Article

The maturation and coordination of sucking, swallowing, and respiration in preterm infants

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Abstract

Objectives Our objectives were to establish normative maturational data for feeding behavior of preterm infants from 32 to 36 weeks of postconception and to evaluate how the relation between swallowing and respiration changes with maturation. Study design Twenty-four infants (28 to 31 weeks of gestation at birth) without complications or defects were studied weekly between 32 and 36 weeks after conception. During bottle feeding with milk flowing only when infants were sucking, sucking efficiency, pressure, frequency, and duration were measured and the respiratory phase in which swallowing occurs was also analyzed. Statistical analysis was performed by repeated-measures analysis of variance with post hoe analysis. Results The sucking efficiency significantly increased between 34 and 36 weeks after conception and exceeded 7 mL/min at 35 weeks. There were significant increases in sucking pressure and frequency as well as in duration between 33 and 36 weeks. Although swallowing occurred mostly during pauses in respiration at 32 and 33 weeks, after 35 weeks swallowing usually occurred at the end of inspiration. Conclusions Feeding behavior in premature infants matured significantly between 33 and 36 weeks after conception, and swallowing infrequently interrupted respiration during feeding after 35 weeks after conception.

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... mentale la coordinazione della sequenza suzione-deglutizione-respiro. Il neonato presenta infatti le tre abilità già dalle prime settimane g sta io ali a fi o a c o si raggiu g tal coor i a io la deglutizione avviene preferenzialmente durante l'apnea e l'inspirazione, aumentando così il rischio di episodi di desaturazione, apnea e inalazione 3,6 . ...
... or as i act t t r a iliti s alr a ro t first gestational weeks, but until such coordination is achieved, the swallowing occurs preferentially during the apnea and the inspiration, thus increasing the risk of episodes of desaturation, apnea and inhalation 3,6 . ...
... In general, oral feeding is not proposed to preterm infants born prior to 32 weeks post-conceptional age 3 . ...
Article
Il neonato pretermine spesso deve acquisire dopo la nascita la maturazione neurologica e le competenze che lo rendano in grado di alimentarsi per bocca, anziché tramite sonda, mantenendo la stabilità dei parametri vitali, e senza presentare desaturazioni, apnee o bradicardie.Tale conquista porta a benefici per il neonato, per la madre, e per l’economia sanitaria, permettendo solitamente una pronta dimissione del neonato.L’infermiere pediatrico sostiene il passaggio dall’alimentazione tramite sonda all’alimentazione per via orale, anche valutando la ‘prontezza’ del neonato rispetto a questo; tale valutazione può essere basata sull’esperienza del singolo, o essere supportata da uno strumento validato.Attualmente in letteratura non è presente uno strumento validato per il contesto italiano per la valutazione della ‘prontezza’ del neonato ad essere alimentato per via orale. Dopo una revisione della letteratura è stato quindi scelto uno strumento pubblicato e validato in altra lingua (inglese) per la sua validazione linguistico-culturale in lingua italiana.
... Il neonato pretermine può presentare difficoltà nel soddisfare il bisogno di alimentazione in maniera autonoma, tanto più marcate quanto più è bassa l'età gestazionale, tali da rendere necessaria la somministrazione di latte tramite sonda gastrica. Il passaggio da alimentazione con sonda ad allattamento al seno prevede, oltre all'integrità delle strutture deputate, l'acquisizione e la maturazione di determinate abilità correlate alla maturità neurologica e all'organizzazione degli stati comportamentali: il neonato deve essere in grado di mantenere uno stato di veglia attiva, la stabilità cardio-respiratoria ed infine coordinare i riflessi di suzione e deglutizione col respiro [1][2][3] . ...
... The newborn has in fact the three abilities already from the first gestational weeks, but until such coordination is achieved, the swallowing occurs preferentially during the apnea and the inspiration, thus increasing the risk of episodes of desaturation, apnea and inhalation 3,6 . ...
... In general, oral feeding is not proposed to preterm infants born prior to 32 weeks post-conceptional age 3 . ...
... This finding is in consonance with the study by Bingham et al. and Mizuno and Ueda. [27,28] Bingham et al. reported that premature newborns who were kept in ventilator usually exhibited poor sucking ability. [27] A study done by Mizuno and Ueda in 24 high-risk full-term infants revealed that maturity of neurological development in premature newborns can be predicted through the sucking behavior seen in them. ...
... [27] A study done by Mizuno and Ueda in 24 high-risk full-term infants revealed that maturity of neurological development in premature newborns can be predicted through the sucking behavior seen in them. [28] Studies on Moro reflex report weak or absent Moro response, which is indicative of serious neurological conditions. [19,29] Five of the selected articles discussed about the Moro reflex in high-risk infants. ...
... Auch wenn ein Fetus intrauterin bereits frühzeitig dazu in der Lage ist zu schlucken, ist die Koordination von Schlucken, Saugen und Atmen extrauterin erst ab der 32. Gestationswoche überhaupt möglich (Mizuno et al., 2003). In den darauffolgenden Gestationswochen der Späten Frühgeburtlichkeit wird das Steuern von Trinken und Atmen besser und Sättigungsabfälle werden seltener. ...
... In den darauffolgenden Gestationswochen der Späten Frühgeburtlichkeit wird das Steuern von Trinken und Atmen besser und Sättigungsabfälle werden seltener. Jedoch bestehen in dieser Phase weiterhin ein verminderter Saugdruck und eine Sauginsuffizienz (Mizuno et al., 2003). So lässt sich das häufigere Auftreten von Fütterungsproblemen und die geringere Rate an vollgestillten LPIs erklären. ...
Thesis
Als Späte Frühgeborene (late preterm infants, LPIs) werden Kinder definiert, die zwischen der 34+0/7 und 36+6/7 Gestationswoche geboren werden. Obwohl LPIs weltweit den Großteil der Frühgeborenen-Population ausmachen, gab es in diesem Bereich bis vor einigen Jahren nur wenige Studien, da klinisch auf den ersten Blick lediglich geringe Unterschiede zu Reifgeborenen erkennbar sind. Allerdings weisen LPIs sowohl in der Neonatalperiode als auch im weiteren Verlauf eine erhöhte Morbidität und Mortalität auf. Ziel dieser Arbeit war es deshalb, die Unterschiede einzelner Gestationswochen Später Frühgeburtlichkeit zu vergleichen sowie die Auswirkungen auf die Entwicklung im Kindesalter zu untersuchen. Im ersten Teil der Studie wurden Neonataldaten der 781 in den Jahren 2008 bis 2014 in der Universitätsklinik Freiburg geborenen LPIs retrospektiv und pseudonymisiert ausgewertet. Im Vergleich der einzelnen Gestationswochen fiel auf, dass die Raten an respiratorischen Komplikationen, Hypoglykämien, Thermoregulationsstörungen, phototherapiepflichtigen Hyperbilirubinämien, Fütterungsproblemen, Notwendigkeit von intensivmedizinischer Betreuung, Wiederaufnahme innerhalb der ersten 24 Lebensmonate sowie die Dauer bis zur Erstentlassung mit steigender Gestationswoche eines LPIs signifikant abnahm. Selbst wenige Tage, die ein LPI später zur Welt kam, beeinflussten das Outcome signifikant. Im zweiten Teil der Studie wurden über einen eigenen Fragebogen und die Child-Behavior-Checklist medizinische Daten von 281 LPIs im zweiten Lebensjahr und im sechsten Lebensjahr erfragt und mit einer Referenzkohorte gleichaltriger Reifgeborener verglichen. Dabei zeigte sich, dass LPIs motorische Meilensteine wie Krabbeln und Laufen signifikant später erreichten. Außerdem zeigten LPIs im zweiten Lebensjahr signifikant häufiger Internalisiertes Verhalten, Angst und Emotionale Reaktivität, was im sechsten Lebensjahr nicht mehr zu beobachten war. Obwohl dieses Phänomen des Aufholens im kognitiven Bereich aufgrund des untersuchten Zeitrahmens dieser Studie nicht eindeutig nachgewiesen werden konnte, zeigten sich auch hier bei sechsjährigen LPIs Defizite in der schulischen Leistung im Vergleich mit Reifgeborenen. Insgesamt kann das Spektrum der Späten Frühgeburtlichkeit demnach nicht als eine homogene Risikogruppe zusammengefasst werden, sondern jede zusätzliche Gestationswoche macht sowohl im kurzzeitigen als auch im langfristigen Outcome einen entscheidenden Unterschied. LPIs holen Defizite in der motorischen, sozialen und kognitiven Entwicklung jedoch zum Teil auf, sodass eher von einer verzögerten Entwicklung als von bestehenden Defiziten gesprochen werden kann. Trotz steigendem Bewusstsein für LPIs als Risikopopulation bestehen allerdings nach wie vor Bereiche, in denen dringender Forschungsbedarf besteht.
... Oral feeding is a complex developmental task. Oral feeding development requires proper structural development, physiologic stability, tone, and coordination (Crowe, Chang, & Wallace, 2016;McGrath & Braescu, 2004;Mizuno & Ueda, 2003). In utero, the development of feeding occurs with fetal swallowing noted as early as 12 weeks' GA, and by 34 weeks' GA, the fetus is known to have a coordinated suck and swallow reflex (Humphrey, 1970). ...
... Another key factor in oral feeding success for preterm infants is their birth GA. Infants who are born at higher birth GA are able to learn to feed faster (Davis, Liu, & Rhein, 2013;Mizuno & Ueda, 2003). This finding is likely due to the fact that these infants are older, have a more mature neurodevelopmental system, and have had more practice sucking and swallowing in the womb. ...
Article
Full-text available
Purpose Successful oral feeding and speech emergence are dependent upon the coordination of shared oral muscles and facial nerves. We aimed to determine if the speech-associated genes, forkhead box P2 (FOXP2), contactin-associated protein-like 2 (CNTNAP2), glutamate receptor, ionotropic, N-methyl D-aspartate 2A (GRIN2A), and neurexin 1, were detectable in neonatal saliva and could predict feeding outcomes in premature newborns. Method In this prospective, observational, preliminary study, saliva collected from 51 premature infants (gestational ages: 30–34 6/7 weeks) at different stages of oral feeding development underwent gene expression analysis. Binary (+/–) expression profiles were explored and examined in relation to days to achieve full oral feeds. Results GRIN2A and neurexin 1 rarely amplified in neonatal saliva and were not informative. Infants who amplified FOXP2 but not CNTNAP2 at the start of oral feeds achieved oral feeding success 3.20 (95% CI [−2.5, 8.9]) days sooner than other gene combinations. Conclusions FOXP2 and CNTNAP2 may be informative in predicting oral feeding outcomes in newborns. Salivary analysis at the start of oral feeding trials may inform feeding outcomes in this population and warrants further investigation.
