Article

Feeding readiness in preterm infants: The relationship between preterm behavioral state and feeding readiness behaviors and efficiency during transition from gavage to oral feeding

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Abstract

The purpose of this secondary analysis was to assess whether alert behavioral states were associated with an increased number of feeding readiness behaviors (FRBs) and whether the number of FRBs were associated with subsequent feeding efficiency in healthy premature infants born between 29 to 35 weeks gestation. The data were collected as part of a larger study designed to compare the frequency of FRBs and feeding efficiency between control and experimental groups. Data from 21 stable premature infants were included in this secondary analysis. Infants were videotaped immediately prior to each of the first three oral feedings, from which infant behavioral state (IBS) and FRBs were assessed. Feeding efficiency was determined by calculating the ratio of feeding intake to feeding duration. IBS was not a significant predictor of the number of FRBs. The number of FRBs was predictive of feeding efficiency (p <.05). Group assignment was a marginally significant predictor of feeding efficiency (p < .10). Infant sex (p < .05), birthweight (p < .01), gestational age at birth (p <.01), and gestational age at entry (p < .05) were identified as significant predictors of the number of FRBs. Group assignment was marginally significant (p < .10). Feeding efficiency may be predicted by the increased number of FRBs immediately prior to feeding. An infant's attributes (sex, birth-weight, and gestational age) may relate to feeding efficiency and should be assessed when instituting oral feeding. Assessment of FRBs can be easily incorporated into routine clinical practice.

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... orally directed behaviors; behavioral states; multisensory intervention; preterm infants Preterm infants are challenged by immature infant behavioral organization (Ardura, Andres, Aldana, & Revilla, 1995;Holditch-Davis, 1990;Ingersoll & Thoman, 1999;Thoman, 1990). Infant behavioral organization is thought to influence the infant' ability to feed orally, especially when infants demonstrate orally directed behaviors prior to feeding (White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005;White-Traut et al., 2002b) and alert behavioral states prior to and during feeding (Lau, 2012;Medoff-Cooper, Bilker, & Kaplan, 2010;Pickler, Best, Reyna, Gutcher, & Wetzel, 2006;White-Traut et al., 2005;White-Traut et al., 2002a;White-Traut et al., 2002b). However, little is known regarding the occurrence of orally directed behaviors in preterm infants prior to oral feeding (White-Traut et al., 2005;White-Traut et al., 2002b). ...
... orally directed behaviors; behavioral states; multisensory intervention; preterm infants Preterm infants are challenged by immature infant behavioral organization (Ardura, Andres, Aldana, & Revilla, 1995;Holditch-Davis, 1990;Ingersoll & Thoman, 1999;Thoman, 1990). Infant behavioral organization is thought to influence the infant' ability to feed orally, especially when infants demonstrate orally directed behaviors prior to feeding (White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005;White-Traut et al., 2002b) and alert behavioral states prior to and during feeding (Lau, 2012;Medoff-Cooper, Bilker, & Kaplan, 2010;Pickler, Best, Reyna, Gutcher, & Wetzel, 2006;White-Traut et al., 2005;White-Traut et al., 2002a;White-Traut et al., 2002b). However, little is known regarding the occurrence of orally directed behaviors in preterm infants prior to oral feeding (White-Traut et al., 2005;White-Traut et al., 2002b). ...
... Infant behavioral organization is thought to influence the infant' ability to feed orally, especially when infants demonstrate orally directed behaviors prior to feeding (White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005;White-Traut et al., 2002b) and alert behavioral states prior to and during feeding (Lau, 2012;Medoff-Cooper, Bilker, & Kaplan, 2010;Pickler, Best, Reyna, Gutcher, & Wetzel, 2006;White-Traut et al., 2005;White-Traut et al., 2002a;White-Traut et al., 2002b). However, little is known regarding the occurrence of orally directed behaviors in preterm infants prior to oral feeding (White-Traut et al., 2005;White-Traut et al., 2002b). Prefeeding interventions have been evaluated, particularly in regard to facilitating an alert behavioral state in preterm infants prior to feeding (White-Traut et al., 2005;White-Traut et al., 2002a;White-Traut et al., 2002b;White-Traut, Nelson, Silvestri, Patel, & Kilgallon, 1993), yet less is known regarding how prefeeding interventions might increase the frequency of orally directed behaviors prior to oral feeding. ...
