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Non-Nutritive sucking for promoting physiologic stability and nutrition in preterm infants (Review)
Abstract
Background:
Non-nutritive sucking is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behaviour and improves digestion of enteral feedings. Non-nutritive sucking has been considered to be a benign intervention, although it has the potential to have a negative effect on breastfeeding or on the incidence of later oral aversion.
Objectives:
To determine whether non-nutritive sucking (NNS) in preterm infants influences: a) weight gain, b) energy intake, c) heart rate, d) oxygen saturation, e) length of hospital stay, f) intestinal transit time, g) age at full oral feeds, or h) any other clinically relevant outcomes.
Search strategy:
MEDLINE and CINAHL databases back to 1976 and the Cochrane Controlled Trials register were searched. Reference lists/bibliographies of relevant articles and reviews were also searched. A comprehensive list of relevant articles was sent to two major authors in this area. They were asked if they knew of any other published or unpublished studies relevant to the area that had not been included in the original list. The searches of MEDLINE, CINAHL and CCTR were updated to December 2000.
Selection criteria:
All trials utilizing experimental or quasi-experimental designs in which non-nutritive sucking in preterm infants was compared to no provision of non-nutritive sucking. Measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted by both reviewers. All potentially relevant titles and abstracts identified by either reviewer were extracted. All retrieved articles were assessed for relevance independently by each reviewer, based on a pre-determined set of criteria. The reference lists/bibliographies of each article were reviewed independently for additional relevant titles and were also retrieved and assessed for relevance. Articles that met all relevance criteria were then assessed for methodologic quality based on a predetermined set of criteria. Those articles judged to have the appropriate quality by both reviewers were included in the analysis.
Data collection and analysis:
Data were extracted independently by the two authors. No subgroup analyses were performed because of the small number of studies related to the relevant outcomes.
Main results:
This review consisted of 20 studies, 14 of which were randomized controlled trials. NNS was found to decrease significantly the length of hospital stay in preterm infants. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, and age at full oral feeds). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds, better bottle feeding performance and behavior. No negative outcomes were reported in any of the studies.
Reviewer's conclusions:
This review found a significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, and age at full oral feeds). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds, better bottle feeding performance and behavior. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects. In view of the fact that there are no long-term data, further investigations are recommended. In order to facilitate meta-analysis of these data, future research in this area should involve outcome measures consistent with those used in previous studies. In addition, published reports should include all relevant data.
... In 1998, the American Academy of Pediatrics declared full oral feeding tolerance as a discharge criterion (14). Today, several studies are conducted on NNS in preterm neonates to maximally speed up independent oral feeding (15)(16)(17)(18). Non-nutritive feeding during gavage increases the secretion of digestive enzymes and improves digestion (12,19,20). ...
... Lappi et al. did not observe a significant impact on heart rate after using pacifier (29). Pinelli and Symington found that NNS had no significant effect on neonate's heart rate and behaviors (18). Hwang et al. performed prefeeding oral stimulation for 19 NICU neonates in Taiwan. ...
... It can also be attributed to the mean gestational age of subjects, which may act as an effective factor in decreasing or increasing the length of hospital stay. A review on Cochran's article by Pinelli and Symmington showed that preterm neonates receiving NNS on pacifier were discharged sooner (18). This is probably because oral feeding attainment can be a milestone for neonates' discharge. ...
Objectives
Effective interventions such as non-nutritive sucking (NNS) improve neonatal development. The current study aimed at assessing the effect of NNS intervention by mothers on physiological factors, duration of full oral feeding attainment, and the length of hospital stay.
Methods
The current clinical trial was conducted in the neonatal care unit (NICU) of Arash hospital affiliated to Tehran University of Medical Sciences, Tehran, Iran. The study was conducted on 2 groups of 38 preterm neonates. Neonates had gestational age of 26 - 34 weeks and received gavage feeding. They did not have assisted ventilation. Control neonates received routine care, whereas the intervention neonates received 3 NNS sessions done by mothers during the first 10 minutes of tube feeding per day. Data collection instrument included a mother-infant demographic form and an observation checklist of infant’s physiological features. The date of full feeding and length of hospitalization were recorded.
Results
Findings did not show any statistically significant correlation between groups in physiological features. Duration of full oral feeding attainment in the intervention and control groups were 22 ± 14.51 and 30.05 ± 18.58 days, respectively. The length of hospital stay in the intervention and control groups were 31.26 ± 16.89 and 41.82 ± 23.07 days, respectively. Then, non-nutritive sucking by mother’s finger sped up the duration of full oral feeding attainment and reduced the hospitalization.
Conclusions
Since NNS does not require skill and expertise, participation of mother is recommended. Then, infants benefit from not only the positive effects of NNS, but also mother-infant interaction.
... Breastfeeding is a dynamic process which several benefits and utilities: (i) calming effect: pacifier has an analgesic effect and is used from birth to reduce anxiety and pain; and SIDS. Among the recommendations of the American Academy of Pediatrics (AAP), the use of the pacifier was introduced to reduce the risk of SIDS; the correct mechanism is not clear, but probably the pacifier promotes the supine position during sleep, increases the patency of the airways, reduces gastropharyngeal reflux and sleep apnea and increases respiratory drive by reducing carbon dioxide (70). The pacifier could also prevent "rebreathing" by avoiding direct face contact with the sheets. ...
... Even the information given to parents about its protective role increases their attention to ensure that the child does not lose the pacifier while sleeping. Furthermore, some theories believe that nonnutritive sucking may regulate the control of the infant's autonomic nervous system (70,71): i) premature children: a review of the literature has shown that in premature babies, nonnutritive sucking is related to a reduction in hospital stay, favours a faster transition from enteral feeding and improves bottle feeding (72); ii) infections: numerous studies have reported that Candida, Streptococci and other microorganisms often colonize pacifiers. In particular, latex pacifiers are more frequently colonized by Candida, Staphylococcus and pathogens commonly responsible for otitis media than silicone ones (73); iii) medium otitis: The American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) have issued guidelines regarding otitis media recommending limiting the use of pacifiers from six months to prevent the risk Furthermore, infants who are breastfed for less than 6 months are more likely to develop pacifier sucking habits than those who are breastfed for more than 6 months (62,63). ...
Functional breastfeeding plays a key role in the correct psychophysical and neuromotor development of a child, and it has repercussions on craniofacial complex growth and functioning. The consequences of not breastfeeding seem to have not only aesthetic complications but can cause significant functional orthodontic repercussions. Each study on breastfeeding has shown how breast milk protects against acute otitis media, pneumonia, syncytial virus, bronchitis, asthma, gastroenteritis, Sudden Infant Death Syndrome (SIDS), leukaemia, obesity, allergies and even constitutes a protective factor against habitual infant snoring and in reduction of the risk of obstructive apnea. By exercising his muscles, the child strengthens his zygomatic processes so that nasal airways have good drainage capacity and consequently a low predisposition to sinus and respiratory infections. Dentists have a fundamental role in the prevention of maternal-infant oral health, and by assisting its management, they can even implement the best development of a child’s immune system. The “primary” function of the dentist which is concretized in encouraging the planning of the first early visits of the interception of spoiled habits and incorrect lifestyles, together with the “internal” one of the intestinal and oral microbiota of the child together with breastfeeding have an indirect yet significant consequence of favoring the harmonic growth of the orofacial complex.
... 11 Al día de hoy no existe una pauta fija consensuada para la estimulación oral que mejore la capacidad de succión, sino que coexisten diversas maneras de proceder. 12,13,14,15,16,17 Así, Rhooms et al. 18 concluyen que, debido a la heterogeneidad de las formas de estimulación oral, no es posible afirmar cuál de ellas es la más adecuada. Sin embargo, afirman que la estimulación de la succión no nutritiva redujo significativamente la duración de la estancia hospitalaria en los RNP, resultados parecidos a los de Tian et al. 19 en ese aspecto. ...
... 18 No obstante, otros autores refieren que la estimulación no muestra beneficio con respecto a la frecuencia cardiaca ni la saturación de oxígeno. 13 Por todo ello, la estimulación de los reflejos orales innatos a través de las reacciones neuromotrices disminuye el tiempo necesario para alcanzar la succión nutritiva en los RNP. Así, consideramos que dicha estimulación debería ser implementada en aquellos casos en los que exista falta de maduración de la misma, de modo que se consiga disminuir el tiempo de hospitalización y los gastos ocasionados por ello, al alcanzar una succión independiente más temprana. ...
... A number of interventions have moderate to strong evidence for positive effects on feeding: managing physiological state (alerting, calming, swaddling, lighting etc) (McGrath & Medoff-Cooper, 2002;Ross & Philbin, 2011;White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005), skin to skin contact (Howe & Wang, 2013), positioning (Benfer et al., 2013;Clark, Kennedy, Pring, & Hird, 2007;Davis, Bruce, Cocjin, Mousa, & Hyman, 2010;Park, Pados, & Thoyre, 2018;Paul & D'Amico, 2013;Redstone & West, 2004), cue-based feeding (weight, alertness, readiness cues, etc) (Kirk, Alder, & King, 2007;Lubbe, 2018;Shaker, 2010), feeding on demand (alternating enteral feeds with oral feeds) (Gray, Medoff-Cooper, Enlow, Mukhopadhyay, & DeMauro, 2017), pacing, and modified equipment/ teats (Howe & Wang, 2013). Non-nutritive sucking (NNS) has been shown in some research to have a positive effect on transition to oral feeds and length of hospital stay as well as feeding performance as a result of increased physiological stability (Foster, Psaila, & Patterson, 2016;Pinelli & Symington, 2011). NNS is controversial in it's use as an oromotor exercise as the activation of non-nutritive and nutritive skills differ neurologically (Harding, Frank, Van Someren, Hilari, & Botting, 2014). ...
... Non-nutritive sucking was not a frequently used intervention which likely relates to its specific use in the neonatal population only. Despite good research evidence for the benefits of non-nutritive sucking in managing physiologic stability prior to feeding, respondents reported it only being effective 50% of the time it was used (Foster et al., 2016;Pinelli & Symington, 2011). Respondents' opinions on frequency that these interventions have improved feeding performance were grouped. ...
Rationale: There has been a rapid growth in research specific to the area of paediatric dysphagia in the last two decades. Little is known about New Zealand speech-language therapists' (SLTs) current management practices with early infant feeding. This study surveyed the practices of SLTs in New Zealand working with bottle-fed infants.
Methods: Thirty-six SLTs (60% with more than 10 years clinical experience; 80% dedicated paediatric caseload only) completed a web-based survey consisting of open-response, forced choice, and ordinal scale questions focussed on assessment, management and supervisory support.