... The maturation of suck, swallow, and breathe coordination occurs around 32-34 weeks postmenstrual age (PMA) in infants born prematurely. It is a common practice in neonatal intensive care units (NICUs) to initiate the transition from gavage to oral feeds around this PMA [5][6][7][8] since delayed initiation has been linked to numerous medical and developmental consequences, such as delayed oral motor development, prolonged hospital stays, and the persistence of feeding disorders [6,[9][10][11][12]. On the other hand, the initiation of oral feeding before preterm infants' swallowing mechanisms have become fully mature can lead to aspiration [13,14]. ...
... The PMA of 34 weeks as the GA to offer oral feeding was the standard clinical practice in our NICU since several publications suggested maturation of the swallow mechanism in preterm infants at this PMA [7,33,34]. Our clinical practice incorporates the offering of oral feeds only to those infants who demonstrate cues of oral feeding readiness as assessed by the bedside registered nurses. This objective oral feeding assessment (based on alertness, tone, hunger cues, and latching) was developed by our NICU and was consistently used during the study period (2012-2017). ...
Article
Full-text available
To determine whether delaying oral feeding until coming off NCPAP will alter feeding and respiratory-related morbidities in preterm infants. In this retrospective pre–post analysis, outcomes were compared in two preterm infant groups (≤32 weeks gestation). Infants in Group 1 were orally fed while on NCPAP, while infants in Group 2 were only allowed oral feedings after ceasing NCPAP. Although infants in Group 2 started feeds at a later postmenstrual age (PMA), they reached full oral feeding at a similar PMA compared with Group 1. Interestingly, there was a positive correlation between the duration of oral feeding while on NCPAP and the time spent on respiratory support in Group 1. Delayed oral feeding until ceasing NCPAP did not contribute to feeding-related morbidities. We recommend caution when initiating oral feedings in preterm infants on NCPAP without evaluating the safety of the infants and their readiness for oral feedings.
... Nutritive sucking involves a number of biomechanical aspects, namely, (i) swallowing in relation to respiratory phase, (ii) the suck:swallow ratio, and (iii) swallowing rate per minute. The coordination between swallowing and respiration changes with age [1,3,4]. In both preterm and term infants, swallowing can be followed by both inhalation and exhalation, but the frequency of exhalation after swallowing increases during the first year of life [4][5][6][7]. ...
... The coordination between swallowing and respiration changes with age [1,3,4]. In both preterm and term infants, swallowing can be followed by both inhalation and exhalation, but the frequency of exhalation after swallowing increases during the first year of life [4][5][6][7]. Shortly after birth, infants drink with a suck:swallow ratio of 1:1, but after 1 month the suck:swallow ratio is higher, 2:1 [1]. ...
Article
Full-text available
Background: Nutritive sucking is a complex activity, the biomechanical components of which may vary in relation to respiratory phase, swallow-rate per minute, suck-swallow ratio, and swallow non-inspiratory flow (SNIF). Quantitative measurement of these components during nutritive sucking in healthy infants could help us to understand the complex development of sucking, swallowing, and breathing. This is important because the coordination between these components is often disturbed in infants with feeding difficulties. The aims of this study were to describe the biomechanical components of sucking and swallowing in healthy 2- to 5-month-old infants during bottle feeding, to assess whether infants adapt to the characteristics of two different teats, and to determine which independent variables influence the occurrence of SNIF. Methods: Submental muscle activity, nasal airflow, and cervical auscultation were evaluated during bottle-feeding with two different teats. Results: Sixteen term-born infants (6 boys) aged 2-5 months were included. All infants showed variable inhalation and exhalation after swallowing. The swallow rate per minute was significantly higher when infants fed with a higher flow teat (Philips Avent Natural 2.0™). Infants had suck:swallow ratios ranging from 1:1 to 4:1. A suck:swallow ratio of 1:1 occurred significantly more often when infants fed with a higher flow teat, whereas a suck:swallow ratio of 2:1 occurred significantly more often when infants fed with a low-flow teat (Philips Avent Classic+™). A suck:swallow ratio of 1:1 was negatively correlated with SNIF, whereas a suck:swallow ratio of 2:1 was positively correlated with SNIF. Conclusion: Healthy infants aged 2-5 months can adapt to the flow, shape, and flexibility of different teats, showing a wide range of biomechanical and motor adaptations.
... Premature infants frequently experience difficulty in sucking, thereby delaying the transition from tube to full oral feeding [24][25][26]. According to the NOMAS cluster system, sucking difficulty can be classified as arrhythmical sucking pattern, inability to sustain sucking pattern, incoordination of SSR sucking pattern, and dysfunctional sucking pattern (Table 1). ...
... However, the relationship between incoordination of SSR and stress signals was suggested through clinical observation and not by direct measurement of SSR. To demonstrate the incoordination of SSR, recordings of intraoral pressure (rhythmic alternation of suction and expression/compression) [11,24], pharyngeal pressure [24,25], nasal thermistor flow [26,30], and thoracoabdominal plethysmography [24] have been used, but these methods are not widely used, particularly in the clinical settings, due to their complexity and invasiveness. However, in terms of research, the relationship between SSR incoordination and clinically observed stress symptoms could be investigated by directly measuring SSR. ...
Article
Full-text available
Background: Stress signals during sucking activity such as nasal flaring, head turning, and extraneous movements of the body have been attributed to incoordination of sucking, swallowing, and respiration (SSR) in premature infants. However, the association of uncoordinated sucking pattern with developmental outcomes has not yet been investigated. The aim of this study was to investigate whether uncoordinated sucking pattern during bottle-feeding in premature infants is associated with the developmental outcomes at 8-12 and 18-24 months of age (corrected for prematurity). Methods: We retrospectively reviewed the medical records and video recordings for the Neonatal Oral-Motor Assessment Scale (NOMAS) of premature infants and divided them into two groups based on the presence or absence of incoordination. The Bayley-III cognition composite scores of the incoordination-positive and incoordination-negative group were compared at 8-12 and 18-24 months of age. Results: Seventy premature infants exhibited a disorganized sucking pattern according to the NOMAS. The average Bayley-III cognition composite scores at 8-12 months of age were 92.5 ± 15.6 and 103.0 ± 11.3 for the incoordination-positive (n = 22) and incoordination-negative groups (n = 48), respectively (p = 0.002). The average Bayley-III cognition composite scores at 18-24 months were 90.0 ± 17.9 and 100.7 ± 11.5 for the incoordination-positive (n = 21) and incoordination-negative groups (n = 46), respectively (p = 0.005). A multiple linear regression analysis indicated that the presence of uncoordinated sucking pattern, grade 3 or 4 germinal matrix hemorrhage-intraventricular hemorrhage, and moderate to severe bronchopulmonary dysplasia were independently associated with cognitive development at 18-24 months of age. Conclusions: Uncoordinated sucking pattern in premature infants was independently associated with a higher risk of abnormal developmental outcome in the cognitive domain of the Bayley-III at both 8-12 and 18-24 months. There may be a need for periodic follow-up and early intervention for developmental delay when incoordination of SSR that results in stress signals on the NOMAS is observed before 40 weeks postmenstrual age.
... Apnoeic episodes during swallowing decrease as the infant matures (Gewolb & Vice, 2006). During the first 12 months of life, the frequency of expiration after swallowing increases (Gewolb & Vice, 2006;Kelly, Huckabee, Jones, & Frampton, 2007;Mizuno & Ueda, 2003). Synchronization of sucking, swallowing and breathing is an important part of successful feeding (Goldfield, Richardson, Lee, & Margetts, 2006). ...
... When learning to bottle feed using different flow teats, infants may display individual differences in the development of the frequency of breathing and sucking (Mathew, 1991). Variations may specifically occur with the swallowing rate per minute, with the suck swallow ratio, and with swallowing in relation to the respiratory phase (Mizuno & Ueda, 2003;Qureshi et al., 2002). ...
Article
Aims and Objectives: For preterm and medically fragile infants, learning to feed orally is challenging. There are many contributing factors that can support the development of oral feeding. The flow rate of a teat can influence feeding success in the bottle-fed infant and, if not supportive, can cause physiological instability during feeding. The flow rate of teats used in a selection of neonatal units in the United Kingdom (UK) was tested to determine their flow rate, which was then compared to the flow rate of commercially available teats. Design and Methods: Flow rate of teats used in several neonatal units across the UK were tested by attaching a teat to a breast pump and measuring the output of milk after 1 min. These values were compared to the flow rates of commercially available teats. The hypothesis was that hospital disposable teats might have a considerably higher flow rate, and a higher rate of variability, than commercially available teats. Results and Conclusions: The results identified that there were differing flow rates as well as a wide variation of flow rates for both hospital disposable and commercial teats. Hospital disposable teats had flow rates ranging from 8.5 mL/min to 23.3 mL/min, and commercial teats had a range of 4.2 mL/min to 31.3 mL/min. Measurement of variability in flow rate identified a moderate mean flow rate for hospital disposable teats (CoV = 0.1), with a low mean variability in flow rate for commercial teats (CoV = 0.07). Applicability of this data to a clinical context is discussed.
... Preterm infants at birth usually do not receive their mother's milk directly from the breast, because active suckling and coordination between suckling, swallowing and breathing are not developed until 32-34 weeks postmenstrual age (Mizuno and Ueda, 2003). However, with adequate support, effective latching and actual breastfeeding are usually possible as the infants develop and grow older (Academy of Breastfeeding Medicine, 2011). ...
... In order to examine the specific role of latching and actual breastfeeding in shaping MOM and infant's oral and gut microbial communities, we included into this study a peculiar population of preterm infants and their mothers. Moderately preterm infants, who are born between 32 and 34 weeks of gestational age, are usually unable to actively suck in the first days/weeks of life (Mizuno and Ueda, 2003), thus initially receiving MOM, DHM and/or formula through an orogastric tube. Mothers of these infants are encouraged to express milk through a breast pump, in order to promote milk production and to guarantee to the infant the benefits related to MOM feeding. ...