... 20 The ATVV intervention improves weight gain and feeding progression and reduces the length of stay. [21][22][23][24][25][26][27][28] In this study, the ATVV intervention was integrated with a parent participatory guidance intervention (Hospital to Home Transition-Optimizing Premature Infant's Environment or H-HOPE) as a means to support mothers' feeding and social interactive skills, as well as infant alertness prior to and during oral feeding, to improve hospital progression. 29 We examined whether premature infants receiving the H-HOPE intervention had more rapid weight gain and growth, improved feeding progression and reduced length of hospital stay, compared with infants assigned to an attention control group. ...
... To ensure fidelity of the ATVV portion of the intervention, the Nurse-Advocate Team and the mothers were taught the ATVV intervention and reliability (490% agreement with the ATVV checklist) was established prior to initiation of the study. 21,22,24,25,33 Mothers were taught how to administer the ATVV during the infants' hospitalization and recorded each time they administered it in the ATVV intervention log. Additionally, the fidelity of the mother's performance of the ATVV was confirmed at the hospital visits by asking the mother to administer the ATVV to the infant while the Nurse-Advocate Team observed the mother. ...
... In the past, the ATVV intervention was initiated when the infant reached 33 weeks PMA to support the beginning of development of these skills. 21,22 Additionally, this intervention has recently been implemented for infants born o 29 weeks gestation; however the intervention was not initiated until the infants were stable and weighed at least 1000 g. 43 The H-HOPE intervention also provides guidance to mothers as to how to read and interpret her infant's behavioral cues. 34 Mothers learn to change their behavior during the ATVV to support optimal infant behavior. ...
Article
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Objective: To examine whether premature infants receiving the maternally administered H-HOPE (Hospital to Home Transition-Optimizing Premature Infant's Environment) intervention had more rapid weight gain and growth, improved feeding progression and reduced length of hospital stay, compared with controls. Study design: Premature infants born at 29-34 weeks gestational age and their mothers with at least two social-environmental risk factors were randomly assigned to H-HOPE intervention (n=88) or an attention control (n=94) groups. H-HOPE consists of a 15-min multisensory intervention (Auditory, Tactile, Visual and Vestibular stimuli) performed twice daily prior to feeding plus maternal participatory guidance on preterm infant behavioral cues. Result: H-HOPE group infants gained weight more rapidly over time than infants in the control group and grew in length more rapidly than control infants, especially during the latter part of the hospital stay. Conclusion: For healthy preterm infants, the H-HOPE intervention appears to improve weight gain and length over time from birth to hospital discharge.
... Most excluded articles did not evaluate the moment of transition to oral feeding or the NB participants in the researches had already received oral feeding. The final sample included 29 articles, with 12 articles published between 2003 and 2007 (10,20,21,23,(34)(35)(36)(37)(38)(39)(40)(41) and 17 published between 2008 and 2012 (8,22,(24)(25)(26)(27)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52) . ...
... Among the articles selected for screening, 41.2% (20)(21)(22)(23)(24)(25)27,(34)(35)(36)(37)(38)(39)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52) of the ones from the MEDLINE research were included in the final analysis, 27.3% (10,26,42) from SciELO, and 18.7% (8,10,48) from LILACS. Of 29 publications, 86.2% were in English (20,21,(23)(24)(25)27,(34)(35)(36)(38)(39)(40)(41)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52) and 13.8% in Portuguese (8,10,26,42) . ...
... Among the articles selected for screening, 41.2% (20)(21)(22)(23)(24)(25)27,(34)(35)(36)(37)(38)(39)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52) of the ones from the MEDLINE research were included in the final analysis, 27.3% (10,26,42) from SciELO, and 18.7% (8,10,48) from LILACS. Of 29 publications, 86.2% were in English (20,21,(23)(24)(25)27,(34)(35)(36)(38)(39)(40)(41)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52) and 13.8% in Portuguese (8,10,26,42) . No publications in Spanish were found. ...