Results: Access to instrumental assessment was 94% for videofluoroscopy and 16% for endoscopy with instrumental assessment guiding non-oral feeding decisions in 71% of respondents but rarely used to guide positioning (10%), pacing (19%), or teat selection (16%). Managing state and positioning were the most commonly prescribed interventions. The frequency of use of an intervention was positively correlated with respondents’ perception of efficacy of intervention (p < .001) and perceived strength of evidence base for intervention (p < .01). Family adherence was the most frequently reported barrier to choice of intervention. Teat choice was primarily decided by flow rate, family preference and availability. Satisfaction with professional development opportunities was poor (6%) and only two-thirds of respondents had regular supervision.
Conclusions: SLTs working with infants are experienced and predominately dedicated to paediatric work. SLTs use a range of interventions but have mixed opinions on the evidence-base and efficacy of the interventions they choose.
... Implicated in sucking, swallowing, breathing, and esophageal transport that needs to work in appropriate temporal synchrony to prevent food penetration into the lungs and to minimize unnecessary energy expenditure [1]. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behavior and improves digestion of enteral feeds [6]. The quantitatively physiological information related to oral feeding can help physicians to make more accurate clinical diagnoses for oral feeding disorders [7]. ...
... These beneficial effects, in turn, can be associated with a significant economic advantage if they reduce the duration of hospitalization [2], [6]. In this study, a wireless monitoring system is designed to evaluate the feeding behavior of infants. ...
... A meta-analysis by Pinelli and Symington showed that positive outcomes were demonstrated for NNS with respect to reduced length of hospital stay. 12 Orocutaneous therapy using pacifiers has been associated with nonnutritive suck development and enhanced feeding performance, 12 in addition to decreased length of hospitalization. ...
... 15 Pacifiers are used as a means for providing sensitivity to mechanical stimuli such as pressure to the orofacial and lingual sucking apparatus for activating the sensory-motor components of cranial nerves V, VII, IX, X, and XII that are involved in safe feeding. 12 The pharyngoesophageal motility of preterm infants does mature with increasing postnatal age. In this study, gastrointestinal motility disturbance with similar symptoms (regurgitation, vomiting, abdominal distension) in the PG was significantly lower than the control group (22%, 77.8%, respectively) ( p < 0.05). ...
Background:
Nonnutritive sucking (NNS) has been identified as having many benefits for preterm infants. NNS may improve the efficacy of oral feeding, reduce the length of time spent in orogastric (OG) tube feeding, and shorten the length of hospital stays for preterm infants.
Aim:
This study aimed to assess the effect of pacifiers on preterm infants in the transition from gavage to oral feeding, their time to discharge, weight gain, and time for transition to full breastfeeding.
Methods:
A prospective, randomized controlled trial was conducted in our center. Ninety infants were randomized into two groups: a pacifier group (PG) (n = 45) and a control group (n = 45). Eligibility criteria included body weight less than or equal to 1,500 g, gestational age (GA) younger than 32 weeks, tolerating at least 100 kcals/kg/day by OG feeding, growth parameters appropriate for GA, and a stable clinical condition.
Results:
Mean GAs were 29.2 ± 1.86 versus 28.4 ± 1.84 weeks (p = 0.46), and birth weights were 1,188.2 ± 272 versus 1,112.8 ± 267 g (p = 0.72) in the PG and CG groups, respectively. The time for transition to full oral feeding (38 ± 19.2 days), time to transition to full breastfeeding (38.1 ± 20 days), and time to discharge (48.4 ± 19.2 days) in the PG were significantly shorter compared with the control group (49.8 ± 23.6, 49.1 ± 22, 65.3 ± 30.6 days, respectively) (p < 0.05). For preterm infants with gastrointestinal motility disturbance, similar symptoms (regurgitation, vomiting, abdominal distension) (n = 6, 22%) in the PG were significantly lower than the control group (n = 21, 77.8%) (p < 0.05).
Conclusion:
In this study, we determined that the method of giving pacifiers to preterm infants during gavage feeding reduced the infants' transition period to oral feeding and the duration of hospital stay. In addition, the pacifiers could be used during gavage feeding and in the transition from gavage to oral/breastfeeding in preterm infants to encourage the development of sucking ability.
... NNS techniques have been described to accelerate the acquisition of mature sucking patterns and improve feeding skills , as well as the transition from gavage to FOF and from the start of oral feeding to FOF (Foster et al., 2016). However, its isolated application has no impact on other clinical variables such as weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds, and behavioral state (Pinelli & Symington, 2005). Thus, when combining NNS and finger stimulation protocols (Fucile's protocol (2002) and PIOMI (Lessen, 2011)), as described in the articles included in this review, the effects are enhanced . ...
Aims:
To review the literature on the effects of unimodal sensorimotor stimulation protocols on feeding outcomes in very preterm and moderate to late preterm infants (PIs).
Methods:
Five databases were searched up to April 2022. Studies comparing unimodal sensorimotor stimulation protocols based on the combination of manual oral stimulation with NNS against usual care in PIs, on-time transition to full oral feeding (FOF), feeding efficacy, length of hospital stay, and/or body weight gain.
Results:
Eleven studies were included. Compared to usual care, unimodal sensorimotor stimulation protocols based on manual oral stimulation combined with NNS demonstrated to be more effective in decreasing time transition to FOF (standardized mean difference [95%CI] - 1.08 [-1.74, -0.41]), improving feeding efficacy (2.15 [1.18, 3.13]) and shortening length of hospital stay (-0.35 [-0.68, -0.03]). However, the proposed intervention was not effective in improving weight gain (0.27 [-0.40, 0.95]). There were no significant differences according to gestational age (p > .05).
Conclusions:
Based on fair-to-high quality evidence, unimodal sensorimotor stimulation protocols combined with NNS reduce time transition to FOF, improve feeding efficacy, and shorten the length of hospital stay; yet the proposed intervention yielded no significant effects on body weight gain when compared to usual care in PIs.
... Although the ability to suck and swallow is present by the 28 weeks gestation, the coordination of these abilities is not developed until the 32-34 weeks gestation. Therefore, neonate's younger than 32 weeks of gestation cannot breastfeed or bottle feed efficiently and are fed by the gavage [7]. The appropriate nutrition for neonates is breastfeeding, which is achieved by successful sucking. ...
Background
The oral nutrition is big challenge for preterm neonates. Since the best oral feeding method for preterm neonates is not yet known, the present study aimed to evaluate the effect of cup, syringe, and finger feeding methods on reaching the time of full oral feeding and weight gain among preterm neonates.
Method
This randomized clinical trial study was conducted on 99 preterm neonate’s, born at 30–34 weeks gestation, admitted to the neonatal intensive care unit (NICU) of Al-Zahra and Taleghani Therapeutic-Educational Centers in Tabriz, Iran. Subjects were assigned into finger feeding (n = 33), cup feeding (n = 33), and syringe feeding (n = 33) groups in the allocation ratio of 1:1:1 using block randomization with a block size 6 and 9. They were studied in terms of reaching the time of full oral feeding and weight gain. The data were analyzed using SPSS/version21 software, and ANOVA, chi-square, and ANCOVA tests.
Results
There was no significant difference in the mean score of reaching the time of full oral feeding among cup, finger, and syringe feeding groups (p = 0.652). The mean score of daily weight gain, oxygen saturation (SaO2), and heart rate after feeding was not significantly different among the three groups (p > 0.05). The effect of confounding variables, including birth weight and age, arterial oxygen saturation, and heart rate before feeding, was controlled.
Conclusion
Based on the results, one of the cup, finger, and syringe feeding methods can be applied in the NICU, considering the staff’s proficiency in feeding neonates.
Trial registration IRCT20150424021917N11.
... It appears that NNS training alone does not have a significant effect on primary outcomes of sucking measures, which may have consequences later in life such as speech and developmental delay (104). However, it does result in clinically significant secondary outcomes of reduced hospital stay, transition from tube to bottle, and improved feeding performance (increased milk volume) (106)(107)(108)(109). ...
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.
... The NNS is the earliest sucking habit in which infants do not get any nutrition [10] and stimulates only their mouth through a pacifier or finger to promote their Nutritive Sucking (NS) ability [11]. To summarize, the main benefits of stimulating the premature infant's mouth by NNS are the reduction in gavage feeding period [12] and Manuscript accelerating both the maturation of the sucking reflex [13] and the weight gain [14]. Therefore, assessing NNS provides valuable information about the sucking pattern [15], the feeding readiness [16], the integrity of the Central Nervous System (CNS) [17], and the healthiness of the muscles in the mouth, tongue, and pharynx [18]. ...
In this paper, a small, compact, and intelligent pediatric portable pacifier is proposed to measure and assess Non-Nutritive Sucking (NNS) activity in premature infants. A prototype of the system is implemented on a 21 W 24 mm2 printed circuit board, which is small enough to be completely embedded on the back of all commercial pacifiers. The system portability allows it to be easily used in space-limited biomedical applications without dealing with any special electronic instruments or technical knowledge. The measured NNS data is stored on an onboard memory card in order to be analyzed by smartphones and computers. Experimental results confirmed that the proposed system is a proper tool for measuring and evaluating NNS data. The parameters extracted from the NNS signal represent crucial information on the physical growth, neural development, and integrity of the central nervous system of premature infants.
... Nonnutritive sucking: Nonnutritive sucking involves providing the infant with a pacifier (also known as a dummy) to suck without breast or formula milk to provide nutrition. Nonnutritive sucking seeks to reduce pain via helping infants becoming calmer and more attentive, coupled with a reduction in crying (Cignacco et al., 2007;Pinelli and Symington, 2011). ...
Early detection of childhood disability is possible using clinically available tools and procedures. Early detection of disability enables early intervention that maximizes the child's outcome, prevents the onset of complications, and supports parents. In this chapter, first we summarize the best-available tools for accurately predicting major childhood disabilities early, including autism spectrum disorder, cerebral palsy, developmental coordination disorder, fetal alcohol spectrum disorder, intellectual disability, hearing impairment, and visual impairment. Second, we provide an overview of the preclinical and clinical evidence for inducing neuroplasticity following brain injury. Third, we describe and appraise the evidence base for: (a) training-based interventions that induce neuroplasticity, (b) rehabilitation interventions not focused on inducing neuroplasticity, (c) complementary and alternative interventions, (d) environmental enrichment interventions in the neonatal intensive care and community settings, and (e) parent-child interaction interventions in the neonatal intensive care and community settings. Fourth, we explore emergent treatment options at clinical trial, designed to induce brain repair following injury. In conclusion, early diagnosis enables early intervention, which improves child and parent outcomes. We now know which interventions provide the biggest gains and the information can be used to help inform parental decision making when designing treatment plans for their children.