Article
Full-text available
Mother’s own milk represents the optimal source for preterm infant nutrition, as it promotes immune defenses and gastrointestinal function, protects against necrotizing enterocolitis, improves long-term clinical outcome and is hypothesized to drive gut microbiota assembly. Preterm infants at birth usually do not receive their mother’s milk directly from the breast, because active suckling and coordination between suckling, swallowing and breathing do not develop until 32–34 weeks gestational age, but actual breastfeeding is usually possible as they grow older. Here, we enrolled moderately preterm infants (gestational age 32–34 weeks) to longitudinally characterize mothers’ milk and infants’ gut and oral microbiomes, up to more than 200 days after birth, through 16S rRNA sequencing. This peculiar population offers the chance to disentangle the differential contribution of human milk feeding per se vs. actual breastfeeding in the development of infant microbiomes, that have both been acknowledged as crucial contributors to short and long-term infant health status. In this cohort, the milk microbiome composition seemed to change following the infant’s latching to the mother’s breast, shifting toward a more diverse microbial community dominated by typical oral microbes, i.e., Streptococcus and Rothia. Even if all infants in the present study were fed human milk, features typical of healthy, full term, exclusively breastfed infants, i.e., high percentages of Bifidobacterium and low abundances of Pseudomonas in fecal and oral samples, respectively, were detected in samples taken after actual breastfeeding started. These findings underline the importance of encouraging not only human milk feeding, but also an early start of actual breastfeeding in preterm infants, since the infant’s latching to the mother’s breast might constitute an independent factor helping the health-promoting assembly of the infant gut microbiome.
... Infants born at less than 32 weeks' gestational age (GA) are developmentally unable to coordinate the sucking, swallowing, and breathing necessary for oral feeding, and must be fed via nasogastric tube. 10 Most mothers must depend on pumps to initiate and maintain milk supply for weeks or months before the infant can suckle at the breast. 8 Moreover, mother's own milk may be insufficient to meet the demands of a preterm infant, who requires more calories per kilogram than a term infant. 1 The establishment of DBF can be delayed because of physical separation while the infant is in the neonatal intensive care unit (NICU), and because infants can be too medically fragile for handling, prohibiting frequent skin-toskin contact. ...
... illnesses were chosen because they may affect execution or coordination of the suck-swallow-breathe process that is required for safe and efficient oral feeding. 10,21,22 The number of days of ventilation and continuous positive airway pressure support were also recorded from the infant's charts to examine how the need for significant respiratory support might affect breastfeeding success. At the KHSC NICU, the time, method, volume or duration, and composition of each feed are recorded in the infant's chart, and these were accessed electronically as well. ...
Article
Background: Despite a mother's intention to breastfeed, there are many barriers to feeding preterm infants that decrease breastfeeding rates. Objective: The objective of this research was to determine factors associated with successful direct breastfeeding (DBF) of the preterm infant at hospital discharge. Materials and methods: A retrospective chart review of 69 preterm (<34 weeks' gestational age) infants in the neonatal intensive care unit, whose mothers intended to breastfeed, was conducted. Infant-, mother-, and feeding-related factors were examined by chi-square or t test for their relationship with breastfeeding success, and by multiple logistic regression to identify predictive factors. Results: Successful DBF at discharge occurred in 64%. Mothers of infants who were breastfed were older (p < 0.0001); had less psychiatric illness (p = 0.03); and were less likely to smoke (p < 0.0001) and use recreational drugs (p = 0.04). The infants had higher birth weights (p = 0.03) and lower incidence of bronchopulmonary dysplasia (p = 0.04). A higher proportion of infants received DBF at their first oral feed (p < 0.001), and were discharged earlier (p = 0.03). Reduced milk supply was cited for breastfeeding failure in 36%. Older maternal age (odds ratio [OR] = 1.24, 95% confidence interval [CI] 1.02-1.51) and DBF at the first oral feed (OR = 7.72, 95% CI 1.37-43.6) were associated with successful DBF at discharge. Conclusion: Maternal age and method of first oral feed are critical predictors of breastfeeding success in preterm infants. Mothers should be encouraged to breastfeed at the infant's first oral attempt and strategic breastfeeding support should be provided before initiation of oral feeding.
... It is well known that the pattern of sucking, swallowing, and breathing in premature infants differs from their fullterm counterparts [2][3][4]. Observational studies have shown that preterm infants begin to develop a coordinated suckswallow-breathing pattern analogous to term infants at an average of 33 weeks' postmenstrual age [4][5][6]. Many experts, therefore, recommend initiating oral feeding attempts near this postmenstrual age [7,8]. ...
... It is well known that the pattern of sucking, swallowing, and breathing in premature infants differs from their fullterm counterparts [2][3][4]. Observational studies have shown that preterm infants begin to develop a coordinated suckswallow-breathing pattern analogous to term infants at an average of 33 weeks' postmenstrual age [4][5][6]. Many experts, therefore, recommend initiating oral feeding attempts near this postmenstrual age [7,8]. ...
Article
Full-text available
Objectives: To ascertain if earlier oral feeding initiation results in earlier attainment of full oral feedings/hospital discharge in very premature infants. Study design: Eligible infants born at <29 weeks' gestation were randomized at 30 weeks' postmenstrual age (PMA) to initiate oral feedings at 30 weeks' PMA (Earlier Oral Feeding Group) versus 33 weeks' PMA (Later Oral Feeding Group). Results: Thirty-four infants were randomized to the Earlier Oral Feeding Group and 32 to the Later Oral Feeding Group. There were no significant differences in our primary outcomes of PMA at full oral feedings (mean difference -0.5 weeks, 95% CI: -2.2 to +1.2 weeks) or hospital discharge (mean difference -0.2 weeks, 95% CI: -1.8 to +1.4 weeks). Conclusions: Initiating oral feeding attempts in very premature infants at 30 weeks' PMA does not result in earlier attainment of full oral feedings or discharge but is safe for infants who are not severely tachypneic or receiving positive pressure.
... 22 Swallowing occurs during respiratory pauses until 33 weeks' PMA, while coordination of swallowing and respiration becomes well established between 33 and 36 weeks' PMA. 23 One of the interventions promoting EI is cue-based feeding. Cue-based feeding involves oral feeding based on the infant's feeding signals rather than at scheduled times. ...
Article
Objective This review aims to examine the impact of early introduction of oral feeding, compared with standard care, on the duration of achieving full oral feeding, postmenstrual ages at full oral feeding and discharge, and weight gain in preterm infants. Introduction Because of their immature oral function, preterm infants are prone to feeding difficulties during hospitalization and after hospital discharge. Early introduction of oral feeding helps infants to coordinate sucking, swallowing, and respiration, thereby improving their oral feeding skills. However, early introduction of oral feeding may also contribute to respiratory adverse events; therefore, safety verification is necessary. Inclusion criteria Early introduction of oral feeding is defined as beginning oral feeding at < 33 weeks’ postmenstrual age and transitioning from tube feeding to oral feeding. The primary outcomes are the duration from the initial oral feeding to full oral feeding; postmenstrual age at full oral feeding and discharge; and weight gain. The secondary outcomes are oxygen desaturation and bradycardia. Methods Eight databases, including MEDLINE (Ovid), CINAHL (EBSCOhost), and Cochrane Central Register of Controlled Trials, will be used with no restrictions on language or publication year. Study selection, critical appraisal, data extraction, and data synthesis will be conducted by 2 independent reviewers according to the JBI methodology for systematic reviews. Quantitative data will be extracted and pooled in a statistical meta-analysis, if possible. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach will be used to assess the certainty of evidence. Systematic review registration number PROSPERO CRD42024530910
... Varios autores han estudiado la maduración de la succión, respiración y deglución en bebés prematuros y asumen que la coordinación entre respiración y deglución no se encuentra completamente organizada hasta la semana 34 de Edad post Concepcional (EPC) (Mizuno & Ueda, 2003) Otros estudian cómo realizar la transferencia de la alimentación por sonda nasogástrica a la alimentación oral en bebés prematuros con distintos enfoques y diferentes resultados (Medeiros et al., 2011), (Lau & Smith, 2011) (Scochi et al., 2010) Es de suma importancia valorar el estado de salud del bebé y ofrecer experiencias orales positivas (Thoyre et al., 2005) (Browne & Ross, 2011) El recién nacido prematuro (RNPT) es un bebé altamente dependiente de los cuidados que recibe por su propia inmadurez y asistirlo en el proceso de transición desde la alimentación enteral por gavage hasta la alimentación oral completa es un gran desafío para la familia y por el equipo de salud de la UCIN ya que es a menudo la competencia final que un RNPT necesita alcanzar antes de ser dado de alta. (Younesian et al., 2015) Por lo tanto, conocer cuál es la edad postconcepcional en la que los bebés prematuros alcanzan su alimentación oral total por sus propios medios podría ser de gran utilidad para saber cómo implementar algún paquete de medidas tendientes a reducir esos tiempos. ...
Article
Full-text available
Alimentarse por vía oral independiente sin necesidad del gavage es un gran desafío para todos los bebés prematuros extremos y un criterio muy importante para considerar al alta hospitalaria. En este trabajo estudiamos retrospectivamente una población de bebés prematuros menores de 30 semanas de gestación y registramos a que edad comenzaron a alimentarse por vía oral y a que edad alcanzaron el volumen total como variables principales. Obtuvimos un resultado relativamente alto que intentaremos mejorar en próximos trabajos de intervención.
... This is acquired and matures between weeks 34 and 36 postnatal. 16 The Premature Infant Oral Motor Intervention (PIOMI) helps strengthen the oral feeding of premature babies. According to the literature, premature babies that were given oral stimulation starting at 29 weeks of corrected gestational age, showed an improved coordination of suction, oral motor function and oral feeding skills. ...
Article
The multiple benefits of human milk in newborns are known, especially in preterm newborns by reducing the rates of neonatal sepsis, necrotizing enterocolitis, retinopathy of prematurity and better results in neurodevelopment. However, rates of exclusive breast milk use remain low. To achieve higher percentages of successful breastfeeding, strategies must be applied from the NICU, such as expressed within the first 6 hours of life, skin-to-skin contact and administration of colostrum in the cheeks, all well, in order to have sufficient volume of breast milk since this is the main barrier they face, not having enough milk. There are very few studies that evaluate when to initiate suctions directly to the maternal breast, using the empty breast as non-nutritive suction could improve the performance of VLBW to the maternal breast.
... Although several studies (3,(12)(13)(14) have used sucking pressure to assess infant oral feeding, no study has examined the influence of OG and NG tubes on sucking pressure. Therefore, in this study, we examined the effect of NG and OG tubes on oral feeding by measuring the sucking pressure to provide additional evidence for selecting the appropriate type of feeding tube for immature infants. ...
Article
Orogastric (OG) and nasogastric (NG) tubes have been reported to delay breastfeeding initiation and affect respiratory function. However, the effects of feeding tubes on sucking pressure have not been well studied. Fourteen preterm infants were enrolled in this study, and their sucking pressures during bottle feeding with an OG tube, NG tube, and without any tube were measured. Sucking pressure significantly increased after changing the OG tube to an NG tube (p = 0.044). However, sucking pressure showed no significant differences after changing the feeding method from an NG tube to oral intake. Thus, NG tubes are superior to OG tubes in terms of sucking pressure.