Article
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To identify and systematize the main studies on the transition from enteral to oral feeding in preterm infants. Articles that describe the transition from oral to enteral feeding in preterm infants were located in MEDLINE, LILACS, and SciELO databases. Original studies, with available abstract, published in the last 10 years were included. Analysis of the methodology and the main results of the studies, and meta-analysis of the effects of sensory-motor-oral stimulation at the time of transition to full oral feeding and duration of hospitalization were conducted. Twenty-nine national and international publications were considered. Most studies were clinical trials (44.8%) and did not use rating scales to start the transition process (82.7%). In the meta-analysis, positive effect of stimulation of the sensory-motor-oral system was observed with respect to the transition time to oral diet (p=0.0000), but not in relation to the length of hospital stay (p=0.09). However, heterogeneity between studies was found both in the analysis of the transition time to full oral feeding (I2=93.98) and in the length of hospital stay (I2=82.30). The transition to oral feeding is an important moment, and various physical and clinical characteristics of preterm infants have been used to describe this process. Despite the impossibility of generalizing the results due to the heterogeneity of the studies, we have noted the importance of strategies for stimulation of sensory-motor-oral system to decrease the period of transition to full oral feeding system.
... Behavioral state organization supports the infant's ability to coordinate the sensory, autonomic, and motor systems yielding optimal neurobehavioral organization [7][8][9][10]. In both preterm and full term infants, a predictable pattern of state development has been observed which is characterized by a decrease in active sleep and an increase in quiet sleep, alert states, and sleep state organization [11][12][13][14][15][16][17]. Differences in the pattern of behavioral states have been noted in infants born at 34, 37, and 40 weeks gestation [18]. ...
... Of the different categories of behavioral states, the alert behavioral state is considered optimal for oral feeding [20][21][22][23][24][25][26]. In preterm infants, the alert behavioral state is associated with improved feeding efficiency [17,27] and is positively associated with improved nutritive sucking, including greater quantity, harder sucking pressure, a more complex pattern of bursts, and greater consistency of sucking waves [2][3][4]. The ability to achieve and maintain alert behavioral states prior to and during oral feeding is thought to be related to oral feeding success [20][21][22][23][24][25][26]. ...
... Orally-directed behaviors are a sensitive indicator of the infant's behavioral organization and communicate to the caregiver the infant's readiness to feed [5,6]. They include mouthing, tonguing, rooting, hand-to-mouth, and sucking-on-hand [6,17,26,28]. In full term infants, orally-directed behaviors emerge in the first hour following birth. ...
... Infant behaviors including robust rooting responses, crying near scheduled feeding times, maintenance of a flexed posture (McGrath, 2015), irritability or increased general activity level turning to alert behavior, ability to engage in nonnutritive sucking (NNS) for 3 min without negative impact on the respiratory or heart rate (Gennattasio and Baranek, 2015;Kirk et al., 2007b), and maintenance of a quiet alert state for variable periods of time (White-Traut et al., 2005) were found to be a better predictor of oral feeding readiness than either weight or postmenstrual age (White-Traut et al., 2005;Medoff-Cooper, 2005). Yet, readiness can be promoted or hindered by other factors such as the caregiver's feeding technique and the infant prior feeding experience (Howe et al., 2007a). ...
... Infant behaviors including robust rooting responses, crying near scheduled feeding times, maintenance of a flexed posture (McGrath, 2015), irritability or increased general activity level turning to alert behavior, ability to engage in nonnutritive sucking (NNS) for 3 min without negative impact on the respiratory or heart rate (Gennattasio and Baranek, 2015;Kirk et al., 2007b), and maintenance of a quiet alert state for variable periods of time (White-Traut et al., 2005) were found to be a better predictor of oral feeding readiness than either weight or postmenstrual age (White-Traut et al., 2005;Medoff-Cooper, 2005). Yet, readiness can be promoted or hindered by other factors such as the caregiver's feeding technique and the infant prior feeding experience (Howe et al., 2007a). ...
... premature infants (White-Traut et al., 2005;Thoyre and Brown, 2004;Pickler et al., 2009;Lau and Schanler, 1996;Bertoncelli et al., 2012;McGrath, 2002;Simpson et al., 2002). Given the lack of association between readiness and GA at birth and the fact that over 50% of the infants experienced oral feeding before 34 weeks PMA infants may be able to safely begin oral feeding before 34 weeks. ...
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.