... Nonnutritive sucking [94][95][96] Oral and perioral stimulation (both manual and patterned pulsating stimulation via a device) 70,97,98 Cue-based or "infant-driven" feeding in neonatal intensive care units [99][100][101] The literature also supports the existence of sensitive periods of development during which certain feeding problems can be prevented by exposing children to different flavors and textures: ...
Feeding disorders often present in children with complex medical histories as well as those with neurodevelopmental disabilities. If untreated, feeding problems will likely persist and may lead to additional developmental and medical complications. Treatment of pediatric feeding disorders should involve an interdisciplinary team, but the core intervention should include behavioral feeding techniques as they are the only empirically supported therapy for feeding disorders.
... Reviews of the literature on non-nutritive sucking have shown that the promotion of non-nutritive sucking in premature babies who require tube feeding, usually by the use of pacifiers, leads to a quicker transition to oral feeding and shorter stays in neonatal units [49][50][51]. While the benefits of nonnutritive sucking on the premature population are well researched, it is less clear whether these benefits continue in older infants who are unable to take nutrition orally during the early months of life. ...
Purpose of Review
A sensitive period in development is one in which it is easier for learning to take place; the behaviour can however still be learned at a later stage, but with more difficulty. This is in contrast to a critical period, a time at which a behaviour must be learned, and if this window of opportunity is missed, then the behaviour can never be acquired. Both might determine food acceptance in childhood.
Recent Findings
There is evidence to support the idea of a sensitive period for the introduction of tastes, a critical period for the introduction of textures and for the development of oral motor function, and a possible critical period for the introduction of new foods but only in children where there is an innate disposition to develop early and extreme disgust responses.
Summary
There are both sensitive and critical periods in the acquisition of food preferences.
... Studies using various types of oral motor programs have shown positive effects on both feeding progression and length of hospital stay. [19][20][21][22] Several researchers 18,23-25 used a more targeted oral motor intervention based on the principals of the Beckman oral motor intervention (BOMI) and have shown improved feeding and decreased length of stay. 26 However, there is no reliability testing in the literature on the use of these interventions to know if they can be consistently performed by the wide range of persons (including parents) who may implement them. ...
Purpose: To establish intervention fidelity of the premature infant oral motor intervention (PIOMI)
Design and sample: A rating tool was developed and tested for interrater reliability before being used to test the fidelity of intervention behaviors. A purposeful convenience
sample of three users was recruited to perform the intervention under direct observation.
Main outcome variables: Three types of reliabilities were calculated: (1) interrater reliability to test the rating tool, followed by (2) interuser reliability, and (3) test–retest reliabilities
to test the intervention behaviors of several registered nurses (RNs) over repeated performances of the intervention.
Results: The rating tool demonstrated a high interrater reliability (97.57 percent), indicating its accuracy for systematically rating the specific intervention
behaviors. Subsequently, the rating tool was used to determine interuser and test–retest performances of the PIOMI and resulted in high reliabilities (97.59 percent and 97.58 percent, respectively). This demonstrates that the intervention can be reliably delivered as prescribed, supporting
intervention fidelity.
Aims
The effect of nonnutritive sucking (NNS) stimulation is unclear in infants with perinatal asphyxia. Thus, the aim of this study was to assess the effect of NNS stimulation on oral intake, discharge time, and early feeding skills in infants with perinatal asphyxia.
Design
A randomized controlled study was conducted.
Method
Of the 94 infants, 47 were included in the experimental group and given NNS stimulation once a day before tube feeding by a speech-language therapist (SLT) in addition to hypothermia treatment. Infants' feeding performances on the days of first oral intake and discharge were evaluated with the Early Feeding Skills Scale (EFS).
Results
The time from tube feeding to oral intake was significantly lower in the experimental group compared to the control group ( p < .05). EFS scores at discharge were significantly higher in the experimental group than in the control group ( p < .05). There was no significant difference between the experimental and control groups in terms of discharge and weight gain ( p > .05).
Conclusions
The findings indicated that the NNS stimulation positively affected oral intake and early feeding skills in infants with perinatal asphyxia, as in preterms. However, NNS stimulation had no significant effect on discharge and weight gain in infants with asphyxia. This finding may be attributed to other factors. It is recommended to use NNS by an SLT in a neonatal intensive care unit within a multidisciplinary team to accelerate the transition to oral feeding and improve feeding skills in infants with perinatal asphyxia. Further studies on the effect of NNS stimulation in infants with perinatal asphyxia are needed to corroborate its effects on discharge time and weight gain.
This retrospective case-control study is the first to examine the spatial conformity between pacifiers and palates in 39 preterm infants (12 females, 27 males) and 34 term infants (19 females, 15 males), taking into account the facial-soft-tissue profile and thickness. The shape of 74 available pacifiers was spatially matched to the palate, and conformity was examined using width, height, and length measurements. In summary, the size concept of pacifiers is highly variable and does not follow a growth pattern, like infant palates do. Pacifiers are too undersized in width, length, and height to physiologically fit the palate structures from 0 to 14 months of age. There are two exceptions, but only for premature palates: the palatal depth index at 9–11 months of age, which has no clinical meaning, and the nipple length at <37 weeks of age, which bears a resemblance to the maternal nipple during non-nutritive sucking. It can be concluded that the age-size concept of the studied pacifiers does not correspond to any natural growth pattern. Physiologically aligned, pacifiers do not achieve the age-specific dimensions of the palate. The effects attributed to the products on oral health in term infants cannot be supposed.
Premature birth has a complex impact on the programmed trajectory of fetal development. The uterus is a natural and stimulating, regulatory and correct development environment for the child. Premature babies are perceived as fetuses evolving in the evolutionary unnatural extrauterine environment of the neonatal ICU. This can significantly affect neurophysiological, emotional and psychosocial development of the child.Neonatology is a field with a very dynamic. New treatments increase the number of survivors severely premature infants is increasing with new and very vulnerable children at risk patient group long-term morbidity. Caring for these children is becoming increasingly challenging volume and quality demands and complexity. Follow-up care for these children must be comprehensive. It should include physical health care, early physiotherapy and sensory rehabilitation, and include parenting and other care for the child's healthy psychosocial development in the context of family and school.In the care of an infant, care is essential for adequate nutrition. Nutrition affects early and long-term morbidity in all weight classes of premature babies. The coordinated function of the orofacial complex is conditioned by oral feeding. Stabilization of this coordination is one of the conditions for the release of an infant in home care. Mother milk is essential for optimal growth and development of premature baby. It's not just about nutritional significance. Breast milk has a complex impact on the development of supporting child health and shaping maternal behavior. It is a direct part of developmental care to mitigate the effects of immaturity on lifelong health. Breastfeeding has a direct relationship to the maturation of the orofacial complex, it affects breathing functions and coordination, speech development and body shape formation.
PURPOSE: This study was conducted to evaluate the effect of breast milk olfactory stimulation on physiological responses, oral feeding progression, and body weight in preterm infants. METHODS: A repeated measures design with nonequivalent control group was used. The participants were healthy, preterm infants born at a gestational age of 28~32 weeks; 12 in the experimental group and 16 in the control group. Data were collected prospectively in the experimental group, and retrospectively in the control group, by the same methods. Breast milk olfactory stimulation was provided 12 times over 15 days. The data were analyzed using the chi-square test, Mann-Whitney U test, Wilcoxon signed rank test and linear mixed models using SPSS 19. RESULTS: The gastric residual volume (GRV) of the experimental group was significantly less than that of the control group. The heart rate, oxygen saturation, respiration rate, transition time to oral feeding, and body weight were not significantly different between the two groups. CONCLUSION: These findings indicate that breast milk olfactory stimulation reduces GRV and improves digestive function in preterm infants without inducing distress.
The clinical feeding-swallowing evaluation is the most widely used method by the speech-language pathologist for assessing a child’s ability to feed safely and efficiently. It is typically the first step taken in the overall assessment process and the most important as it often sets a plan in motion. The clinical feeding-swallow evaluation has various purposes and goals. Per the American-Speech-Language-Hearing Association (ASHA), the goals include (1) diagnosing or suspecting a feeding and/or swallowing impairment, (2) determining the phase of the swallow that may be involved in the disorder, (3) determining if the patient should be referred to an interdisciplinary team assessment or other medical specialists, (4) determining if an instrumental evaluation is warranted, and (5) developing a therapy/treatment program. The patient’s age and history may influence the overall goal of the evaluation, but the overriding objective is to determine safety and efficiency of eating for all patients.
Jusque dans les années 2000, les progrès ont été manifestes dans la prise en charge des nouveau-nés prématurés. Cependant, le suivi de ces enfants nous a permis de mettre en évidence des difficultés développementales neuromotrices, neurosensorielles mais également cognitives et comportementales. La recherche des facteurs de risque de ces difficultés de développement a permis de comprendre l’impact de l’environnement sensoriel mais aussi psychoaffectif sur le cerveau immature du nouveau-né prématuré. Les soins de développement sont une nouvelle philosophie de soins intégrant l’environnement au sens large dans la prise en charge des nouveau-nés prématurés. Ils comprennent des stratégies environnementales mais également comportementales. Le nidcap ® (Programme néonatal individualisé d’évaluation et de soins de développement) est un programme de soins de développement complet, validé scientifiquement, qui permet par une approche individualisée de diminuer le stress des nouveau-nés prématurés et de mieux soutenir leur développement. En réintégrant la famille dans les unités de soins, le nidcap ® redonne aux parents leur rôle auprès de leur bébé hospitalisé.
Background:
Premature infants have difficulties in transitioning from gavage to breastfeeding. Targeted interventions to support breastfeeding in premature infants in the neonatal intensive care unit are scarce.
Purpose:
This pilot study evaluates the effectiveness of nonnutritive sucking at the mother's breast in premature infants to facilitate breastfeeding performance and exclusive breastfeeding.
Methods:
The study design constituted a single-blinded randomized control trial, with 9 participants randomly allocated into experimental (n = 4) and control (n = 5) groups. The intervention, nonnutritive sucking at the mother's breast thrice a day for 5 minutes, till nutritive breastfeeding was started, was done in addition to standard care, which was nonnutritive sucking on a finger during gavage feeds. The control group received only standard care. Nonnutritive sucking was assessed using "Stages of Nonnutritive Sucking Scale," and breastfeeding performance was assessed using the "Preterm Infant Breastfeeding Behavior Scale" by a blinded assessor unaware of the infants' allocation.
Results:
Five infants in the control arm and 4 in the intervention arm completed the study. The infants in the intervention group showed faster transition to mature stages of nonnutritive sucking (P = .05) and had longer sucking bursts during breastfeeding (P = .06) than those in the control group. There was no difference in the rates of exclusive breastfeeding at 6 months in the intervention and control groups.