... 5 The maturation of suck, swallow, and breath coordination occurs in preterm infants around 33 to 36 weeks of gestation, at which time oral feeding -including breast feeding, bottle feeding, and cup feeding -can be initiated. 6 Initiation of oral feeding before a preterm infant's swallowing mechanism has become fully established can lead to aspiration. 7,8 However, research has shown that delays in transition from tube feeding to oral feeding may lead to delayed oral motor development, prolonged hospital stays, and persistent feeding disorders. ...
Article
No health technology assessments or systematic reviews were identified regarding the clinical effectiveness of oral feeding in preterm infants while on continuous positive airway pressure or high-flow nasal cannula. No evidence-based guidelines were identified regarding oral feeding in preterm infants while on continuous positive airway pressure or high-flow nasal cannula that met the criteria for this review.
... Parenteral and trans dermal formu lations, including subcutaneous formu lations or micro array patches, could be particularly beneficial for preterm neonates who have feeding intolerances and in whom gastrointestinal developmental changes influence drug absorption. 25,26 However, caution is needed, particularly for preterm neonates, as their skin is very permeable during the first days of life, which puts them at risk for chemical damage and infections. 27 Also, the development of long acting formulations for neonatal use could be challenged by the rapid changes in drug metabolism, clearance, and body growth through this age period. ...
Article
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Although 23 antiretroviral drugs are approved for use in adults, only six are approved by regulatory authorities for use in term neonates born to women with HIV, with even fewer options for preterm neonates. A major hurdle for approvals is the delay in the generation of pharmacokinetic and safety data for antiretrovirals in neonates. The median time between the year of approval from the US Food and Drug Administration of an antiretroviral agent for adults and the first publication date for pharmacokinetic data in neonates less than 4 weeks old is 8 years (range 2–23 years). In this Viewpoint, we address pharmacokinetic research gaps and priorities for current and novel antiretroviral use in neonates. We also consider the challenges and provide guidance on neonatal clinical pharmacology research on antiretroviral agents with the goal of stimulating research and expediting the availability of safe medications for the prevention and treatment of HIV in this vulnerable population.
... 2,3 Most PT infants (born before 34 weeks of gestation) have not developed this ability at the time of birth. 4 Some authors consider oral feeding the earliest indicator of wellness in newborn (NB) development. 5 The development of effective feeding depends on multiple factors, such as gestational age, muscle tone, the maturity of the nervous and gastrointestinal systems and the presence of comorbidities, especially those involving the respiratory or gastrointestinal systems. ...
Article
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Introduction Oral feeding of preterm newborns (PTNB) is hampered by their immaturity and intercurrent diseases, which can prolong their hospital stay. The objective of this study was to assess the effectiveness of a program that combines tactile, kinesthetic and oral stimulation (T + K + OS) compared to another intervention based on exclusively oral stimulation (OS), in the time necessary to achieve independent feeding and hospital discharge. Patients and methods A clinical study of 2 randomized groups (OS vs. T + K + OS) was carried out on 42 PTNB with gestational age between 27-32 weeks and birth weight > 900 g. The stimulation programs were carried out in sessions of 15 min, for 10 days. Results The PTNBs in the T + K + OS group achieved independent oral feeding earlier, compared to the OS group (24.9 ± 10.1 vs. 34.1 ± 15.6 days, P = .02). An analysis of covariance was performed, which confirmed that the birth weight and gestational age covariates had significant effects on time to reach suction feeding (birth weight: F[1, 38] = 5.79; P = .021; gestational age: F[1, 38] = 14.12; P = .001) and that once its effect was controlled, the intervention continued to have a significant effect (F[1, 38] = 6.07; P = .018). The T + K + OS group, compared to the OS group, achieved an earlier hospital discharge (39 ± 15 vs. 45 ± 18 days), although the differences were not significant (P = .21). Conclusions Combined therapies that include T + K + OS are more effective than OS alone, in order to achieve independent oral feeding in PTNBs.
... NNS, which is characterized by alternating epochs of burst and brief pause periods, is a basic ability of newborns [14]. Indeed, preterm infants (<34 weeks of gestational age (GA)) rarely show coordinated sucking. ...
Article
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Due to the lack of enough physical or suck central pattern generator (SCPG) development, premature infants require assistance in improving their sucking skills as one of the first coordinated muscular activities in infants. Hence, we need to quantitatively measure their sucking abilities for future studies on their sucking interventions. Here, we present a new device that can measure both intraoral pressure (IP) and expression pressure (EP) as ororhithmic behavior parameters of non-nutritive sucking skills in infants. Our device is low-cost, easy-to-use, and accurate, which makes it appropriate for extensive studies. To showcase one of the applications of our device, we collected weekly data from 137 premature infants from 29 week-old to 36 week-old. Around half of the infants in our study needed intensive care even after they were 36 week-old. We call them full attainment of oral feeding (FAOF) infants. We then used the Non-nutritive sucking (NNS) features of EP and IP signals of infants recorded by our device to predict FAOF infants’ sucking conditions. We found that our pipeline can predict FAOF infants several weeks before discharge from the hospital. Thus, this application of our device presents a robust and inexpensive alternative to monitor oral feeding ability in premature infants.
... One reason for prolonged hospitalizations among very preterm infants is that these patients require admission to the neonatal intensive care unit (NICU) and enteral tube feeding until they are mature enough to feed orally from the breast or bottle. While institutional protocols for feeding advancement differ significantly, the transition from naso-or oro-gastric tube to oral (PO) feeding among very premature infants is generally initiated at first sign of "readiness," which typically occurs at 32-34 weeks' postmenstrual age (PMA), when coordinated sucking, swallowing, and breathing develops [8][9][10]. Recent research has demonstrated that more aggressive early introduction of oral feeding at 31-32 weeks may accelerate the transition from tube to oral feeding [11][12][13]. ...
Article
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Objective Develop a model to predict gastrostomy tube (GT) for feeding at discharge in infants born < 30 weeks’ (w) gestational age (GA). Study design A single-center retrospective study at academic NICU. Total of 391 (78 GT, 313 non-GT) infants < 30 w GA admitted in 2015–2018 split into test (15–16) and validation (17–18) cohorts. Classification and regression tree analysis was used to identify predictive factors for GT. Results Several factors were associated with GT requirements. Four factors included in the model were postmenstrual age (PMA) at first oral feeding, birth GA, high-frequency ventilation exposure, necrotizing enterocolitis stage II/III. Area under the receiver operator characteristic curve was 0.944 in the test cohort, 0.815 in the validation cohort. Implementation plan based on the model was developed. Conclusions We developed a predictive model to risk-stratify infants born < 30 w GA for failing full oral feeding. We hope implementation at 38 w PMA will result in earlier placement of needed GT and discharge.
... Varios autores han estudiado la maduración de la succión, respiración y deglución en bebés prematuros y asumen que la coordinación entre respiración y deglución no se encuentra completamente organizada hasta la semana 34 de Edad post Concepcional (EPC) (Mizuno & Ueda, 2003) Otros estudian cómo realizar la transferencia de la alimentación por sonda nasogástrica a la alimentación oral en bebés prematuros con distintos enfoques y diferentes resultados (Medeiros et al., 2011), (Lau & Smith, 2011) (Scochi et al., 2010) Es de suma importancia valorar el estado de salud del bebé y ofrecer experiencias orales positivas (Thoyre et al., 2005) (Browne & Ross, 2011) El recién nacido prematuro (RNPT) es un bebé altamente dependiente de los cuidados que recibe por su propia inmadurez y asistirlo en el proceso de transición desde la alimentación enteral por gavage hasta la alimentación oral completa es un gran desafío para la familia y por el equipo de salud de la UCIN ya que es a menudo la competencia final que un RNPT necesita alcanzar antes de ser dado de alta. (Younesian et al., 2015) Por lo tanto, conocer cuál es la edad postconcepcional en la que los bebés prematuros alcanzan su alimentación oral total por sus propios medios podría ser de gran utilidad para saber cómo implementar algún paquete de medidas tendientes a reducir esos tiempos. ...
Article
Alimentarse por vía oral independiente sin necesidad del gavage es un gran desafío para todos los bebés prematuros extremos y un criterio muy importante para considerar al alta hospitalaria. En este trabajo estudiamos retrospectivamente una población de bebés prematuros menores de 30 semanas de gestación y registramos a que edad comenzaron a alimentarse por vía oral y a que edad alcanzaron el volumen total como variables principales. Obtuvimos un resultado relativamente alto que intentaremos mejorar en próximos trabajos de intervención.
... Preterm infants fed before the adequate development of SSB are at an increased risk for aspiration [10,11]. There is now considerable evidence that maturation of sucking may be accelerated by the early cue-based, or infant-driven, introduction of suckling feeding where the infant controls the timing and These authors contributed equally: Audrey Lane, Jonathan Pacella amount [12][13][14][15]. The unique feeding challenges of preterm infants necessitate a nuanced approach to initiating oral feedings. ...
Article
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Objective The goal of this study was to assess the impact of infant-driven feeding (IDF) compared to traditional feeding protocols in promoting earlier successful feeding outcomes. Study design We performed a cross-sectional analysis of infants admitted to a level three neonatal intensive care unit (NICU) over a 2-year period. We compared infants fed with the traditional protocol to those under the IDF protocol. Results Infants in the IDF group were younger at first feed (p < 0.001). There was no difference in age at nasogastric (NG) tube removal or at discharge, length of stay, or percentage breastfeeding at discharge. There were no differences in outcomes within two subgroups born at <35 and <32 weeks gestation, respectively. Conclusion The IDF program led to earlier initiation of oral feeding. However, this did not lead to earlier NG tube removal or discharge, a shorter length of stay, or increase in the rates of breastfeeding.
... We limited our analysis to infants without severe BPD (those not requiring CPAP or higher respiratory support at 36 weeks PMA) since lung disease has a major impact on milestone acquisition [16,17]. Our unit guideline recommends waiting until an infant transitions off CPAP to discontinue caffeine and initiate oral feeding, whereas other units might discontinue caffeine sooner or allow bottle feeding for infants on CPAP [18][19][20]. ...