... Scientific support of interventions for infants is also building. A number of interventions have moderate to strong evidence for positive effects on feeding: managing physiological state (alerting, calming, swaddling, lighting etc) (McGrath & Medoff-Cooper, 2002;Ross & Philbin, 2011;White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005), skin to skin contact (Howe & Wang, 2013), positioning (Benfer et al., 2013;Clark, Kennedy, Pring, & Hird, 2007;Davis, Bruce, Cocjin, Mousa, & Hyman, 2010;Park, Pados, & Thoyre, 2018;Paul & D'Amico, 2013;Redstone & West, 2004), cue-based feeding (weight, alertness, readiness cues, etc) (Kirk, Alder, & King, 2007;Lubbe, 2018;Shaker, 2010), feeding on demand (alternating enteral feeds with oral feeds) (Gray, Medoff-Cooper, Enlow, Mukhopadhyay, & DeMauro, 2017), pacing, and modified equipment/ teats (Howe & Wang, 2013). Non-nutritive sucking (NNS) has been shown in some research to have a positive effect on transition to oral feeds and length of hospital stay as well as feeding performance as a result of increased physiological stability (Foster, Psaila, & Patterson, 2016;Pinelli & Symington, 2011). ...
... A number of 'best practice' interventions were frequently used by the majority of SLTs, for example: managing physiological state (McGrath & Medoff-Cooper, 2002;Ross & Philbin, 2011;White-Traut et al., 2005), positioning (Benfer et al., 2013;Davis et al., 2010;Paul & D'Amico, 2013;Redstone & West, 2004), and cue-based feeding (Kirk et al., 2007;Lubbe, 2018;Shaker, 2010). These easy-to-implement techniques require no equipment and have a broad range of benefits for a wide population. ...
Article
Rationale: There has been a rapid growth in research specific to the area of paediatric dysphagia in the last two decades. Little is known about New Zealand speech-language therapists' (SLTs) current management practices with early infant feeding. This study surveyed the practices of SLTs in New Zealand working with bottle-fed infants. Methods: Thirty-six SLTs (60% with more than 10 years clinical experience; 80% dedicated paediatric caseload only) completed a web-based survey consisting of open-response, forced choice, and ordinal scale questions focussed on assessment, management and supervisory support. Results: Access to instrumental assessment was 94% for videofluoroscopy and 16% for endoscopy with instrumental assessment guiding non-oral feeding decisions in 71% of respondents but rarely used to guide positioning (10%), pacing (19%), or teat selection (16%). Managing state and positioning were the most commonly prescribed interventions. The frequency of use of an intervention was positively correlated with respondents’ perception of efficacy of intervention (p < .001) and perceived strength of evidence base for intervention (p < .01). Family adherence was the most frequently reported barrier to choice of intervention. Teat choice was primarily decided by flow rate, family preference and availability. Satisfaction with professional development opportunities was poor (6%) and only two-thirds of respondents had regular supervision. Conclusions: SLTs working with infants are experienced and predominately dedicated to paediatric work. SLTs use a range of interventions but have mixed opinions on the evidence-base and efficacy of the interventions they choose.
... 12 , 37 In the model of feeding readiness for preterm infants, Pickler 38 emphasized the importance of alert states prior to feeding in achieving oral feeding success. In our previous research, 13 we were not able to identify the relationship between alert states and oral feeding efficiency due to a small sample size. In this research, with a sample of 147 infants (compared with 26 infants in our previous research), 13 the influence of alert states on oral feeding efficiency was identified. ...
... In our previous research, 13 we were not able to identify the relationship between alert states and oral feeding efficiency due to a small sample size. In this research, with a sample of 147 infants (compared with 26 infants in our previous research), 13 the influence of alert states on oral feeding efficiency was identified. ...
Article
Background: The relationship between behavioral states (alert, sleep, drowsy, and crying) and oral feeding efficiency in preterm infants is not well understood. Purpose: To determine the relationship between behavioral states and feeding efficiency in preterm infants. Methods: This correlational study was conducted as a secondary analysis from a randomized controlled trial. Medically stable preterm infants born between 29 and 34 weeks' gestational age participated. Baseline data from the randomized controlled trial (week 0), 1 minute prior to feeding, were used. Behavioral states were coded by 2 blinded coders. Oral feeding efficiency (mL/min) was calculated as the amount of intake over the first 10 minutes of feeding. Results: Data from 147 infants were included. The proportion of time spent in alert states (?= .76, F = 11.29, P ? .05), sleep states (?=-1.08, F = 25.26, P ? .05), and crying (?= 1.50, F = 12.51, P ? .05) uniquely predicted oral feeding efficiency. Implications for practice: Comprehensive assessment of behavioral states and infant characteristics for oral feeding readiness is crucial. Alert states are optimal for oral feeding. Forced oral feeding when infants are sleeping should be avoided. Infants in crying or drowsy states prior to feeding should be closely evaluated. Sleeping or drowsy infants may benefit from interventions (eg, oral sensory stimulation, nonnutritive sucking, or multisensory intervention) to support transition to alert states prior to feeding. Implications for research: Future research should evaluate behavioral states prior to and during feeding and their relationship to oral feeding efficiency.