Implications for practice:
Early initiation of nonnutritive sucking at the mother's breast in very preterm infants is a safe and effective intervention to facilitate maturation of oral feeding and breastfeeding behavior.
Implications for research:
Nonnutritive sucking at the mother's breast can be explored as an intervention, with a larger sample, to facilitate exclusive breastfeeding and to establish intervention fidelity.
Sensorineural hearing loss (SNHL) is an inner ear disease which affect from 1 to 3 per 1000 newborns; the World Health Organization estimated a lower prevalence of congenital hearing loss in industrialized countries (2 to 4 per 1000 live births) with respect to developing countries. Particularly, among children admitted to neonatal intensive care unit (NICU) and those with other audiologic risk factors (e.g., very low birthweight, craniofacial abnormalities, intrauterine infections, family history of hearing loss, ototoxic drugs, mechanical ventilation, etc.), hearing loss may have a prevalence 10-20 fold higher. A severe to profound bilateral hearing loss, if not treated, can compromise the normal development of the child, interfering with the process of speech development. Thus, identification and knowledge of non-genetic etiologies of neonatal SNHL may help in developing an early and effective rehabilitation plan.
Purpose: Oral glucose and pH are known as critical indicators for the growth of microorganism inside the oral cavity. This study was performed to identify oral glucose and pH variances in the early postnatal days of newborns. Methods: An explorative study which included 67 newborns was conducted to measure the oral glucose and pH during the first three days of life. Oral secretions were collected every 8 hours for three days or 6 to 9 times immediately after birth up to discharge. Oral glucose and pH variances during the three days were analyzed using the SPSS 22.0. Results: Oral glucose was 30.66 ±22.01mg/dl at birth then increased to 54.77 ±27.96mg/dl at the third day of life (F=8.04, p < .001) while oral pH decreased from 7.35 ±0.36 to 5.53±0.39 during the three days (F=113.35, p < .001). Oral glucose and pH were related to gestational age, regurgitation, and maternal diabetic mellitus. A negative correlation was found between oral glucose and pH (r=-.34, p < .001). Conclusion: Oral glucose and pH can be utilized for oral health assessment in newborns. Further study is needed to explore the factors which influence oral glucose and pH in high-risk newborns.
Background: The use of pacifiers is an ancient practice, but often becomes a point of debate when parents and
professionals aim to protect and promote breastfeeding as most appropriately for nurturing infants. We discuss the current literature available on pacifier use to enable critical decision-making regarding justifiable use of pacifiers, especially in the Baby-Friendly Hospital Initiative context, and we provide practical guidelines for clinicians.
Discussion: Suck-swallow-breathe coordination is an important skill that every newborn must acquire for feeding success. In most cases the development and maintenance of the sucking reflex is not a problem, but sometimes the skill may be compromised due to factors such as mother–infant separation or medical conditions. In such situations the use of pacifiers can be considered therapeutic and even provide medical benefits to infants, including reducing the risk of sudden infant death syndrome. The argument opposing pacifier use, however, is based on potential risks such as nipple confusion and early cessation of breastfeeding. The Ten Steps to Successful Breastfeeding as embedded in the Baby-Friendly Hospital Initiative initially prohibited the use of pacifiers in a breastfeeding friendly environment to prevent potential associated risks. This article provides a summary of the evidence on the benefits of non-nutritive sucking, risks associated with pacifier use, an identification of the implications regarded as ‘justifiable’ in the clinical use of pacifiers and a comprehensive discussion to support the recommendations for safe pacifier use in healthy, full-term, and ill and preterm infants.
Summary: The use of pacifiers is justifiable in certain situations and will support breastfeeding rather than interfere with it. Justifiable conditions have been identified as: low-birth weight and premature infants; infants at risk for hypoglyceamia; infants in need of oral stimulation to develop, maintain and mature the sucking reflex in preterm infants; and the achievement of neurobehavioural organisation. Medical benefits associated with the use of pacifiers include providing comfort, contributing towards neurobehavioural organisation, and reducing the risk of sudden infant death syndrome. Guidelines are presented for assessing and guiding safe pacifier use, for specific design to ensure safety, and for cessation of use to ensure normal childhood development.
Keywords: Breastfeeding, Pacifier, Baby-friendly hospital initiative, Clinician’s guide, Neonatal intensive care unit, Pacifierrisks, Justifiable pacifier use, Recommendations for pacifier use
The article deals with the infant's need to suck not only for the reason of feeding but also for the reason of self-pacification, self-satisfaction or pain relief. This can be achieved by giving the baby a pacifier, the advantages and disadvantages of which are documented in the article on the basis of earlier foreign research. It could lead to a conclusion that the problem whether to give a pacifier to an infant or not has already been resolved in western countries, but in our country, we are still at the beginning of the solution. So far, the opinion not to give the pacifier is prevailing, the main reason being the fear that the infant will not learn to suck from the breast. Therefore the article deals also with other advantages and disadvantages of giving the baby a pacifier, including the recommendations published by American associations of paediatricians, paediatric dentists and family physicians.
This is the protocol for a review and there is no abstract. The objectives are as follows:
• To describe the forms of breastfeeding education and support for women with multiple pregnancies examined in randomised controlled studies.
• To examine the effectiveness of different modes of interventions (e.g. face-to-face or over the telephone, or by different sorts of healthcare or lay practitioners), and whether interventions containing both antenatal and postnatal elements are more effective than those taking place in the antenatal or postnatal period alone.
• To examine the effectiveness of education and support from different care providers and (where information was available) training for care providers.
This chapter provides an overview of the normal mechanism of swallowing and the neurologic control of deglutition. The function of the upper esophageal sphincter is reviewed in the context of oropharyngeal dysphagia. A pediatric perspective is given regarding the etiology, assessment, and management of feeding and swallowing disorders.
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.
Background: Survival rate in early preterm infants has increased over the last 30 years, but many of these infants have medical and developmental problems. Difficulty with feeding and poor nutrition complications are common, which contribute to their readmission and morbidity.Objective: To assess whether an oral motor stimulation intervention can decrease the time to achieve full oral feeding and shorten the length of hospitalization in preterm infants.Design and Methods: Seventy-five preterm infants born at 30 to ≤ 32 weeks gestational age were randomly assigned to three groups to assess intervention effects. Two groups received the intervention once per day with varying different intervention doses across time, while the control group received a sham intervention.Results: The time needed to reach full oral feeding was significantly different among groups (P <0.0001). Infants who received the intervention from initiation of tube feedings until full oral feeding (high dose) gained full oral feedings and were discharged from the hospital earlier than the low dose and control groups (P = 0.0001). Infants in the high dose group were discharged 6 days earlier than controls and 4 days earlier than the low dose group.Conclusion: Oral motor stimulation intervention accelerated the time to full oral feeding and decreased the length of hospital stay.
Background:
Non-nutritive sucking (NNS) is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants to improve the development of sucking behavior and the digestion of enteral feedings.
Objectives:
To assess the effects of non-nutritive sucking on physiologic stability and nutrition in preterm infants.
Search methods:
We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016), and CINAHL (1982 to 25 February 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials.
Selection criteria:
Randomised controlled trials and quasi-randomised trials that compared non-nutritive sucking versus no provision of non-nutritive sucking in preterm infants. We excluded cross-over trials.
Data collection and analysis:
Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported mean differences (MD) for continuous data, with 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses. We did not perform subgroup analyses because of the small number of studies related to the relevant outcomes. We used the GRADE approach to assess the quality of evidence.
Main results:
We identified 12 eligible trials enrolling a total of 746 preterm infants. Meta-analysis, though limited by data quality, demonstrated a significant effect of NNS on transition from gavage to full oral feeding (MD -5.51 days, 95% CI -8.20 to -2.82; N = 87), transition from start of oral feeding to full oral feeding (MD -2.15 days, 95% CI -3.12 to -1.17; N = 100), and the length of hospital stay (MD -4.59 days, 95% CI -8.07 to -1.11; N = 501). Meta-analysis revealed no significant effect of NNS on weight gain. One study found that the NNS group had a significantly shorter intestinal transit time during gavage feeding compared to the control group (MD -10.50 h, 95% CI -13.74 to -7.26; N = 30). Other individual studies demonstrated no clear positive effect of NNS on age of infant at full oral feeds, days from birth to full breastfeeding, rates and proportion of infants fully breastfeeding at discharge, episodes of bradycardia, or episodes of oxygen desaturation. None of the studies reported any negative outcomes. These trials were generally small and contained various methodological weaknesses including lack of blinding of intervention and outcome assessors and variability on outcome measures. The quality of the evidence on outcomes assessed according to GRADE was low to very low.
Authors' conclusions:
Meta-analysis demonstrated a significant effect of NNS on the transition from gavage to full oral feeding, transition from start of oral feeding to full oral feeding, and length of hospital stay. None of the trials reported any adverse effects. Well-designed, adequately powered studies using reliable methods of randomisation, concealment of treatment allocation and blinding of the intervention and outcome assessors are needed. In order to facilitate meta-analysis of these data, future research should involve outcome measures consistent with those used in previous studies.
Background:
Preterm infants (< 37 weeks' postmenstrual age) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge.
Objectives:
To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' postmenstrual age (PMA).To conduct subgroup analyses for the following prespecified subgroups.? Extremely preterm infants born at < 28 weeks' PMA.? Very preterm infants born from 28 to < 32 weeks' PMA.? Infants breast-fed exclusively.? Infants bottle-fed exclusively.? Infants who were both breast-fed and bottle-fed.
Search methods:
We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 25 February 2016). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles.
Selection criteria:
Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention in preterm infants and reporting at least one of the specified outcomes.
Data collection and analysis:
One review author searched the databases and identified studies for screening. Two review authors screened the abstracts of these studies and full-text copies when needed to identify trials for inclusion in the review. All review authors independently extracted the data and analysed each study for risk of bias across the five domains of bias. All review authors discussed and analysed the data and used the GRADE system to rate the quality of the evidence. Review authors divided studies into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model.
Main results:
This review included 19 randomised trials with a total of 823 participants. Almost all included trials had several methodological weaknesses. Meta-analysis showed that oral stimulation reduced the time to transition to oral feeding compared with standard care (mean difference (MD) -4.81, 95% confidence interval (CI) -5.56 to -4.06 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days), as well as the duration of initial hospitalisation compared with standard care (MD -5.26, 95% CI -7.34 to -3.19 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days).Investigators reported shorter duration of parenteral nutrition for infants compared with standard care (MD -5.30, 95% CI -9.73 to -0.87 days) and compared with another non-oral intervention (MD -8.70, 95% CI -15.46 to -1.94 days). They could identify no effect on breast-feeding outcomes nor on weight gain.