Article
Background: Very low birth weight (VLBW) infants must achieve several maturational milestones to be discharged home from the NICU. Objective: Describe the timing of maturational milestones in VLBW infants and the impact of clinical variables and milestone achievement on postmenstrual age (PMA) at discharge. Methods: For VLBW infants without severe lung disease discharged home from a level IV NICU, we assessed PMA at the achievement of thermoregulation, cardiorespiratory stability, feeding, and discharge. Results: In 400 infants (median GA 28.4 weeks), lower birth weight, white race, and having multiple comorbidities of prematurity predicted later discharge PMA. The most common milestone sequence was CPAP discontinuation, caffeine discontinuation, thermoregulation, apnea resolution, and full oral feeds. PMA at apnea resolution and full oral feeds correlated highly with discharge PMA. Conclusions: In a single-center VLBW cohort, comorbidities of prematurity impacted the timing of NICU discharge through delay in oral feeding and cardiorespiratory stability.
... La alimentación del recién nacido (RN) requiere la coordinación de la succión, la deglución y la respiración, que en el RN a término está presente desde el nacimiento 2,3 . La mayoría de los RNPT, nacidos antes de las 34 semanas de edad gestacional, todavía no tienen desarrollada esta capacidad 4 . ...
Article
Full-text available
Resumen Introducción La alimentación oral de los recién nacidos pretérmino (RNPT) está dificultada por su inmadurez y enfermedades intercurrentes, lo que puede prolongar su estancia hospitalaria. El objetivo de este estudio fue valorar la efectividad de un programa que combina la estimulación táctil, kinestésica y oral (ET + K + O) frente a otro de estimulación oral sola (EO), en el tiempo necesario para lograr la alimentación independiente y el alta hospitalaria. Pacientes y métodos Estudio clínico de 2 grupos aleatorizados (EO vs. ET + K + O), realizado en 42 RNPT con una edad gestacional entre 27-32 semanas y un peso al nacimiento > 900 g. Los programas de estimulación fueron realizados en sesiones de 15 min, durante 10 días. Resultados Los RNPT del grupo de ET + K + O consiguieron antes la alimentación oral independiente, en comparación con el grupo de EO (24,9 ± 10,1 vs. 34,1 ± 15,6 días, p = 0,02). Se realizó un análisis de covarianza, observando que las covariables PN y EG tuvieron efectos significativos en el tiempo hasta alcanzar la alimentación por succión (peso al nacimiento: F[1, 38] = 5,79; p = 0,021; edad gestacional: F[1, 38] = 14,12; p = 0,001) y que una vez controlado su efecto, la intervención seguía teniendo un efecto significativo (F[1, 38] = 6,07; p = 0,018). El grupo de ET + K + O, en comparación con el de EO, consiguió antes el alta hospitalaria (39 ± 15 vs. 45 ± 18 días), si bien la diferencia no fue significativa (p = 0,21). Conclusiones Las terapias combinadas que asocian ET + K + O son más eficaces que la EO sola, para lograr la alimentación oral independiente en los RNPT.
... Another limitation, and one which is important in interpreting the results of this study, is that the testing system does not necessarily 'mimic' a neonate's suck strength, rate or variability. Research has demonstrated that there are individual variations in sucking, swallowing and breathing patterns (Lau, 2015), and that coordination of these can take some time to reach neurological maturation in a preterm infant (Mizuno and Ueda, 2003). In addition, both positive (teat compression) and negative pressure (intra-oral vacuum) are required to facilitate successful bottle-feeding (Lau, 2015), and the equipment employed in this study used vacuum pressure only. ...
Article
Aims To compare flow rates for Australian bottle/teat systems marketed as ‘slow’ or ‘extra-slow’ flow, and to examine flow consistency within each teat type. Methods Established assessment methods were used to test 27 types of teats. Fifteen teats of each type were tested by measuring the amount of infant formula extracted in 1-min by a breast pump system. Teats were compared within ‘slow’ and ‘extra-slow’ categories, a coefficient of variation was calculated for each teat type, and a cluster analysis was performed to group teats with similar flow. Results There was significant variability observed between teats in the same 'slow' and 'extra-slow' categories, and sometimes between teat brands. Cluster analysis revealed 5 clusters. Many teats were considered to have moderate to high variability in flow rate. Conclusions This study provides information regarding Australian bottle/teat systems. This is of relevance to those who support the neonatal bottle-feeding journey, particularly with premature or medically complex neonates.
... tador la que demostró beneficios significativos. Esto se debe a que en el prematuro menor de 34 semanas de gestación el reflejo de succión no se coordina con la deglución, por lo que el inicio temprano de la succión en este tipo de pacientes favorece exclusivamente el gasto calórico sin proveer el beneficio de abastecimiento energético; [19][20][21][22] sin embargo, el principio de la técnica mixta de alimentación es reducir en la medida posible el esfuerzo durante la alimentación (mediante el uso de la sonda orogástrica) sin excluir el proceso fisiológico de la alimentación (mediante el uso de alimentador y succión). Se pretendió ajustar el efecto que tienen todas estas variables previamente comentadas, como el aporte de oxígeno y la regulación térmica en incubadora, con dos tipos de análisis estadísticos. ...
... For the premature baby to be fed effectively and safely orally, coordination of sucking, swallowing, and breathing is required. [2] Therefore, the feeding of premature infants born before 34 weeks should be done by gavage method (nasogastric/orogastric), which is a safe way initially. [3] It is important to start with proven data in planning the nutrition of very low birth weight (VLBW) preterm babies in the risky group. ...
Article
Full-text available
Objectives: The aim of this study was to determine the effect of intermittent bolus feeding and continuous feeding models on early growth and discharge time in very low birth weight infants. Methods: The study was designed as a prospective, randomized, and controlled study. Infants born in our hospital with birth weight below 1500 g within a 1 year period were included in the study. The number of samples was determined by power analysis. Babies were randomized according to birth weight and fed with intermittent bolus feeding and continuous feeding models. Demographic characteristics, clinical findings, diagnosis, nutritional status, and length of hospital stay were compared. Results: The study was conducted with 80 preterm infants, which consisted of continuous feeding (n=41) and intermittent bolus feeding (n=39). There was no significant difference in gender, gestational week, birth weight, height, and head circumference distribution of the babies between groups. The difference between the reach time to birth weight and maximum weight loss rates, parenteral feeding time, transition time to full enteral feeding, transition time to oral feeding, development of feeding intolerance, mechanical ventilation time, and hospitalization time in intensive care unit were not statistically significant. Necrotizing enterocolitis (NEC) Stage I and II developed in 34.1% of babies fed with continuous feeding model and 28.2% of babies fed intermittently; NEC was detected to start in 4.5±2.8 days in the continuous feeding group and in 2.8±5.2 days in the intermittent group. These differences were found to be insignificant between the two groups (p=0.634 and p=0.266, respectively). Conclusion: There was no difference between growth parameters and discharge time of preterm babies who were applied continuous and intermittent bolus feeding model. Although there was no statistically significant difference on the development of NEC, it was determined that NEC developed earlier in the intermittent bolus feeding model.
... The skills necessary for an infant to coordinate efficient suckling, swallowing and respiration, which are essential for safe oral milk feeding, start to appear from around 32 to 34 weeks of gestation (Mizuno and Ueda, 2003), but this will vary depending on the degree of prematurity and related illness. ...
Article
Full-text available
Abstract Following a request from the European Commission, the Panel on Nutrition, Novel Foods and Food Allergens (NDA) revised its 2009 Opinion on the appropriate age for introduction of complementary feeding of infants. This age has been evaluated considering the effects on health outcomes, nutritional aspects and infant development, and depends on the individual's characteristics and development. As long as foods have an age‐appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (
... at the beginning of either inspiration or expiration [2]. Further significant maturation of feeding behaviour has been observed between 33 and 36 weeks CGA in a cohort of infants born at 28 to 31 weeks gestation [3]. Nipple shields may be employed to facilitate the preterm infant's attachment to the breast and improve milk transfer. ...
... Un RNPT de 32 a 34 semanas de EPC demuestra con mucha frecuencia un patrón de succión inmaduro. 26 La succión y la deglución ocurren durante un período de apnea, porque el RNPT tiene que parar la succión para respirar. Si este patrón de succión inmaduro está bien organizado, el RN succionará y deglutirá tres a cinco veces, luego realizará una pausa para respirar, repitiendo este patrón durante la alimentación. ...
... Centers for swallowing and respiratory control are situated close to each other in the brainstem, with this anatomical proximity facilitating coordination [25]. Coordination between swallowing and breathing matures in the 32 nd -36 th week of gestation [26]. Neural immaturity of the newborn impairs coordination. ...
Article
Introduction: In physiological conditions, neonatal airways are well-protected against aspiration of fluid or particulate material into the lungs, with laryngeal chemoreflex (LCR) being the most powerful mechanism. Failure of this protection allows substances to enter the lower airways, which starts a series of pathophysiological events initiated by inflammation and surfactant inactivation. The condition is defined as neonatal acute respiratory distress syndrome (ARDS), and its symptoms can range from mild respiratory distress to respiratory failure, often accompanied by persistent pulmonary hypertension (PPHN), in turn even leading to death. The management, therefore, may be very challenging. Areas covered: This review covers protection mechanisms of the neonatal lower airways, the etiology and pathophysiology of neonatal aspiration syndrome (NAS), its definition in view of current literature, possible treatment options, and future trends. Expert commentary: Inflammation and secondary surfactant deficiency stand in the foreground of neonatal aspiration. Management focuses mainly on appropriate oxygenation, ventilation, improvement in PPHN, and maintenance of systemic circulation, which is largely symptomatic and supportive. Future research is required to evaluate the justification of using exogenous surfactants, antibiotics, anti-inflammatory and antioxidative drugs, or their combinations.
... Gestational age and current weight are often listed as the indicators of feeding readiness (Amaizu et al., 2008;Hwang et al., 2012;Lau and Smith, 2011;Medoff-Cooper et al., 2009). Some studies suggest that 34 weeks postmenstrual age is an appropriate age to initiate oral feeding in preterm infants (Mizuno and Ueda, 2003;Fucile et al., 2002;McCain et al., 2001), while another study concluded that oral feeding can be safely initiated earlier by assessing sucking performance with better health outcomes (Nyqvist, 2008). Measurement of preterm readiness has also been based upon an infant's ability to consume a designated milk volume or to empty the bottle, regardless of the infant's behavioral indicators or whether caregiver manipulation of the bottle was necessary to complete the feeding (Ludwig and Waitzman, 2007). ...