... Yawning has been shown to increase behavioral arousal in preterm infants between 30-35 weeks post-conceptual age and could play a role in stabilizing the drowsy state in preterm infants 16 .Such an improved alertness has shown to improve feeding performance and feeding effi cacy in preterm infants. Moreover, yawning is also considered to indicate readiness for feeding in preterm infants 17,18 . ...
... Although yawning is reported as a behavior associated with feeding 18 , it could also be interpreted as a stress behavior, resulting from a challenged ...
Article
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Background: Behavioral responses of preterm infant to sensory stimulation in the Neonatal Intensive Care Unit (NICU) are important to understand. This would enable NICU professionals to be cautious of overloading stimulations and ensure stability in preterm infants. The aim of this study was to describe the range of behavioral responses associated with multisensory (auditory, visual, tactile and vestibular) stimulation in preterm infants. Material and Methods: We recruited twenty-five preterm infants born at 28 to 36 weeks and birth weight of 1000 to 2000 grams for the study using convenience sampling. In the NICU, preterm infants from 32 weeks gestational age received multisensory stimulation session for duration of 12 minutes per day until discharge along with routine NICU care. During the stimulation, the behavioral responses of the preterm infants were observed and documented. Results: Limb activity and yawning were the most frequently observed behaviors. Sixty-five percent of the behavioral responses were observed during tactile stimulation. The frequency of observed behavioral responses decreased with successive stimulation sessions, which could indicate habituation responses in preterm infants to multisensory stimulation. Conclusions: Preterm infants showed behavioral responses indicating improved alertness and ability to integrate sensory stimulus. However, interpretation of preterm behaviors is a challenge because these behavioral responses could also indicate stress in preterm infants when coupled with other physiological and behavioral cues. Further studies are required to provide a detailed evidence for better clarity of infant’s responses to environmental stimuli.
... As an infant matures, oral readiness signs are emerging although these signs may initially be variable (White-Traut et al., 2005). Alert states are associated with being an indicator of maturity as well as supporting successful oral feeding (Howe et al., 2007;Kish, 2013;Thoman, 1990;McCain, 1992;Pickler et al., 2006). ...
... No of correct matches to description (N gain and gestational age, for example, but infant states, in particular those which benefit the development of competent oral feeding are less tangible as they are fleeting in their presentation (White-Traut et al., 2005). Perhaps this is a reason why confident identification of states is hard. ...
Article
Background Recognizing oral readiness signs in infants is vital when planning the introduction of oral feeding. However, with premature infants, this can be difficult to gauge accurately because of immature development. Methods Twenty three staff from a level 2 neonatal unit participated. A questionnaire elicited knowledge about oral readiness and other factors related to oral feeding with premature infants. Participant knowledge of the written Als (1986) infant state descriptors was completed. A comparison was made of the skills in identification of the various infant states on video without and with written descriptors (Als, 1986). Correlations investigated if years of experience and grade had any relation to accurate infant state identification. Results There was wide variation in the type of training about premature infant feeding participants had received. Participants (65%) recognized the importance of oral readiness signs in relation to feeding development. A Wilcoxon signed ranks test revealed no significant differences in ability to identify infant states without and with the written Als (1986) descriptors when observing infant video materials. When not using the written descriptors, there was a strong negative correlation between grade and the identification of the [Active sleep] state, (p < 0.01), and a strong positive correlation between grade and the identification of the [Drowsy] state, (p < 0.05). There were no strong correlations between grade and years working when using the written descriptors. Conclusion Oral readiness signs are important when introducing oral feeding with premature infants. However, accurate identification of oral readiness remains challenging.
... 17,21,23,64 Orally directed behaviors are often evaluated by the occurrence of mouthing, rooting, tonguing, hand-to-mouth, hand swipes at mouth, empty sucking, sucking-on-hand, and sucking-on-tongue. 24,[65][66][67][68][69] In preterm infants, orally directed behaviors prefeeding predicted feeding efficiency. 24, 66 Kirk and colleagues 36 stating that natural display of orally directed behaviors was an important prerequisite to OFS. ...