Authors' conclusions:
Although the included studies suggest that oral stimulation shortens hospital stay, days to exclusive oral feeding and duration of parenteral nutrition, one must interpret results of these studies with caution, as risk of bias and poor methodological quality are high overall. Well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should use reliable methods of randomisation while concealing treatment allocation, blinding caregivers to treatment when possible and paying particular attention to blinding of outcome assessors.
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.
Preterm births are defined as those before 37 weeks of gestation. With advances in fertility medicine and neonatal medicine, the numbers of preterm children in the community have significantly increased. Developmental delays and complications among preterm children are well recognized. Much less consideration is given to the dental complications of preterm children. Manifestations include palatal deformations, enamel defects, tooth size variations and tooth shape deformities, malocclusions, and increased risks of early childhood caries and tooth wear. This article explores orodental risks and orodental needs of preterm children and suggests preventive and management strategies for optimizing the oral health of special needs children.
Elternberatung, Handling des Kindes, Maßnahmen zur Vorbereitung auf die orale Nahrungsaufnahme und nonnutritives Saugen sind die Basis für eine Therapie von Kindern mit Schluckstörungen. Die orofaziale und intraorale Stimulation stellt einen Schwerpunkt vor allem bei Kindern mit neurologischen Auffälligkeiten dar. In diesem Kapitel wird praxisnah auf die verschiedenen Elemente der logopädischen Therapie von frühkindlichen Schluckstörungen und Trinkschwächen eingegangen.
C’est en 1991 que l’OMS/UNICEF, face au déclin mondial de l’allaitement et aux effets délétères des pratiques hospitalières, développe l’initiative et le label « Hôpital Ami des bébés », attribué aux hôpitaux qui respectent les « 10 conditions pour le succès de l’allaitement », basées sur des données scientifiques validées [1] et une 11e issue du Code international de commercialisation des substituts du lait maternel [2] repris par l’ANAES en 2006 [3]. C’est un programme qualité dont les objectifs sont de favoriser l’initiation et d’augmenter la durée de l’allaitement maternel. Il vise également à respecter les besoins et rythmes physiologiques du nouveau-né et de sa mère, allaitante ou non, en favorisant le contact et la proximité tout en garantissant la sécurité médicale. Les parents sont accompagnés dans le respect de leur choix et le soutien de leurs compétences.
Les soins de développement sont un ensemble de techniques non médicamenteuses de nature environnementale et comportementale destinées à préserver le confort du nouveau-né hospitalisé par une réduction du stress et à améliorer son développement ultérieur [1]. Ces techniques peuvent être utilisées de façon isolée ou associées dans des programmes intégrés comme le NIDCAP [2]. Le rôle des parents est essentiel si l’on désire développer une approche centrée sur la famille.
Children admitted to intensive care units benefit essentially from chest physiotherapy (CP) and/or from postures. Mobilization does not seem to be a priority to unstable children: 9,5% of them benefit from early mobilization while 26% are mobilized later if CP prevails on mobilization. Predictive factors of early mobilization are: age, multiple organ failure, mechanical ventilation, sedation, vasopressor drugs, muscle blockers and winter season admission. The main institutional obstacles against mobilization are the lack of “rehabilitation” protocols and the mandatory medical prescription for the beginning of the treatment. The presence of an intubation catheter should not be an obstacle to early mobilization. Randomized controlled studies remain necessary to precise the feasibility, safety and benefits of early mobilization. If the interest of early mobilization cannot rely on large-scale studies, the results obtained are highly in favor of early motor, kinesthetic and postural management of the child for orality and postural torticollis. Recommendations about pediatric practices to follow during early mobilization are proposed in this review.
Even though direct breastfeeding holds many benefits for preterm infants, the transition from gavage to direct breastfeeding remains suboptimal in this population. Failing this transition can contribute to an early cessation of direct breastfeeding and jeopardize the preterm infants’ growth and development. Preterm infants could benefit from interventions that promote the transition to direct breastfeeding and thus, facilitate this challenging step. This review identifies and analyzes interventions classified in four categories: non-nutritive sucking (NNS) and oral stimulation, promotion of direct breastfeeding experience and avoidance of bottles, cue-based feeding approach, and exposure to human milk odor. All of these interventions improved the preterm infants’ sucking competency, decreased their hospitalization length or increased the breastfeeding rates at discharge. NNS and oral stimulation, and promotion of direct breastfeeding experience and avoidance of bottles are the interventions with the highest evidence level, with the most potential for NICU implementation.
Trial registration:
ClinicalTrials.gov: NCT02023216.
Non-nutritive sucking (NNS) is one of the most significant spontaneous actions of infants. The suction/expression rhythmicity of NNS remains unknown. We developed a sensorized pacifier for an objective measurement of NNS. Two miniaturized digital pressure sensors are embedded into a commercial pacifier and they acquired suction and expression pressures simultaneously. Experimental tests with nine newborns confirmed that our device is suitable for the measurement of the natural NNS behavior and for the extrapolation of parameters related to the suction/expression rhythmicity. Preliminary results encourage future studies to evaluate the possibility to use these parameters as indicators of oral feeding readiness of premature infants.
Pediatric dysphagia-feeding and swallowing difficulties that begin at birth, last throughout childhood, and continue into maturity-is one of the most common, least understood complications in children with developmental disorders. We argue that a major cause of pediatric dysphagia is altered hindbrain patterning during pre-natal development. Such changes can compromise craniofacial structures including oropharyngeal muscles and skeletal elements as well as motor and sensory circuits necessary for normal feeding and swallowing. Animal models of developmental disorders that include pediatric dysphagia in their phenotypic spectrum can provide mechanistic insight into pathogenesis of feeding and swallowing difficulties. A fairly common human genetic developmental disorder, DiGeorge/22q11.2 Deletion Syndrome (22q11DS) includes a substantial incidence of pediatric dysphagia in its phenotypic spectrum. Infant mice carrying a parallel deletion to 22q11DS patients have feeding and swallowing difficulties that approximate those seen in pediatric dysphagia. Altered hindbrain patterning, craniofacial malformations, and changes in cranial nerve growth prefigure these difficulties. Thus, in addition to craniofacial and pharyngeal anomalies that arise independently of altered neural development, pediatric dysphagia may result from disrupted hindbrain patterning and its impact on peripheral and central neural circuit development critical for feeding and swallowing. The mechanisms that disrupt hindbrain patterning and circuitry may provide a foundation to develop novel therapeutic approaches for improved clinical management of pediatric dysphagia.
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.
To increase the number of neonates who were fed according to cues prior to discharge and potentially decrease length of stay.
Continuous quality improvement.
Eighty-five bed level IV neonatal intensive care unit.
Surgical and nonsurgical neonates of all gestational ages. Neonates younger than 32 weeks gestation, who required intubation, continuous positive airway pressure (CPAP), high flow nasal cannula (HFNC), or did not have suck or gag reflexes were excluded as potential candidates for infant-driven feeding.
The project was conducted over a 13-month period using the following methods: (a) baseline data collection, (b) designation of Infant Driven Feeding (IDF) Champions, (c) creation of a multidisciplinary team, (d) creation of electronic health record documentation, (e) initial staff education, (f) monthly team meetings, (g) reeducation throughout the duration of the project, and (h) patient-family education.
Baseline data were collected on 20 neonates with a mean gestational age of 36 0/7(th) weeks and a mean total length of stay (LOS) of 43 days. Postimplementation data were collected on 150 neonates with a mean gestational age of 36 1/7(th) weeks and a mean total LOS of 36.4 days. A potential decrease in the mean total LOS of stay by 6.63 days was achieved during this continuous quality improvement (CQI) project.
Neonates who are fed according to cues can become successful oral feeders and can be safely discharged home regardless of gestational age or diagnosis.
© 2015 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.
30 newborn human infants were observed on 4 occasions during the lying-in period to determine the behavioral consequences of nonnutritive sucking. On 2 of these occasions a bottle-nipple placed over E's finger was inserted in S's mouth for 30 sec.; on the other 2 occasions E stroked S's forehead lightly with a cloth for 30 sec. Determinations were made of S's movement and, for 20 Ss, of mouthing and crying. Within 5 sec. of nipple insertion S's movement dropped to a significantly lower level; within 25 sec. after the removal of the nipple S's movement had returned to baseline levels. Nipple insertion produced a significantly higher level of mouthing and a significantly lower level of crying. No significant effects of the forehead stimulation were found. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A simple method to promote the use of human milk and subsequent breast feeding in low birthweight infants was evaluated in 32 babies. In the 'intervention' group (n = 16; mean (SD) weight 1559 (228) g and length of gestation 33.2 (1.8) weeks), infants were allowed to suckle at the breast when their general condition permitted after as much milk as possible had been expressed, and were then given the full required feeds by tube. Full breast feeding was started as soon as the infant could suck adequately. Sixteen control infants (mean (SD) weight 1605 (198) g and length of gestation 34.1 (2.4) weeks), were breast fed in the conventional manner only after it had been established that they could suck well; until then they received all their feeds by tube. After discharge the mean (SD) periods of exclusive and total breast feeding were longer in the group that had received the intervention (3.7 (1.3) and 5.1 (2.2) months, respectively) than among the controls (1.9 (0.6) and 3.3 (1.9) months, respectively). This 'intervention' method helps to promote milk formation, provides sucking experience for low birthweight infants without interfering with their nutritional intake and consequent weight gain, and encourages subsequent breast feeding with its well recognised advantages.
Behavioral and physiologic responsivity to nasogastric gavage feeding was assessed in 36 preterm infants on 2 consecutive d. On one of these days, a pacifier was provided during and after the gavage segment of the standardized protocol. The protocol was divided into segments that included baseline, preparatory handling, pregavage, gavage, and postgavage periods. Patterns of cardiac (heart period and vagal tone), oxygen saturation, behavioral state, and defensive behavioral responses to gavage were quantified. These stable preterm infants responded to handling and gavage feeding with reduction in heart period, vagal tone, and oxygen saturation. These responses were not altered by provision of a pacifier, although there was a tendency for fewer episodes of bradycardia and oxygen desaturation. Conversely, behavioral state was affected significantly by nonnutritive sucking: when provided with a pacifier, infants exhibited less behavioral distress, spent less time in fussy and active awake states during and after feeding, and returned to a sleep state significantly faster. There is converging evidence to suggest that nonnutritive sucking lessens behavioral distress to iatrogenic stressors but does not alter physiologic responsiveness.