Article
Background Preterm infants develop a coordinated suck and swallow depending upon their postmenstrual age and neurological status. However, criteria to determine when to best initiate oral feeding are unclear. Yet, infant readiness for oral feeding is essential for successful transition from enteral tube to oral feeding. Aim This study aimed to (a) identify infant characteristics associated with feeding readiness assessed with the Neonatal Oral Motor Assessment Scale (NOMAS)1 and (b) examine the relationship between readiness and preterm infants’ time to reach full oral feeding and length of hospital stay. Study design This is a secondary descriptive analysis from a randomized controlled study to determine the effect of a premature infant oral motor intervention on feeding progression and length of hospital stay. Seventy-five stable premature infants were recruited from five neonatal intensive care units in Assiut city, Assiut governorate, Egypt. Eligible infants’ gestational age ranged from 30 to 32 weeks gestational age (GA). Readiness was assessed individually for each infant during non/nutritive sucking using NOMAS. Result Preterm infants who demonstrated greater oral feeding readiness achieved full oral feeding sooner (P < 0.0001) and were discharged earlier from the hospital (P < 0.0001) than those with less readiness. Gender, gestational age at birth, birth weight, number of intervention days were not related to infant oral feeding readiness. Conclusion Readiness for oral feeding in premature infants is related to earlier feeding progression and shorter hospital stays.
... Primeramente, nos interesa saber si la leche es de fórmula, leche materna o banco de leche. En este mismo apartado se recogerá la exploración de la alimentación por vía oral, el estado de conciencia durante la lactancia, el grado de fuerza de la succión, variación del ritmo de la deglución, las pausas que se realizan durante la deglución, alteraciones en la respiración, falta de coordinación entre succión, deglución y respiración y si se duerme durante el amamantamiento (Costas, Santos, Godoy y Martell, 2006;Lau, Smith y Schanler, 2003;Mizuno y Ueda, 2003). ...
Article
Objective: There is a known concern about feeding difficulties in preterm infants. In order to have an instrument that collects the characteristics and severity of these difficulties, an observational questionnaire on feeding behaviors has been designed and its reliability and validity have been examined. Material and methods: The main updated references were consulted for the design of the protocol. A questionnaire has been defined consisting of 8 sections: medical history, orofacial features, intraoral features, sensitivity, oral reflexes, breathing, feeding and feeding features. The feeding behavior of a sample of 100 neonates was observed in the Hospital Clínic-Maternitat de Barcelona. Results: The results showed a good reliability of the questionnaire presenting a score of Cronbach's Alpha of.891 and a correlation with the Apgar test of.63, as well as the set of sections, in which we find positive correlations that range between.38 and.54. In order to assess sensitivity, the ANOVA statistic for each of the sections and the total for each level of prematurity has been calculated. Significant differences have been found in all the sections of the questionnaire. Finally, to assess the discriminative capacity of the COCANP questionnaire in connection with premature or full-term babies, the area under the curve was calculated with a result of.979, which we consider very high. Conclusion: The COCANP questionnaire has proven to be a reliable and valid tool for the features of the premature baby's feeding patterns. © 2018 Elsevier España, S.L.U. y Asociación Española de Logopedia, Foniatría y Audiología e Iberoamericana de Fonoaudiología
... Premature babies cannot coordinate between sucking, swallowing, and breathing. This coordination is obtained at 34 weeks in premature babies [4,16]. In addition, 26.5% of patients with dysphagia and 40% patients with feeding difficulties had a poor nutritional status. ...
Article
Full-text available
Children's eating and swallowing ability is dynamic and is closely related to the growth processes. Anatomical structure during growth can impact the maturity of swallowing ability. Disruption of the swallowing process may cause dysphagia. This study is a descriptive cross-sectional design involving 54 subjects with consecutive sampling to assess the difficulties with swallowing and feeding. This study used the flexible endoscopic evaluation of swallowing (FEES) and assessed the characteristics of the subjects including age, gestation length age, caregivers, symptoms, complications, and medical disorders. This study showed the prevalence of dysphagia was 63% in children with suspected dysphagia. Dysphagia symptoms in children <6 months included apnea during bottle/breast feeding (7/34). In children >6 months, postural impairment (10/34), drooling (6/34), and coughing while eating (8/34) were the symptoms of dysphasia. Underlying diseases included structural anomaly (5/34), cardiopulmonary-larynx disorder (24/34), and neurological disorders (23/43). Complications included gastroesophageal reflux disease (GERD) (12/34), failure to thrive (10/34), and aspiration pneumonia (3/34). In FESS examination, standing secretion (22/34) and impaired tongue movement (20/34) indicated dysphagia. Residue was more common occur in gastric rice consistency (44.7%), penetration in thin liquid (44.2 %) and aspiration in thick liquid (34.8%).
... Moreover, neural development, as well as later developmental outcome, is reflected by the newborn's feeding patterns, as these require synchronization of neural circuits that master integrated sucking-swallowing-breathing ability and normal vagal tone [45,[54][55][56]. Sucking reflex develops at 16 weeks in utero, coordination of suck/swallow appears at 32-34 gestational weeks, and coordination of suck/swallow/breath appears at 37 gestational weeks or later [57][58][59]. Suck/swallow/breath coordination and rhythmicity control requires involvement of many brain circuits, including afferent and efferent fibers of cranial nerves (IV, V, VII, IX, X, XII), brain stem Lower Medulla nuclei (Ambiguus, Solitarius, Hypoglossus) participating in Bulbar circuits, sensory supra-bulbar fibers and motor cortical circuits [60]. Problematic feeding patterns occur frequently in babies born premature, in neonatal encephalopathy, chronic lung disease, after intra-uterine drug exposure, abnormal somatosensory balance, structural abnormalities and pain. ...
... Este documento es elaborado por Medigraphic alimentador la que demostró beneficios significativos. Esto se debe a que en el prematuro menor de 34 semanas de gestación el reflejo de succión no se coordina con la deglución, por lo que el inicio temprano de la succión en este tipo de pacientes favorece exclusivamente el gasto calórico sin proveer el beneficio de abastecimiento energético; [19][20][21][22] sin embargo, el principio de la técnica mixta de alimentación es reducir en la medida posible el esfuerzo durante la alimentación (mediante el uso de la sonda orogástrica) sin excluir el proceso fisiológico de la alimentación (mediante el uso de alimentador y succión). Se pretendió ajustar el efecto que tienen todas estas variables previamente comentadas, como el aporte de oxígeno y la regulación térmica en incubadora, con dos tipos de análisis estadísticos. ...
Article
Full-text available
Introducción: La ganancia ponderal en el neonato es un marcador pronóstico para morbilidad, mortalidad y reingresos hospitalarios. La técnica de alimentación representa un reto para el manejo de estos pacientes. Objetivo: Determinar la asociación entre el tipo de alimentación, volumen, aporte calórico, tipo de leche y comorbilidades en el incremento de peso en neonatos hospitalizados. Material y métodos: De julio de 2015 a julio de 2016 en la Unidad de Cuidados Intermedios Neonatales del Hospital Ángeles Pedregal se realizó un estudio de cohortes en neonatos sin enfermedad en crecimiento y desarrollo registrándose edad gestacional, peso al nacimiento, tipo de alimentación, tipo de leche, volumen y calorías administradas por día. La variable de desenlace fue el incremento de peso de 15 g/día al día 10. Las variables confusoras: días de oxígeno e incubadora. Análisis estadístico: Medidas de dispersión y tendencia central. ANOVA de muestras repetidas; análisis de regresión lineal y prueba de Mantel y Haenzel ajustada por confusores. Resultados: Total de 50 pacientes, 52% del sexo femenino. La variable más asociada al incremento de peso fue la alimentación mixta con sonda orogástrica y alimentador. Conclusiones: La técnica de alimentación mixta con sonda orogástrica y alimentador es la variable más independiente al incremento de peso.
... Studies show that efficiency in sucking increases with the advance of gestational age, and higher gestational ages are predictors of higher breastfeeding rates and frequency [16][17][18]. In our study, the preterm infants in the cup group had higher gestational ages when they started oral feeding, what could have been reflected in higher breastfeeding rates, however it did not occur. ...
Article
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La alimentación oral en los Recién Nacido Pretérmi- no (RNPT) se puede ver alterada debido a la inma- durez de varios sistemas. Un protocolo de estimula- ción de succión y deglución (ESD) podría ayudar al logro de la alimentación independiente. OBJETIVO: Elaboración, aplicación y evaluación de un protoco- lo ESD en RNPT, incorporando aspectos somatosen- soriales, ingresados a la Unidad de Cuidados Inten- sivos Neonatal (UCIN) en Clínica Alemana Temuco. Pacientes y método: Se elaboró un protocolo para la ESD de manera multidisciplinaria. Se incluyeron 53 RNPT, el grupo 1, que recibió cuidados neonatales estándar y ESD sin un protocolo de acción por parte del equipo multidisciplinario de salud, y el grupo 2 recibió cuidados neonatales estándar y la aplicación del protocolo de ESD.
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The initial edition of Data to Action: CDC’s Public Health Surveillance for Women, Infants and Children, published in 1994, was the first comprehensive description of the Centers for Disease Control’s many surveillance and data system activities related to the health of women and children. It covered critical public health concerns, spanning the life cycle from infancy to reproductive-age women, with each chapter structured similarly so that differences and connections could be more easily discerned. Public health professionals have always been concerned with measuring health events across the life span. Maternal and child health surveillance captures data on reproductive health, pregnancy, birth, infancy, childhood, adolescence. Public health planners need to know the data that are available and how to use that information. In turn, public health data systems need to respond to the needs of stakeholders by providing and interpreting data that can be translated into appropriate action. The demand for such information is rapidly increasing in the public health community and will become even more critical in the face of emerging public health crises and emergency preparedness and response. This monograph is a step toward making the surveillance systems of the Centers for Disease Control and Prevention (CDC) more accessible to persons concerned with the health of women, infants, and children. It aims to note achievements from previous decades as well as identify new and ongoing challenges. Data needs evolve over time, and surveillance systems can adapt and respond to these challenges. This monograph offers health practitioners and planners at national, state, local and tribal levels a better appreciation of the uses and limitations of these surveillance systems, and enables us to think more critically about improvements in measuring the health of these populations.