... 24,[65][66][67][68][69] In preterm infants, orally directed behaviors prefeeding predicted feeding efficiency. 24, 66 Kirk and colleagues 36 stating that natural display of orally directed behaviors was an important prerequisite to OFS. ...
Article
Background: The term "oral feeding success" (OFS) is frequently used in clinical practice and research. However, OFS is inconsistently defined, which impacts the ability to adequately evaluate OFS, identify risk factors, and implement interventions in clinical practice and research. Purpose: To develop the defining attributes, antecedents, and consequences for the concept of OFS in preterm infants during their initial hospitalization. Methods: PubMed, CINAHL, and PsycINFO databases were searched for English articles containing the key words "oral feeding success" and "preterm infants." The Walker and Avant method for concept analysis was employed. Results: Sixteen articles revealed the defining attributes, antecedents, and consequences. Defining attributes included (1) physiologic stability; (2) full oral feeding; and (3) combined criteria of feeding proficiency (≥30% of the prescribed volume during the first 5 minutes), feeding efficiency (≥1.5 mL/min over the entire feeding), and intake quantity (≥80% of the prescribed volume). Implications for practice: The 3 defining attributes may be used in clinical practice to consistently evaluate OFS. The antecedents of OFS provide clinicians with a frame of reference to assess oral feeding readiness, identify risk factors, and implement effective interventions. The consequences of OFS allow clinicians to anticipate challenges when OFS is not achieved and create a care plan to support the infants. Implications for research: The empirical referents of OFS provide consistent and clear operational definitions of OFS for use in research. The antecedents and consequences may guide researchers to select specific measures or covariates to evaluate valid measures of OFS.
... In this study, we targeted clinically stable premature infants born at 29-34 weeks (considered at biologic risk due to prematurity but without severe biologic risk factors) who also had at least two social-environmental risk factors. These infants are sufficiently intact neurologically to achieve optimal development with intervention (Bendersky & Lewis, 1994;Burchinal et al., 2006;Nelson & Halverson, 1996;White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005). However, in the presence of multiple social/environmental risk factors such as poverty and racial and ethnic discrimination, the mother and infant are likely to be challenged by prematurity and infants have poorer long term health and development Williams et al., 2013). ...
... The H-HOPE intervention offers a unique approach to help mother-preterm infant dyads establish positive interaction patterns. The infant-directed component of H-HOPE, the ATVV, helps the preterm infant achieve more mature behavioral organization, including clearer cues that are easier for mothers to interpret and increased capacity to maintain the quiet alert state that is optimal for social interaction (White-Traut et al., 2005;White-Traut & Nelson, 1988;White-Traut & Pate, 1987). The mother-directed component of H-HOPE helps mothers understand and respond appropriately to their preterm infants' behaviors. ...
Article
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While premature infants have a high need for positive interactions, both infants and their mothers are challenged by the infant's biological immaturity. This randomized clinical trial of 198 premature infants born at 29-34 weeks gestation and their mothers examined the impact of the H-HOPE (Hospital to Home: Optimizing the Infant's Environment) intervention on mother-premature infant interaction patterns at 6-weeks corrected age (CA). Mothers had at least 2 social environmental risk factors such as minority status or less than high school education. Mother-infant dyads were randomly assigned to the H-HOPE intervention group or an attention control group. H-HOPE is an integrated intervention that included (1) twice-daily infant stimulation using the ATVV (auditory, tactile, visual, and vestibular-rocking stimulation) and (2) four maternal participatory guidance sessions plus two telephone calls by a nurse-community advocate team. Mother-infant interaction was assessed at 6-weeks CA using the Nursing Child Assessment Satellite Training-Feeding Scale (NCAST, 76 items) and the Dyadic Mutuality Code (DMC, 6-item contingency scale during a 5-min play session). NCAST and DMC scores for the Control and H-HOPE groups were compared using t-tests, chi-square tests and multivariable analysis. Compared with the Control group (n=76), the H-HOPE group (n=66) had higher overall NCAST scores and higher maternal Social-Emotional Growth Fostering Subscale scores. The H-HOPE group also had significantly higher scores for the overall infant subscale and the Infant Clarity of Cues Subscale (p<0.05). H-HOPE dyads were also more likely to have high responsiveness during play as measured by the DMC (67.6% versus 58.1% of controls). After adjustment for significant maternal and infant characteristics, H-HOPE dyads had marginally higher scores during feeding on overall mother-infant interaction (β=2.03, p=0.06) and significantly higher scores on the infant subscale (β=0.75, p=0.05) when compared to controls. In the adjusted analysis, H-HOPE dyads had increased odds of high versus low mutual responsiveness during play (OR=2.37, 95% CI=0.97, 5.80). Intervening with both mother and infant is a promising approach to help premature infants achieve the social interaction patterns essential for optimal development.