Non-nutritive sucking in premature infants accelerates weight gain for unclear reasons. The effects of non-nutritive sucking on enteral hormone secretion may augment digestion and/or absorption of nutrients. Blood concentrations of gastrin, motilin, insulin and insulin-like growth factor-1 were measured before and 72 h after the initiation of nasogastric feedings in 21 premature infants randomly assigned to either a non-nutritive suckling or control group. Gastrin and motilin concentrations increased significantly after feedings in all infants (mean ± SEM) (gastrin, 4 ± 4 to 73 ± 9 pg/ml, p
. The aim of the present investigation was to study the effect of non-nutritive sucking on plasma levels of insulin, gastrin, and somatostatin in infants. These hormones were measured with radioimmunoassay in plasma collected from fullterm and preterm infants sucking a pacifier. In fullterm infants, sucking caused a significant increase of insulin levels from 13 ± 10 μU/ml to 40 ± 36 μU/ml and 21 ± 17 μU/ml after 45 sec and 5 min respectively, from when the infants started sucking. A similar pattern was seen in preterm infants. In contrast, gastrin and somatostatin levels were not significantly affected. We suggest that sucking causes an activation of the vagal nerve, which results in the release of insulin. We also suggest that in infants, oral feeding is superior to bolus feeding, since in the latter case no vagal activation and consequently no release of hormones with anabolic properties occurs.
The effects of ad libitum access to a pacifier on the behavioral state and motor activity of preterm infants have been compared with those observed in full-term neonates. Regardless of maturity, nonnutritive sucking (NNS) decreases the amount of time spent in active states and increases that spent in quiescent states, lengthens the longest state bout, and decreases the frequency of state transitions. NNS also reduces overall motor activity as well as that during Active Sleep. Provided such ad libitum sucking opportunity, preterm infants thus appear to derive no less benefit from NNS than do term neonates. This result contrasts with an earlier finding that preterms are less soothed by NNA than are term infants.
Fifty-nine infants, 28–34 weeks'gestation, were assigned to treatment and control groups. Treatment infants were offered a pacifier during and following every tube feeding; control infants received routine care. The treatment began when an infant could tolerate room air and 10 cc of full-strength formula by tube; it ended when the infant was totally bottle fed. Treated infants showed readiness for bottle feeding 3.4 days earlier, i.e., with 27 fewer tube feedings each. Performance during the first bottle feeding was assessed with a feeding scale and was statistically similar for both groups. From study entry to fast bottle feeding the treated infants gained 2.6 gm/day more and were discharged 4 days sooner. Complications differed between the two groups.
To evaluate the effect of sweet taste stimulation in augmenting the reported growth-enhancing effects of nonnutritive sucking in preterm infants who are gavage-fed.
Random assignment of preterm infants to receive stimulation by one of three methods during each feeding until totally orally fed.
Hospital intensive-care and infant transitional units.
Eligibility criteria included body weight greater than or equal to 1,250 g, gestational age younger than 34 weeks, growth parameters appropriate for gestational age, tolerating at least 100 kcals/kg/day by gavage feeding with evidence of weight gain, and no clinical evidence of health complications. Data are presented for 42 infants who completed 14 days of treatment.
Exposure to a sweet pacifier, a latex pacifier, or maternal heartbeat sounds during gavage feedings.
Growth, time to total oral feeding, and sucking responses.
No significant differences in sucking measures were noted among treatment groups. Differences in progression time to total oral feedings and weight gain favored the sweet-pacifier group but were not statistically significant.
Oral stimulation of gavage-fed, preterm infants during a 2-week hospitalization was not sufficient to elicit a significant improvement in growth efficiency, progression to total oral feedings, or sucking maturation. Additional studies may show a beneficial effect of chemosensory Stimulation in preterm infants.
Fifty-nine infants, 28--34 weeks' gestation, were assigned to treatment and control groups. Treatment infants were offered a pacifier during and following every tube feeding; control infants received routine care. The treatment began when an infant could tolerate room air and 10 cc of full-strength formula by tube; it ended when the infant was totally bottle fed. Treated infants showed readiness for bottle feeding 3.4 days earlier, i.e., with 27 fewer tube feedings each. Performance during the first bottle feeding was assessed with a feeding scale and was statistically similar for both groups. From study entry to first bottle feeding the treated infants gained 2.6 gm/day more and were discharged 4 days sooner. Complications differed between the two groups.
The relationship between transcutaneous oxygen tension (tcpO2:) and sucking opportunities in noncrying, preterm neonates was investigated. Twenty-six measurements of nonnutritive sucking and its relationship to tcpO2 were collected on 11 neonates who were monitored continuously for tcpO2. Of the 26, 10 sets of measurements were recorded on 6 neonates receiving assisted ventilation, and 16 were recorded on 4 neonates breathing room air. One neonate was measured one time on assisted ventilation and two times breathing room air. The design consisted of three 8-minute time periods: pretreatment, treatment (sucking opportunities). and posttreatment. There was a significant relationship between the pretreatment-treatment and treatment-posttreatment tcpO2 levels (both at p < .01). These results suggest that sucking facilitates more adequate oxygenation in noncrying, preterm neonates.
The neonatal period represents one of the most vulnerable periods in human life, particularly with respect to nutrition. During this period of rapid growth and development, there is a high demand for essential nutrients as well as for an adequate energy supply. At birth, with the sudden transfer from the high carbohydrate diet of the fetus to the high fat diet of the newborn, fat becomes the major energy source for the growing infant. In human milk and in most infant formulas, 45-50% of the total calories are present as fat, although the fat content is only 3.5-4.0%. The fat content varies widely in the milk of different species, from 1.9% in the horse to 12 and 17% in the rat or reindeer, respectively; the highest amounts of fat (as much as 50%) are found in the milk of aquatic mammals. More than 90% of milk fat is in the form of triglycerides which contain saturated and unsaturated long-chain fatty acids contain more than 14 carbon atoms). The overall process of fat digestion and absorption is dominated by the fact that dietary lipids, in contrast to other nutrients such as carbohydrates and protein, are nonpolar and, therefore, largely water insoluble. Digestion and absorption of dietary fat represents thus a process of transport of water-insoluble molecules from one water phase, the intestinal lumen, to another water phase, the lymph and plasma. The role of lingual lipase in the fat digestion of the newborn is discussed.
The interaction between respiration and non-nutritive sucking rhythms was investigated in 12 sleeping, normal full-term, newborn infants and in 14 preterm infants were were examined repeatedly at 34, 40 and 46 wk of conceptional age. Full-term infants showed a shortening of breath intervals in the middle of sucking bursts and a lengthening of the breath interval spanning the end of sucking bursts. The differences were more marked in females than males. A rhythm interaction between sucking and respiration was also observed in preterm infants as young as 34 wk of conceptional age. Clinical neurological examinations did not discriminate between preterm infants above and below a median score for optimal obstetric conditions, but the interaction between breathing and sucking rhythms made such discrimination, most clearly in females. Preterm infants with lower optimal obstetric scores showed less change of breath durations during sucking than preterms with higher scores. It was concluded that interaction of concurrent motor rhythms may be a sensitive index of central nervous system integrity in newborn infants, even when there are no clinical neurological signs of nervous system dysfunction.
Changes in non-nutritive sucking contingent upon presentation of an auditory stimulus previously found capable of eliciting heart-rate acceleration was investigated in a sample of 24 premature infants. Across 30 10-sec. presentations of the stimulus, only transient changes in sucking rate during the first 6 trials were observed, and these effects obtained primarily for those infants showing few abnormalities in their non-nutritive sucking behavior. These results were discussed as reflecting possible differences in infants' attention associated with sucking pathology and the dependence of psychological assessment upon the specific response index used.
Nonnutritive sucking has been found to affect movement, sleep, state regulation and arousal, oxygenation, and nutrition and growth. Its quality is used as an indicator of central nervous system well-being. Speculations have been suggested about improved outcomes from respiratory distress syndrome, patent ductus arteriosus, and necrotizing enterocolitis. The possible effect of sucking movements on attachment between mother and infant has also been described. Further research in the many areas in which this sucking phenomenon has effects are indicated. Exploration of the impact of nonnutritive sucking on the preterm infant of less than 28 weeks gestation and less than 800 gm and on the infant with bronchopulmonary dysplasia is recommended. Further research also needs to focus on implications of clinical applications of these findings to nursing care.
Forty-two pre-term infants were studied to determine the effect of nonnutritive sucking pre-feeding on behavioral state. Infants were randomly assigned to pacifier or rest groups. Pacifiers or rest were given for 5 minutes following routine caregiving and before each of the first 16 bottle feedings. A 12-category scale was used to measure state immediately before the 5-minutes and after. Frequencies of states that precede optimal feedings changed for infants given pacifiers versus rest: alert inactivity (+6 vs. -2), quiet awake (+19 vs. -6), and active awake (-24 vs. +12); infants given pacifiers had more sleep and fewer restless states. Group differences were non-significant before nonnutritive sucking (p = 0.16) but significant after (p = 0.00001). When self-regulatory feeding policies based on early hunger cues are not allowed, nonnutritive sucking for 5 minutes pre-feeding is simple, brief, and appropriate for busy intensive care units. These findings confirm those from earlier less conclusive research and indicate that nonnutritive sucking modulates behavioral state.
Inactive awake behavioral states have been associated with reduced heart rates and more successful feeding in preterm infants. The purpose of this study was to test the efficacy of three different interventions to facilitate these optimal feeding states. Twenty preterm infants (gestational ages 27-33 weeks, M = 31.6, SD = 1.7; birth weights 931-2,140 grams, M = 34, SD = 373) serving as their own controls were randomly administered nonnutritive sucking, nonnutritive sucking plus rocking, and stroking interventions; and a control condition. There were significantly more inactive awake states with the nonnutritive sucking and nonnutritive sucking plus rocking interventions than with the stroking intervention and the control conditions. The results suggest that there are interventions that can help preterm infants in the transition from gavage to oral feeding and potentially shorten their hospital stays.
The effects of nonnutritive sucking (NNS) were studied in 40 preterm infants weighing less than or equal to 1800 g and of less than or equal to 35 weeks gestation by using a pacifier. The provision of NNS accelerated the maturation of sucking resulting in a faster transition from gavage to oral feedings. Treated infants (20) were ready for bottle feeds 1.54 days earlier, took their bottle feeds 1.5 min/30 ml faster and were transferred out of the nursery on an average .5 days earlier than the control infants. No adverse effects due to NNS were observed throughout the period of study. This resulted in an earlier union with their mother, less maternal deprivation and decreased work load on the nursery staff. Used judiciously this simple and safe modality of providing a pacifier for NNS during tube feeding may be useful in the management of preterm infants.