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Background: Our ability to understand the molecular mechanisms responsible for delayed maturation of oral feeding in the preterm newborn is limited. Our objective was to perform RNA Sequencing (RNASeq) on salivary gene transcripts to advance our understanding of the developmental pathways, associated networks, and sex-specific differences associated with oral feeding success in the newborn. Methods: This prospective, observational, single-center study was conducted in the Neonatal Intensive Care Unit at Tufts Medical Center (Boston, MA) from 2014 to 2017. Infants ranging from 34 to 39 weeks' post-menstrual age were recruited for this study (n=26). There was equal representation of successful (n=13) and unsuccessful (n=13) oral feeders. Differential gene expression profiles between successful (n=13) and unsuccessful oral feeders (n=13), matched for gestational age, post-menstrual age, and weight, as an entire cohort and separated by sex (males n=12; females n=14) were measured and analyzed. Results: There was no statistically significant difference in gestational age, birth weight, or post-menstrual age between either successful and unsuccessful oral feeders or males and females enrolled in this study. Sixty-three genes were differentially expressed between the successful (n=13) and unsuccessful oral feeders (n=13), highlighting delayed maturation of the nervous system, tissue morphology, embryonic and hematologic development, and hematopoiesis amongst unsuccessful oral feeders. When separated by sex, females (n=88 genes) and males (n=78 genes) revealed distinct salivary profiles. Unsuccessful male oral feeders were found to have delayed maturation in neurodevelopment, memory and learning pathways, while unsuccessful female oral feeders had delayed maturation of facial, palate, and gastrointestinal development. Conclusions: RNASeq analysis of genes present in neonatal saliva provides a near real-time window into ongoing development, identifies sex-specific pathways and biological networks associated with oral feeding success, and provides caregivers with important opportunities to personalize care and target treatment strategies based upon an infant's sex and individual gene expression profile.
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Purpose Bronchopulmonary dysplasia, or BPD, is a serious lung condition that mostly affects premature newborns who need prolonged oxygen therapy. Certain factors place infants at risk for developing BPD, including lung immaturity, poor nutrition, and need for mechanical ventilation as well as mothers with pregnancy-induced hypertension and maternal infection. Given that breathing is the foundation for sucking and feeding behaviors, infants with BPD have difficulty coordinating the suck–swallow–breathe pattern needed for successful feeding. This review article examines the current research on oral feeding in this population and clinical implications for speech-language pathologists. Conclusion By reviewing oral feeding and its relation to cardiorespiratory support, suck–swallow–breathe coordination, bottle-feeding behaviors, and gastroesophageal reflux, speech-language pathologists will gain valuable insights into current research findings, possible interventions, and suggestions for clinical practice when working with infants with BPD.
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Purpose A successful transition from gavage to full oral feeding is a decisive indicator for discharging premature infants from the neonatal intensive care unit. A clinically useful measure of oral feeding readiness would help nurses initiate implementation of the cue-based feeding model in Taiwan. The study aimed to assess the validity and reliability of the Traditional Chinese Preterm Oral Feeding Readiness Assessment Scale (TC-POFRAS). Design and methods 81 preterm infants were enrolled and assessed by TC-POFRAS regarding their oral feeding readiness. This study included two phases. Phase 1 conducted a cross language validation procedure and item-level content validity indices (I-CVIs) for content validity were estimated. In phase 2, Cronbach's alpha for internal consistency at each category and total scale levels were estimated. A receiver operating characteristic (ROC) curve was estimated to explore the scale's performance. The optimal cut-off value of TC-POFRAS was identified by the best Youden's Index [maximum (sensitivity + specificity − 1)]. Results All of the I-CVIs were 1.00. The whole Cronbach's alpha for internal consistency was 0.804 (95% CI = 0.736–0.862), and Cronbach's alpha values were between 0.538 (95% = 0.332–0.689) and 0.687 (95%CI = 0.572–0.781) for categories. The area under ROC was 92.2%, and an optimal cut-off value of TC-POFRAS was 29 (sensitivity: 0.938, specificity: 0.941). Conclusions The TC-POFRAS has been verified to be an effective and accurate instrument to determine the initiation of oral feeding in preterm infants. Practice implications The TC-POFRAS is an appropriate and complementary assessment instrument for professionals to conveniently use in clinical practice.
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Background Stress signals during sucking activity such as nasal flaring, head turning, and extraneous movements of the body have been attributed to incoordination of sucking, swallowing, and respiration (SSR) in premature infants. However, the association of uncoordinated sucking pattern with developmental outcomes has not yet been investigated. The aim of this study was to investigate whether uncoordinated sucking pattern during bottle-feeding in premature infants is associated with the developmental outcomes at 8-12 and 18-24 months of age (corrected for prematurity). Methods We retrospectively reviewed the medical records and video recordings for the Neonatal Oral-Motor Assessment Scale (NOMAS) of premature infants and divided them into two groups based on the presence or absence of incoordination. The Bayley-III cognition composite scores of the incoordination-positive and incoordination-negative group were compared at 8-12 and 18-24 months of age. Results Seventy premature infants exhibited a disorganized sucking pattern according to the NOMAS. The average Bayley-III cognition composite scores at 8-12 months of age were 92.5±15.6 and 103.0±11.3 for the incoordination-positive (n=22) and incoordination-negative groups (n=48), respectively (p=0.002). The average Bayley-III cognition composite scores at 18-24 months were 90.0±17.9 and 100.7±11.5 for the incoordination-positive (n=21) and incoordination-negative groups (n=46), respectively (p=0.005). A multiple linear regression analysis indicated that the presence of uncoordinated sucking pattern, grade 3 or 4 germinal matrix hemorrhage–intraventricular hemorrhage, and moderate to severe bronchopulmonary dysplasia were independently associated with cognitive development at 18-24 months of age. Conclusions Uncoordinated sucking pattern in premature infants was independently associated with a higher risk of abnormal developmental outcome in the cognitive domain of the Bayley-III at both 8-12 and 18-24 months. There may be a need for periodic follow-up and early intervention for developmental delay when incoordination of SSR that results in stress signals on the NOMAS is observed before 40 weeks postmenstrual age.
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Background Stress signals during sucking activity such as nasal flaring, head turning, and extraneous movements of the body have been attributed to incoordination of sucking, swallowing, and respiration (SSR) in premature infants. However, the association of uncoordinated sucking pattern with developmental outcomes has not yet been investigated. The aim of this study was to investigate whether uncoordinated sucking pattern during bottle-feeding in premature infants is associated with the developmental outcomes at 8-12 and 18-24 months of age (corrected for prematurity). Methods We retrospectively reviewed the medical records and video recordings for the Neonatal Oral-Motor Assessment Scale (NOMAS) of premature infants and divided them into two groups based on the presence or absence of incoordination. The Bayley-III cognition composite scores of the incoordination-positive and incoordination-negative group were compared at 8-12 and 18-24 months of age. Results Seventy premature infants exhibited a disorganized sucking pattern according to the NOMAS. The average Bayley-III cognition composite scores at 8-12 months of age were 92.5±15.6 and 103.0±11.3 for the incoordination-positive (n=22) and incoordination-negative groups (n=48), respectively (p=0.002). The average Bayley-III cognition composite scores at 18-24 months were 90.0±17.9 and 100.7±11.5 for the incoordination-positive (n=21) and incoordination-negative groups (n=46), respectively (p=0.005). A multiple linear regression analysis indicated that the presence of uncoordinated sucking pattern, grade 3 or 4 germinal matrix hemorrhage–intraventricular hemorrhage, and moderate to severe bronchopulmonary dysplasia were independently associated with cognitive development at 18-24 months of age. Conclusions Uncoordinated sucking pattern in premature infants is associated with developmental delay in the cognitive domain of the Bayley-III at both 8-12 and 18-24 months. There may be a need for periodic follow-up and early intervention for developmental delay when incoordination of SSR that results in stress signals on the NOMAS is observed before 40 weeks postmenstrual age.
Article
Objective: To assess the frequency of gastrostomy tube (GT) placement in extremely low birth weight (ELBW) infants, associated comorbidities, and long-term outcomes. Study design: Analysis of ELBW infants from 25 centers enrolled in the National Institute of Child Health and Human Development Neonatal Research Network's Generic Database and Follow-up Registry from 2006 to 2012. Frequency of GT placement before 18-22 months, demographic and medical factors associated with GT placement, and associated long-term outcomes at 18-22 months of corrected age were described. Associations between GT placement and neonatal morbidities and long-term outcomes were assessed with logistic regression after adjustment for center and common co-variables. Results: Of the 4549 ELBW infants included in these analyses, 333 (7.3%) underwent GT placement; 76% had the GT placed postdischarge. Of infants with GTs, 11% had birth weights small for gestational age, 77% had bronchopulmonary dysplasia, and 29% severe intraventricular hemorrhage or periventricular leukomalacia. At follow-up, 56% of infants with a GT had weight <10th percentile, 61% had neurodevelopmental impairment (NDI), and 55% had chronic breathing problems. After adjustment, small for gestational age, bronchopulmonary dysplasia, intraventricular hemorrhage/periventricular leukomalacia, poor growth, and NDI were associated with GT placement. Thirty-two percent of infants with GTs placed were taking full oral feeds at follow-up. Conclusions: GT placement is common in ELBW infants, particularly among those with severe neonatal morbidities. GT placement in this population was associated with poor growth, NDI, and chronic respiratory and feeding problems at follow-up. The frequency of GT placement postneonatal discharge indicates the need for close nutritional follow-up of ELBW infants. Trial registration: ClinicalTrials.gov: NCT00063063.
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Purpose Measure the intervention time required for transition from gavage to exclusive oral feeding, comparing newborns exposed exclusively to the mother’s breast with those who, in addition to breastfeeding, received supplementation using a cup or baby bottle. Methods Analytical, longitudinal, cohort study conducted with 165 newborns (NB) divided into groups according to severity of medical complications (G1-with no complications; G2-with significant complications), and into subgroups according to feeding mechanism (A and B). All NBs were low birth weight, on Kangaroo Mother Care, and breast stimulated according to medical prescription and hospital routine. Regarding feeding pattern, subgroup A comprised NBs exclusively breastfed at hospital discharge, whereas subgroup B was composed of NBs fed through cup/bottle at some time during hospitalization. The number of days spent in each stage of transition was recorded for each NB. Results History of clinical complications significantly influenced total intervention time. Study participants in subgroups G1-A (10 days), G1-B (9 days), and G2-A (12 days) displayed greater chances of early discharge compared with those in subgroup G2-B (16 days). Conclusion NBs with no important history of clinical complications displayed greater chances of early hospital discharge. NBs with significant history of clinical complications that underwent gavage to exclusive breastfeeding transition presented smaller intervention time than those that required supplementation using cup/bottle. Feeding transition using the gavage-to-exclusive oral feeding technique is recommended for Speech-language Pathology practice in Neonatology.