... As was noted in the present study, Pickler et al. [12] and White-Traut et al. [13] also reported that older GA at birth was a significant predictor of higher frequency of feeding readiness behaviours. Birth-weight was another significant predictor in the present study, which was consistent with the findings reported by White-Traut et al. [13]. ...
... As was noted in the present study, Pickler et al. [12] and White-Traut et al. [13] also reported that older GA at birth was a significant predictor of higher frequency of feeding readiness behaviours. Birth-weight was another significant predictor in the present study, which was consistent with the findings reported by White-Traut et al. [13]. This may be because higher birth-weight is related to improved coordination of breathing, sucking and swallowing, thus leading to better feeding as observed by Reynolds et al. [14]. ...
Article
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Objective: To determine predictors of nutritive-sucking in babies < 34 weeks and estimate the appropriate preterm sucking readiness (PTSR) score as an indicator of readiness of nutritive-sucking. Methods: Prospective longitudinal observational study conducted in Neonatal unit of a referral hospital attached to Medical College. Forty-nine inborn babies of 28-34 weeks' gestation and on full gavage feeds were enrolled. Results: (a) Nutritive-sucking was achieved at a median age of 14 days (Range 7-50). (b) Low birth weight (LBW) (< 1531.1 ± 142.8) and lesser gestational age (GA) (< 32.8 ± 1) were poor predictors (p < 0.05) and have a significant independent negative association (Correlation birth weight (BW) - 0.0222, GA - 2.2177) with age at which established nutritive-sucking was achieved. (c) PTSR score of ≥9 had the best prediction for achievement of nutritive-sucking at 14-days of life, with a sensitivity of 92.3% and specificity of 100%. Conclusion: PTSR score is a sensitive and specific tool to predict the readiness for nutritive-sucking in preterm babies < 34 weeks.
... Infants engaged in non-NS for about a minute to ready them for feeding. 26 Instrumentation was paused, and the prepared NS bottle, with prior recommended nipple, position, etc, was presented to the infant by the caregiver. Data collection then resumed. ...
... As pulmonary function improves, these infants often manifest oromotor dyscoordination, absent or weak non-nutritive suck, poor airway protection, dysphagia, and poor state control. 32,33 The invasiveness of lengthy intubation and oxygen supplementation procedures associated with prematurity and lung disease cost the baby precious sensory and motor experiences during a critical period of brain development for oromotor pattern generation. [34][35][36][37] Even the presence of a nasogastric (NG) feeding tube has negative effects on sucking and breathing. ...
Article
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Objective: For the premature infant, extrauterine life is a pathological condition, which greatly amplifies the challenges to the brain in establishing functional oromotor behaviors. The extent to which suck can be entrained using a synthetically patterned orocutaneous input to promote its development in preterm infants who manifest chronic lung disease (CLD) is unknown. The objective of this study was to evaluate the effects of a frequency-modulated (FM) orocutaneous pulse train delivered through a pneumatically charged pacifier capable of enhancing non-nutritive suck (NNS) activity in tube-fed premature infants. Study design: A randomized trial to evaluate the efficacy of pneumatic orocutaneous stimulation 3 × per day on NNS development and length of stay (LOS) in the neonatal intensive care unit among 160 newborn infants distributed among three sub-populations, including healthy preterm infants, respiratory distress syndrome (RDS) and CLD. Study infants received a regimen of orocutaneous pulse trains through a PULSED pressurized silicone pacifier or a SHAM control (blind pacifier) during gavage feeds for up to 10 days. Result: Mixed modeling, adjusted for the infant's gender, gestational age, postmenstrual age and birth weight, was used to handle interdependency among repeated measures within subjects. A significant main effect for stimulation mode (SHAM pacifier vs PULSED orosensory) was found among preterm infants for NNS bursts per min (P=0.003), NNS events per min (P=0.033) and for total oral compressions per min (NNS+nonNNS) (P=0.016). Pairwise comparison of adjusted means using Bonferroni adjustment indicated RDS and CLD infants showed the most significant gains on these NNS performance indices. CLD infants in the treatment group showed significantly shorter LOS by an average of 2.5 days. Conclusion: FM PULSED orocutaneous pulse train stimuli delivered through a silicone pacifier are effective in facilitating NNS burst development in tube-fed RDS and CLD preterm infants, with an added benefit of reduced LOS for CLD infants.
