata, 26-29, 30-33, and 34-36 weeks GA. OFS was divided into 4 levels delineated by PRO (≥ or <30%) and RT (≥ or <1.5 ml/min). ANOVA with post-hoc Bonferroni and multiple regression analyses were used.

RESULTS

OFS levels were correlated with GA. OT, PRO, and days from SOF-IOF were associated with OFS and GA, whereas RT was only correlated with OFS levels.

CONCLUSIONS

OFS is a novel objective indicator of infants' feeding ability that takes into account infants' skills and endurance. As a clinical tool, it can help caretakers monitor infants' skills as they transition to oral feeding and identify oral feeding issues arising from immature skills and/or poor endurance.

Influência da estimulação sensório-motora-oral em recém-nascidos pré-termo

OBJETIVO: verificar a influência da estimulação sensório-motora-oral em recém-nascidos pré-termo. MÉTODOS: a amostra constou de 28 recém-nascidos pré-termo internados na Unidade de Terapia Intensiva Neonatal de um Hospital Universitário. Os sujeitos foram alocados em dois grupos, o estimulado e o controle. O grupo estimulado recebeu estimulação sensório-motora-oral duas vezes por dia. Realizaram-se duas avaliações, mensurando frequência respiratória e cardíaca, taxa de transferência, tempo de transição entre sonda e via oral plena, bem como incremento de peso. Os resultados foram analisados por meio do software STATA (10), comparando-se os grupos com o Teste T Student independente (p<0,05). RESULTADOS: não foram encontradas diferenças estatisticamente significantes entre os grupos. CONCLUSÃO: não houve influência do programa de estimulação sensório-motora-oral sobre os parâmetros avaliados.

Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice

Title

Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice.

Aim

This paper is a discussion of evidence-based core measures for developmental care in neonatal intensive care units.

Background

Inconsistent definition, application and evaluation of developmental care have resulted in criticism of its scientific merit. The key concept guiding data organization in this paper is the United States of America’s Joint Commission’s concept of ‘core measures’ for evaluating and accrediting healthcare organizations. This concept is applied to five disease- and procedure-independent measures based on the Universe of Developmental Care model.

Data sources

Electronically accessible, peer reviewed studies on developmental care published in English were culled for data supporting the selected objective core measures between 1978 and 2008. The quality of evidence was based on a structured predetermined format that included three independent reviewers. Systematic reviews and randomized control trials were considered the strongest level of evidence. When unavailable, cohort, case control, consensus statements and qualitative methods were considered the strongest level of evidence for a particular clinical issue.

Discussion

Five core measure sets for evidence-based developmental care were evaluated: (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family-centred care, and (5) the healing environment. These five categories reflect recurring themes that emerged from the literature review regarding developmentally supportive care and quality caring practices in neonatal populations. This practice model provides clear metrics for nursing actions having an impact on the hospital experience of infant-family dyads.

Conclusion

Standardized disease-independent core measures for developmental care establish minimum evidence-based practice expectations and offer an objective basis for cross-institutional comparison of developmental care programmes.

Evidence-based systematic review: effects of oral motor interventions on feeding and swallowing in preterm infants

PURPOSE

To conduct an evidence-based systematic review and provide an estimate of the effects of oral motor interventions (OMIs) on feeding/swallowing outcomes (both physiological and functional) and pulmonary health in preterm infants.

METHOD

A systematic search of the literature published from 1960 to 2007 was conducted. Articles meeting the selection criteria were appraised by 2 reviewers and vetted by a 3rd for methodological quality.

RESULTS

Twelve studies were included and focused on 3 OMIs-nonnutritive sucking (NNS), oral/perioral stimulation, and NNS plus oral/perioral stimulation. Six studies addressed the effects of OMI on the feeding/swallowing physiology outcomes of feeding efficiency or sucking pressures. Ten studies addressed the functional feeding/swallowing outcomes of oral feeding or weight gain/growth. No studies reported data on pulmonary health. Methodological quality varied greatly. NNS alone and with oral/perioral stimulation showed strong positive findings for improvement in some feeding/swallowing physiology variables and for reducing transition time to oral feeding. Prefeeding stimulation showed equivocal results across the targeted outcomes. None of the OMIs provided consistent positive results on weight gain/growth.

CONCLUSIONS

Although some OMIs show promise for enhancing feeding/swallowing in preterm infants, methodological limitations and variations in results across studies warrant careful consideration of their clinical use.

Ad libitum or demand/semi-demand feeding versus scheduled interval feeding for preterm infants

BACKGROUND

Scheduled interval feeding of prescribed enteral volumes is current standard practice for preterm infants. However, feeding preterm infants in response to their hunger and satiation cues (ad libitum or demand/semi demand) rather than at scheduled intervals might help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of a policy of feeding preterm infants on an ad libitum or demand/semi-demand basis versus feeding prescribed volumes at scheduled intervals on growth rates and the time to hospital discharge.

SEARCH STRATEGY

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2009), MEDLINE (1966 to Oct 2009), EMBASE (1980 to Oct 2009), CINAHL (1982 to Oct 2009), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (including cluster randomised trials) that compared a policy of feeding preterm infants on an ad libitum or demand/semi-demand basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We found eight randomised controlled trials that compared ad libitum or demand/semi-demand regimens with scheduled interval regimes in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and of variable methodological quality. The duration of the intervention and the duration of data collection and follow-up in most of the trials was not likely to have allowed detection of measurable effects on growth. Three trials reported that feeding preterm infants using an ad libitum or demand/semi-demand feeding regimen allowed earlier discharge from hospital (by about two to four days) but other trials did not confirm this finding.

AUTHORS' CONCLUSIONS

Limited evidence exists that feeding preterm infants with ad libitum or demand/semi-demand regimens allows earlier attainment of full oral feeding and earlier hospital discharge. This finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large randomised controlled trial is needed to confirm this finding and to determine if ad libitum of demand/semi-demand feeding of preterm infants affects other clinically important outcomes.