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Background For infants born moderately/late preterm (32–37 weeks of gestation), immaturity of the intestine has the potential to impact both short- and long-term gastrointestinal function. The aim of this study conducted in sheep was to compare the morphology and smooth muscle contractility of the ileum in term and late preterm lambs.Materials and methodsLambs delivered preterm (132 days gestation; n = 7) or term (147 days gestation; n = 9) were milk-fed after birth and euthanased at 2 days of age. A segment of distal ileum was collected for analysis of the length and cellular composition of the villi and crypts, smooth muscle width and contractility, and mRNA expression of the cell markers Ki67, lysozyme, mucin 2, synaptophysin, chromogranin A, olfactomedin 4, axis inhibition protein 2, and leucine-rich repeat-containing G-protein coupled receptor 5 (LGR5).ResultsThere was no difference in the proportion of inflammatory, proliferating, apoptotic, enterocyte, or goblet cells between groups, but preterm lambs exhibited a significant upregulation of the stem cell marker LGR5 (p = 0.01). Absolute villus height (term: 1,032 ± 147 µm, preterm: 651 ± 52 µm; p < 0.0001) and crypt depth (term: 153 ± 11 µm, preterm: 133 ± 17 µm; p = 0.01) were significantly shorter in the preterm ileums, with a trend (p = 0.06) for a reduction in muscularis externa width. There was no difference between groups in the contractile response to acetylcholine, but peak contractility in response to bradykinin (p = 0.02) and angiotensin II (p = 0.03) was significantly greater in the preterm lambs.Conclusion Findings demonstrate that the crypt-villus units are shorter in the ileum of late preterm offspring, but functionally mature with an equivalent cellular composition and normal contractile response to acetylcholine compared with term offspring. The exaggerated contractility to inflammatory mediators evident in the preterm ileum, however, may be of concern.
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Little is known of the development of efficient coordination between suckle feeding and breathing in human infants. To establish baseline data, we recorded breathing and swallowing activity during bottle feeds in 23 infants at 14-48 h postnatal age. Most swallows (overall mean 68%) were organized into runs, with intervals starting at 0.6-0.8 s and slowing to 1-1.3 s after 30-40 s. The proportion of run swallows to total swallows increased significantly with age. Swallow intervals were regular (coefficient of variation = 18-38%) compared with breathing (coefficient of variation = 50%). Both breathing rate and tidal volume were significantly reduced by the onset of suckle feeding, and the pattern of respiratory airflow became markedly irregular. Mild transient desaturation was common, but was not accompanied by changes in heart rate. Swallows could occur in all phases of breathing. Overall, equal numbers of swallows were preceded by expiration and inspiration, but twice as many were followed by expiration compared with inspiration. Swallows were classified by the respiratory phases both preceding and following the swallow. Swallows occurred in all possible classifications in each of the infants studied. The incidence of the most frequent classification (inspiration-swallow-expiration), was 24% overall (individual range 5-50%). The phase relation between swallows and breaths changed frequently but showed occasional short periods of stability during which the breathing became regular and tidal volume increased. We conclude that at less than 48 h the normal infant has little coordination between swallowing and breathing rhythms and maintains rhythmic swallowing at the expense of eupnea.
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To gain a better understanding of the development of sucking behavior in low birth weight infants, the aims of this study were as follows: (1) to assess these infants' oral feeding performance when milk delivery was unrestricted, as routinely administered in nurseries, versus restricted when milk flow occurred only when the infant was sucking; (2) to determine whether the term sucking pattern of suction/ expression was necessary for feeding success; and (3) to identify clinical indicators of successful oral feeding. Infants (26 to 29 weeks of gestation) were evaluated at their first oral feeding and on achieving independent oral feeding. Bottle nipples were adapted to monitor suction and expression. To assess performance during a feeding, proficiency (percent volume transferred during the first 5 minutes of a feeding/total volume ordered), efficiency (volume transferred per unit time), and overall transfer (percent volume transferred) were calculated. Restricted milk flow enhanced all three parameters. Successful oral feeding did not require the term sucking pattern. Infants who demonstrated both a proficiency > or = 30% and efficiency > or = 1.5 ml/min at their first oral feeding were successful with that feeding and attained independent oral feeding at a significantly earlier postmenstrual age than their counterparts with lower proficiency, efficiency, or both. Thus a restricted milk flow facilitates oral feeding in infants younger than 30 weeks of gestation, the term sucking pattern is not necessary for successful oral feeding, and proficiency and efficiency together may be used as reliable indicators of early attainment of independent oral feeding in low birth weight infants.
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The health benefits of mother's milk feedings are especially significant for immunocompromised premature and high-risk infants; however, mothers of these infants experience documented physiologic and emotional barriers to the initiation and maintenance of lactation. This article reviews evidence-based interventions to optimize breastfeeding outcomes for this population, using the Rush Mothers' Milk Club program of breastfeeding services as an example. Included are (1) strategies to help mothers make informed decisions about providing milk, (2) preventing and treating milk volume problems, (3) comparisions of suck-breathe patterning for bottle- and breastfeeding, (4) strategies for measuring and facilitating milk intake during breastfeeding, and (5) the appropriateness of alternative feeding methods for this population.
Article
The aim of the present study was to examine whether immaturity of cardiorespiratory control corresponds to a less mature behavioural state pattern and/or to less efficient feeding behaviour. Fifty-four infants were observed and data polygraphically recorded for 6 hours; a feeding session was included. It was found that infants with immature cardiorespiratory control spent more time in REM-sleep, less time in the active awake state, and were more likely to be inefficient feeders. In addition, 100 infants were observed for risk signs of sudden infant death syndrome and their parents were asked to answer a questionnaire on the sleeping and feeding behaviour of their infants. The majority of the infants with immature cardiorespiratory control were described as bad feeders but good sleepers. We conclude that gathering information about sleeping and feeding behaviour is useful when screening for immaturity of cardiorespiratory control.
Article
Energetics and mechanics of sucking in preterm and term neonates were determined by simultaneous records of intraoral pressure, flow, volume, and work of individual sucks. Nine term infants (mean postconceptional age: 38.6 +/- 0.7 SD weeks; mean postnatal age: 18.4 +/- 6.1 SD days) and nine preterm infants (mean postconceptional age: 35.2 +/- 0.7 SD weeks; mean postnatal age: 21.9 +/- 5.4 SD days) were studied under identical feeding conditions. Preterm infants generated significantly lower peak pressure (mean values of 48.5 cm H2O compared with 65.5 cm H2O in term infants; P less than 0.01), and the volume ingested per such was generally less than or equal to 0.5 mL. Term infants demonstrated a higher frequency of sucking, a well-defined suck-pause pattern, and a higher minute consumption of formula. Energy and caloric expenditure estimations revealed significantly lower work performed by preterm infants for isovolumic feeds (1190 g/cm/dL in preterm infants compared with 2030 g.cm/dL formula ingested in term infants; P less than 0.01). Furthermore, work performed by term infants was disproportionately higher for volumes greater than or equal to 0.5 mL ingested. This study indicates that preterm infants expend less energy than term infants to suck the same volume of feed and also describes an objective technique to evaluate nutritive sucking during growth and development.
Article
The effect of oral feeding on breathing pattern and ventilation was studied in 19 healthy term neonates in the semiupright supine position. Ventilation was measured with a nasal flowmeter, and sucking pressure via a modified nipple that permitted milk delivery. The feeding pattern in these infants consisted of an initial period of continuous sucking followed by intermittent sucking for the remainder of the feed. A significant reduction in minute ventilation (P less than 0.01) was observed during continuous sucking, and resulted entirely from a reduction in breathing frequency (P less than 0.01). Tidal volume did not change (P greater than 0.05), but prolongation of expiration (P less than 0.01) and shortening of inspiration (P less than 0.05) were also observed. During intermittent sucking, the minute ventilation was similar to that of the control period. However, smaller but significant changes in breathing frequency and in duration of inspiration and expiration persisted during intermittent sucking. Our results document a significant reduction in ventilation during the initial part of oral feeding in term neonates, and subsequent recovery with continued feeding. Depending on the magnitude of this reduction in ventilation, cyanosis and bradycardia may develop in some infants during oral feeding.
Article
As respiratory difficulty may accompany nipple feeding in preterm neonates, we studied the effect of oral feeding on ventilation in 23 preterm infants. The infants composed two groups based on their postconceptional age at the time of study: Group A comprised 12 infants 34 to 35.9 weeks of age, and group B, 11 infants 36 to 38 weeks. Ventilation was measured via a nasal mask pneumotachometer, and sucking pressure via a nipple that also permitted milk delivery; transcutaneous PO2 and PCO2 were continuously monitored. The feeding pattern comprised an initial period of continuous sucking of at least 30 seconds, followed by intermittent sucking bursts for the remainder of the feed. When compared with an initial semi-upright control period, minute ventilation (V1) during continuous sucking fell by 52 +/- 6% (P less than 0.001) and 40 +/- 2% (P less than 0.001) in groups A and B, respectively. This was the result of a decrease in respiratory frequency and tidal volume and was associated with a fall in TcPO2 of 13 +/- 4 mm Hg (P less than 0.01) in group A and 10 +/- 2 mm Hg (P less than 0.01) in group B. During intermittent sucking, V1 and TcPO2 recovered partially only in the more mature infants (group B). At the end of the feed, TcPCO2 have risen by 3 +/- 1 mm Hg (P less than 0.001) in group A and by 2 +/- 2 mm Hg (P less than 0.05) in group B. Thus oral feeding results in an impairment of ventilation during continuous sucking and the subsequent recovery during intermittent sucking is dependent on postconceptional age.
Article
In 100 bottle-fed preterm infants feeding efficiency was studied by quantifying the volume of milk intake per minute and the number of teat insertions per 10 ml of milk intake. These variables were related to gestational age and to number of weeks of feeding experience. Feeding efficiency was greater in infants above 34 weeks gestational age than in those below this age. There was a significant correlation between feeding efficiency and the duration of feeding experience at most gestational ages between 32 and 37 weeks. A characteristic adducted and flexed arm posture was observed during feeding: it changed along with feeding experience. A neonatal feeding score was devised that allowed the quantification of the early oral feeding behavior. The feeding score correlated well with some aspects of perinatal assessment, with some aspects of the neonatal neurological evaluation and with developmental assessment at 7 months of age. These findings are a stimulus to continue our study into the relationships between feeding behaviour and other aspects of early development, especially of neurological development.
Article
This study in 10 term infants investigated the effects of different fluids on the coordination between swallowing and breathing during bottle feedings. Sucking pressure, swallowing, breathing and O(2) saturation were examined in each infant during bottle feedings with breast milk, formula and distilled water. When receiving breast milk, the infants showed a significantly higher breathing rate than with the other liquids. Swallows followed by inspiration were demonstrated less often with breast milk compared with formula or distilled water. In conclusion, expressed breast milk is suitable for neonates because better coordination between swallowing and breathing could be obtained and subclinical aspiration could be prevented.