The effect of nonnutritive sucking during gavage feeding on nutritional outcome and gastrointestinal transit time was evaluated in 18 premature appropriate for gestational age infants whose birth weights were less than or equal to 1,400 g and gestational ages were less than or equal to 30 weeks. Infants were randomized to a treatment (nonnutritive sucking infants received a pacifier for 30 minutes with each feeding, 12 times per day until they reached a weight of 1,500 g, eight times per day thereafter) or control (no pacifier) group. The nine nonnutritive sucking (five girls, four boys) and nine control (five girls, four boys) infants were treated for 14 days. Infants were without medical complications and were fed a single premature formula by intermittent gastric gavage at exactly 120 kcal/kg/d throughout the study period. Weight gain, linear growth, subscapular and triceps skinfold, and arm circumference accretions were assessed weekly. Serum proteins (albumin, prealbumin, retinol-binding protein, and transferrin) were measured weekly. Gastrointestinal transit times were measured weekly using carmine red markers. In contrast to previous studies, these data indicate no apparent effect of nonnutritive sucking on growth outcome, serum proteins, or gastrointestinal transit time in growing, very low birth weight infants when nutrient intake was controlled. In a subgroup of eight boys (four nonnutritive sucking, four control), energy and fat excretions were determined from 72-hour fecal collections and energy expenditure was estimated from six-hour cumulative heart rate measurements. Neither excretion of fat and calories nor estimated energy expenditure was affected significantly by nonnutritive sucking in this subgroup of baby boys. Fat excretion correlated well (r = .987) with energy excretion.
The present study investigated the way that sucking of a pacifier influences gastric secretory and motor functions in connection with tube feeding. Experiments were performed on eight preterm infants who were tube fed twice--once with and once without sucking of a pacifier. The time for tube feeding was significantly decreased and gastric retention decreased in five of seven infants when sucking a pacifier. Maternal milk was found to contain gastrin-17, somatostatin-14, and a somatostatin-like peptide larger than somatostatin-28. Somatostatin levels were significantly reduced in connection with non-nutritive sucking. Gastrin levels were increased in six of ten experiments 2 h and/or 3 h after bolus feeding, suggesting that these peptides were not only supplied by the milk, but were also released from the gastric mucosa. The presence of gastrin and somatostatin in gastric aspirates was established by use of chromatographic methods. The results indicate that somatostatin and gastrin are released into the gastric lumen in preterm infants and that sucking of a pacifier, in connection with bolus feeding, stimulates the gastric motor functions and facilitates the digestion process, probably via activation of vagal mechanisms.
Cette etude des balances energetique, azotee et lipidique et du temps de transit du carmin chez 10 prematures nes en moyenne a 1111 g± 189 et âges de 28± 24 jours au debut de l'etude, ne montre aucun effet immediat de la stimulation de la succion non nutritive au cours de l'alimentation par sonde, sur des differents parametres
To describe the effect of nonnutritive sucking (NNS) on behavioral state (BSt) in preterm infants before feedings 24 preterm infants were randomly assigned and studied before each of their first 16 bottle feedings. Twelve received NNS by pacifier for 5 minutes; 12 did not receive a pacifier. BSt was measured with a 12-category scale for 30 seconds before the 5-minute period (BSt1) and for 30 seconds after (BSt2). Sleep states decreased for both groups. BSts considered more optimal for feeding increased more during NNS (86 vs. 46). Restless states were three times less frequent after NNS (23 vs. 68). Differences between groups were nonsignificant at BSt1, but were significant at BSt2, p less than .001. In the absence of self-regulatory feeding policies based on early hunger cues, NNS for 5 minutes prefeeding is simple, brief, and suitable for implementation in busy neonatal intensive care units. Nonnutritive sucking was an effective modulator of behavioral state for this sample.
A laboratory and a field experiment used within-subject designs to test the hypothesis that nonnutritive sucking (NNS) reduces heart rate (HR) in preterm infants. Infants in Experiment A were provided a standard pacifier nipple for 30 min under strictly controlled conditions. In the field Experiment B, nursing staff provided infants with a standard pacifier during alternate intervals in a sequence of four interfeed intervals spanning 12 hr. NNS significantly reduced average HR in each experiment. Given the strongly positive relationship between HR and energy expenditure, these results suggest that NNS reduces energy expenditure in preterm infants. Such an effect, in turn, could help to explain how the opportunity to engage in NNS enhances growth in preterms.
To evaluate the effect of pacifier use (nonnutritive sucking) on gastroesophageal reflux in infants, 48 infants younger than 6 months of age with pathologic reflux were prospectively evaluated with pH probe. In each infant, parameters of reflux were blindly quantified during paired periods in a cross-over design when pacifier use was either encouraged or prohibited. To determine whether positioning was a factor in the effect of nonnutritive sucking on reflux, 24 of the infants were studied seated and 24 studied prone. Pacifier use significantly affected only the frequency of reflux episodes, increasing it in prone infants from 7.2 +/- 1.1 to 12.8 +/- 2.3 episodes/120 min postprandially (p = 0.040) and decreasing it in seated infants, from 21.1 +/- 3.1 to 14.8 +/- 2.6 postprandially (p = 0.003) and from 17.3 +/- 4.8 to 5.9 +/- 0.9 in the fasting period (p = 0.035). It did not significantly affect the clearance of reflux episodes or the total reflux time. These results suggest that infants with pathologic reflux frequency might best avoid pacifier use while in the beneficial prone position. When seated position is necessary, the pacifying effects of nonnutritive sucking may be useful in decreasing reflux events as well as in reducing crying behavior.
The role of nonnutritive sucking (NNS) in the care of the sick infant is discussed. Several benefits may be derived from NNS: 1) in behavioral and physiologic terms; 2) the maturation of the sucking reflex, the resulting efficiency in feeding, and early hospital discharge; and 3) the change in the perceptions of the caretakers in their alertness and responsiveness to the infants' needs.
The advantages and limitations of meta-analysis in clinical nursing research are explained and illustrated with five studies of nonnutritive sucking (NNS) in preterm infants. This article addresses steps of locating studies, systematic comparison of studies for like variables, and qualitative decisions needed before quantitative methods are applied to cumulate findings across studies. Several approaches of calculating effect size and confidence intervals were used to interpret the power of the treatment effect of NNS. On average, across the five NNS studies, NNS intervention reduced time to first bottle feeding by 2.9 days and days of hospitalization by 6.3 days.
Nutritive and non-nutritive sucking was studied in 9 preterm infants with postmenstrual ages ranging from 28 to 33 weeks and postnatal ages ranging from 0 to 8 weeks. During nutritive sucking, sucking bursts were longer than sucking pauses. During non-nutritive sucking the opposite was seen. The sucking rate was lower during nutritive sucking. During nutritive sucking the respiratory rate was higher during the pauses than during the bursts. During non-nutritive sucking the respiratory rate was higher during sucking. It is concluded that non-nutritive sucking cannot serve as a model for studying feeding mechanisms in the preterm infant.
The effect of nonnutritive sucking bursts (NNSBs) on respiratory frequency was sequentially evaluated in 12 healthy preterm infants. Studies were performed during active sleep in infants between 32 and 37 weeks postconceptional age. The duration of NNSBs was classified as follows: (a) less than 3 s, (b) between 3 and 6 s, and (c) greater than 6 s. NNSBs of each duration were found at all ages, although NNSBs greater than 6 s were the least frequently observed. Respiratory rate increased significantly during NNSBs of less than 3 s, and also in those of 3-6 s duration. There was no significant effect on respiratory frequency of sucking bursts longer than 6 s. Our results document an early interaction between these two motor rhythms, which is influenced by the length of the NNSB. Moreover, they indicate that the decrease in respiratory frequency reported in a similar group of preterm infants during feeding should not be interpreted as an effect of sucking per se.
Ten healthy preterm infants were studied to determine if non-nutritive and nutritive suck significantly altered gastric emptying patterns when compared with gavage feeding alone. We used a 10% dextrose meal with phenol red marker and a double sampling technique to determine gastric emptying at 10-min intervals over a 30-min test period. A crossover study design compared the effects of the three feeding methods in each infant. The gastric residual volumes expressed in milliliters per kilogram did not differ significantly when comparisons were made among groups at 10, 20, and 30 min following the test meal. Non-nutritive suck and nutritive suck and swallow of a liquid dextrose meal do not significantly improve gastric emptying in healthy preterm infants. The beneficial effects of non-nutritive and nutritive sucking on the nutritional status of preterm infants, demonstrated by others, are not related to improved gastric evacuation of feeds. Alternative explanations for these beneficial effects require further investigation.
Alteration of the breathing pattern seen during oral feeding has been attributed to the behavioral activity of sucking, repeated swallowing, and laryngeal chemoreceptor stimulation. Because it preserves the behavioral activity of sucking but eliminates the laryngeal chemoreceptor stimulation and repeated swallowing that occurs during nutritive sucking, the effects of nonnutritive sucking was evaluated in 19 term infants. The suck-pause pattern seen during nonnutritive sucking is similar to that of nutritive sucking. None of the variables measured (inspiratory duration, expiratory duration, breathing frequency, and tidal volume) were significantly altered during the overall period of nonnutritive sucking when compared with previously obtained control values. These results suggest that the alteration of breathing pattern observed during oral feeding cannot be accounted for by the behavioral activity of sucking per se. However, when the sucking phases of the nonnutritive period were compared with the intervening pauses, a reduction in the expiratory duration (P less than 0.05) and a reduction in tidal volume (P less than 0.05) were observed. Thus, the breathing pattern of human neonates is indeed altered during the sucking phase of the nonnutritive period; pressure changes associated with sucking may account for this alteration.
Changes in non-nutritive sucking contingent upon the repeated presentation of unpatterned and patterned light stimulation were examined in a sample of 18 premature infants. Stimulus contingent sucking change in chronologically younger infants tended to be somewhat shorter in duration than that of the chronologically older infants and showed stimulus contingent sucking acceleration as well as suppression. Evidence was also found for less orienting among infants showing abnormalities in their sucking behavior. No evidence for habituation was found in any subgroup. Possible factors contributing to the strength and nature of stimulus contingent non-nutritive sucking changes in infants are discussed.
Discrete changes in the human newborn's sucking behavior in response to acoustic stimulation was studied. In order to obtain a sensitive comparison measure for stimulus conditions, control trials were randomly interspersed with stimulus trials. To prevent temporal biasing effects, variable interstimulus intervals were used, and stimuli were presented contingent on the infant's sucking state on each trial. Results from 30 Ss clearly demonstrate the presence of two dichotomous responses: (1) response initiation to the stimulus in the presence of non-sucking; and (2) response cessation to the stimulus in the presence of active-sucking. No differences were found among three groups exposed to qualitatively different stimuli of the same intensity, and there was no evidence of habituation of either response.
50 HUMAN NEWBORNS WERE OBSERVED DURING THE 1ST 3 DAYS OF LIFE TO DETERMINE EFFECTS OF AGE AND FOOD DEPRIVATION ON THE INFANT'S TENDENCY TO QUIET WHEN GIVEN AN OPPORTUNITY TO SUCK ON A BLIND NIPPLE. 30 SS WERE OBSERVED PRIOR TO THEIR 1ST POSTNATAL FEEDING. UNDER THE CONDITIONS OF OBSERVATION, ALMOST ALL SS IN THE 2ND AND 3RD DAYS OF LIFE SHOWED A SUDDEN REDUCTION OF MOVEMENT WITH NIPPLE STIMULATION; THE SS WHO SUCKED WELL PRIOR TO THE 1ST FEEDING ALSO QUIETED WHEN THE NIPPLE WAS INSERTED INTO THEIR MOUTHS. FEEDING, EVEN THE 1ST, TENDED TO REDUCE THE LEVEL OF SS' MOVEMENT. THE SUCKING-QUIETING PHENOMENON IS APPARENTLY ORGANIZED CONGENITALLY.
The motor response to tickling of 24 4-day-old healthy neonates was tested during ordinary restful sleep, when the infants were sucking on a pacifier in sleep, and during sleep when they had a pacifier in their mouth but were not sucking. The results indicate that sucking renders the sleeping infant unresponsive to an external stimulus. A similar but less marked rise in response thresholds was observed when a pacifier was in the baby's mouth but the baby was not sucking. In this condition, the infant usually responded to the stimulus with a new burst of sucking rather than a burst of diffuse motility, as in ordinary sleep. Various interpretations for these findings are considered.
Light and sound stimulations of 1-minute duration were presented to 10 newborn infants on each of their first 5 days of life. Differential stimulus effects on frequency of sucking "bursts" were observed. No differential effects were found on time spent sucking during periods of stimulation. An inverted U-shaped relation was found between level of light intensity and number of sucking bursts. Sound stimulation decreased burst frequency. No additive effects of combined light and sound stimulation were found. Stimulus change affected sucking bursts but did not inhibit sucking. Reliable individual differences were found for average number of sucking bursts per minute, burst length, interburst interval length, and seconds of sucking per minute.
The effects of nonnutritive sucking (NNS) by means of a pacifier during gavage feeding were studied in 30 premature infants whose birth weight was less than 1,500 g. The addition of NNS accelerated the maturation of the sucking reflex, facilitating a more rapid transition from gavage to oral feedings. Additionally, NNS decreased intestinal transit time and caused a more rapid weight gain despite comparable caloric intake resulting in a shortened hospital stay. Although the physiologic mechanisms resulting from this form of oral stimulation remain to be investigated, our data suggest that NNS may be an important factor to consider in the feeding of premature infants.
The effects of nonnutritive sucking on transcutaneous oxygen tension, heart rate, and respiratory rate were studied sequentially in 14 sleeping preterm infants breathing room air. Transcutaneous oxygen tension increased during nonnutritive sucking in infants between 32 and 35 weeks postconceptional age, but not in those between 36 and 39 weeks. This response was not associated with a change in respiratory rate or sleep state, although heart rate tended to increase. These data offer further support for the beneficial effects of nonnutritive sucking in preterm infants.
Preterm neonates (mean 32 weeks' gestation, 1,300 gm birth weight) were provided a pacifier for nonnutritive sucking during tube feedings in the intensive care nursery. Their clinical course, subsequent bottle feeding behavior, and performance on the Brazelton Neonatal Behavior Assessment scale were compared with those of control group infants. The infants provided with pacifiers averaged 27 fewer tube feedings, started bottle feeding three days earlier, averaged a greater weight gain per day, and were discharged eight days earlier for an average hospital cost savings of approximately $3,500. Formula intake was similar for the two groups, although nurses appeared to provide more feeding stimulation for the control infants. On the Brazelton scale, the infants provided with pacifiers showed weak reflexes more frequently. Increased restfulness and diminished activity level in these infants may have contributed to the appearance of weak reflexes. The consistency between these findings and those of previous investigators suggests that the provision of a pacifier for nonnutritive sucking during tube feedings may be a cost-effective form of intervention.
Motilin is likely to be accepted as a member of the established gut hormone club in the near future. It will require further research to determine whether the role of motilin in the alimentary tract is limited to its motor activity or other functions such as secretory function. Moreover, the effort will be made to determine whether, indeed, motilin limits its role to the motor activity in the interdigestive state only or if it acts in the postprandial state as well. In order to investigate these aspects, investigators will have to improve the sensitivity of radioimmunoassay methodology to be able to determine motilin levels that cannot be detected by the currently available method. Physiological stimuli for endogenous release of motilin will have to be determined and the mechanism for release of motilin will have to be investigated. The lack of elevation of plasma motilin in response to nutrients except for fats or intravenous amino acids makes us wonder whether the paracrine or neurocrine functions of this peptide may be more predominant than its endocrine function. If motilin acts predominantly as a paracrine hormone, the investigation into its physiological actions on a local tissue or organ will require a new approach, different from the traditional endocrine research. As its physiological roles become defined, disordered physiology of motilin in diseased states will undoubtedly emerge.
Neonatal sucking responses or behaviors have been of great interest to researchers and clinicians since the early 1800s. Since 1960, there has been a resurgence of interest in the objective study of sucking behaviors in both the psychological and medical literature. The studies have examined both nutritive and non-nutritive sucking measurements. Sucking behaviors have been studied to understand the development of the feeding mechanism as well as to track neurobehavioral development. The relationship between sucking behaviors and behavioral organization of the newborn are considered, along with a historical perspective of sucking measurements, relevant literature on nutritive sucking, physiologic correlates, differences in breast and bottle feeding patterns, non-nutritive sucking, and factors that modify sucking organization. Implications for nursing practice will be discussed.
The purpose of this study was to explore the possible protective effect of nonnutritive sucking (NNS) against the development of necrotizing enterocolitis (NEC). A retrospective chart review was conducted to examine the histories of 12 preterm infants who were enrolled in a longitudinal study of the effects of NNS on energy expenditure, weight gain, and feeding readiness. Six infants were enrolled in the control group; they did not receive NNS but did develop NEC. Six infants were in the experimental group and did not develop NEC. The groups were compared on the basis of clinical correlates associated with NEC. These included race, gender, birth weight, five-minute Apgar, maternal bleeding, maternal age, and length of ruptured membranes. For infants who developed NEC, the number of clinical correlates ranged from one to four. For infants who received NNS, the range of clinical correlates was from one to five. It is not possible to conclude from this study that NNS protects preterm infants from NEC. Prospective studies of larger sample sizes that involve examination of the effect of NNS on gastric motility and enzyme and hormone secretion are needed.
Transition of preterm infants from enteral to nipple feeding is a necessary milestone for hospital discharge. This study tested the efficacy of one potential intervention to facilitate the transition process. Ten minutes of nonnutritive sucking (NNS) and a control condition were administered randomly before first nipple feedings. The sample consisted of 20 preterm infants (gestational ages 27-33 weeks, M = 31.6, SD = 1.7; birth weights 931-2, 140 g, M = 1,649, SD = 373) who served as their own controls. NNS resulted in fewer behavioral state changes during feedings and produced quiet, awake states more frequently during feedings. Heart rates did not differ between feedings following NNS compared with those in the control condition.
To examine the effects of nonnutritive sucking on the physiologic and behavioral stress reactions of preterm infants at early bottle feedings and to examine the effect of nonnutritive sucking on the feeding performance of preterm infants at early bottle feedings.
Quasi-experimental with a matched sample.
A level III neonatal intensive-care unit in a large medical center.
Twenty preterm infants whose gestational ages at birth ranged from 26 to 34 weeks.
Ten infants were provided nonnutritive sucking for 5 minutes before and 5 minutes after an early bottle feeding. Ten infants served as controls.
Physiologic stress was measured by heart rate and oxygen saturation rate. Behavioral stress was measured by observation of behavioral state. Feeding performance was measured by duration, percentage of formula taken by bottle, and behavioral state after feeding.
Infants who received nonnutritive sucking before and after bottle feedings were more likely to be in a quiescent behavior state 5 minutes after the feeding (p = .01) and had higher feeding performance scores (p = .01) than infants who did not receive nonnutritive sucking.
The purpose of this study was to examine the effects of nonnutritive sucking (NNS) on behavioral organization and feeding performance in preterm infants. Thirteen preterm infants were observed at four bottle-feedings, two of which involved treatment with prefeeding NNS. NNS had a positive effect on oxygen saturation and behavior state, as well as on the initiation and duration of the first nutritive suck burst.
To study the effect of milk odor on nonnutritive sucking by premature newborns.
Blinded, crossover study of the effects of milk vs sham odor on nonnutritive sucking.
Urban neonatal intensive care unit.
Twenty-nine premature newborns with gestational age of 29 to 36 weeks.
Fourteen subjects were tested with fortified breast milk odor (group 1) and 15 were tested with formula odor (group 2). For the test observation, milk odor was directed to the nose (orthonasal exposure) using a specially modified pacifier. For the control observation, water was used as a sham odor. Observations were made concurrently with tube feeding of the newborn with either fortified breast milk (group 1) or formula (group 2).
Total number of sucks and sucking bursts, measured from a digital record of pressure changes within the pacifier.
Nutrient odor increased suck bursts in group 1 subjects, with borderline statistical significance (46.6 bursts/10 min with odor [95% confidence interval (CI), 39-54] vs 35.4 bursts/10 min without odor [95% CI, 28-43]). Unexpectedly, when test and control observations were combined, subjects in group 1 showed an overall increase in number of sucks (260.4 [95% CI, 206-315]) and suck bursts (41.0 [95% CI, 36-46]) compared with group 2 subjects (144.8 [95% CI, 87-203] vs 27.4 [95% CI, 21-34]).
Nutrient odor exposure via pacifier may stimulate nonnutritive sucking during gavage feeding of premature newborns. Further studies on the effects of nutrient odor on nonnutritive sucking by premature newborns must take into account the effects of nutrients given via gavage.
Premature infants are fed by gavage tube before 34 weeks adjusted gestational age and when nipple feeding results in detrimental changes in respiration and heart rate. Nipple feeding skill must be developed and correlates with length of hospitalization and neurobehavioral development. This study provided music reinforcement for nonnutritive sucking and assessed nipple feeding rates pre- and posttreatment for 32 infants referred as poor feeders. A pacifier fitted with a pressure transducer activated 10 seconds of recorded music in a one-trial, 15-minute intervention given to experimental infants (n = 16) 30 to 60 minutes before the late afternoon bottle feeding. Feeding rates were collected for bottle feedings pre- and postintervention and for a similar interval for a no-contact control group (n = 16). Results showed that the intervention significantly increased feeding rates. Music functioned as reinforcement and the sucking behavior transferred from a nonnutritive to a nutritive event.