... In addition, allowing infants to self-awake before initiation of caregiving, especially for oral feeding is recommended for feeding effectiveness. [33,34] While infant sleep-wake state affected heart rate stability for the entire bundled care event, as expected, infant state at the initiation of bundled care did not predict heart rate stability during diapering alone. To understand the impact of sleep-wake state on specific activities like diapering it would be important to know the infant's sleep-wake state immediately prior to the activity in addition to the state at the beginning of bundled care. ...
Article
Background Bundling nurse caregiving interventions are promoted to minimize infant stress. Purpose To evaluate impact of bundled nursing care and diaper change frequency on vital sign stability and skin health of preterm infants born ≤32 weeks gestation. Method Stable preterm infants on a 3-hour feeding schedule were randomly assigned to 3- vs. 6-hour diaper changes. Diapers were changed prior to 6 h if stool was present. Direct observation of bundled care events (BCE) identify caregiving activities during each BCE. Skin pH, transepidermal water loss (TEWL), and neonatal skin condition scores (NSCS) were obtained. Vital sign data (HR, RR, O2 saturation) was downloaded from bedside monitors. Results Forty-six infants contributed to 605 BCEs. BCEs lasted on average 28 min and included nine different activities (e.g., vital signs, feeding). Significant increases in heart rate during BCEs occurred in approximately half of the observations. Among observations with a diaper change increases in heart rate during diapering occurred in over 74% of observations Infants who were awake at the beginning of BCEs had 48% lower odds of having a change in heart rate than infants who were sleeping (p = .02). There were no group differences (3- vs. 6-hour diaper change) in skin health outcomes (TEWL, pH, NSCS). Conclusion Reducing diaper change frequency without stool present should be considered to minimize caregiving stress in preterm infants. Additional research should evaluate the intrusiveness and clusters of activities that significantly impact physiologic stability to better individualize the timing of routine yet intrusive activities. Clinicaltrials.gov registry # NCT03370757
... The first suck feed (normally a breastfeed) was introduced relatively late at 333 weeks CGA in our study, and first teat feed at 343 weeks CGA, despite a policy to introduce oral feeds when the infant exhibits cues of developmental readiness. 30,31 Full suck feeds were achieved at 37 to 38 weeks CGA. Had the infants begun suck feeds earlier they may have subsequently achieved full feeds earlier. ...
Article
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Objective: We aimed to determine if a novel feeding system where milk only flowed when the preterm infant created a vacuum would influence time to full oral feeds, the length of stay (LOS) in hospital and breastfeeding at discharge. Study design: This was a randomized controlled trial in the tertiary neonatal intensive care unit at King Edward Memorial Hospital, Perth, Australia. Eligibility criteria were: preterm infants of gestational age 25 to 34 weeks receiving >75% human milk by gastric tube. Infants were randomly assigned to being fed with a novel teat (NT) or conventional teat (CT). Intention to treat analysis was performed. Result: Time to full suck feeds was not different between groups. LOS was shorter (mean: 2.5 days; P=0.026) and less formula was fed at discharge in the NT group (P=0.036). Conclusion: Use of a NT that releases milk when the infant applies vacuum while establishing breastfeeding reduces duration of hospitalization of preterm infants.Journal of Perinatology advance online publication, 10 December 2015; doi:10.1038/jp.2015.184.
... The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) distinguishes 6 behavioral states (Als, 1986): (1) deep sleep, seldom seen in the preterm infant; (2) light sleep; (3) drowsy/alert inactive; (4) quiet awake and/or alert; (5) actively awake and aroused; and (6) highly aroused, agitated, upset, and/or crying. Oral feeding is best recommended when infants are at states 3, 4, and 5 (Gill, Behnke, Colon, & Anderson, 1992;White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005). Awareness that preterm infants' behavioral states can fluctuate rapidly would assist caregivers understand why an infant's feeding can also fluctuate during a feeding. ...
Article
Full-text available
This review presents a summary of our current understanding of the development of preterm infant oral feeding skills, the feeding issues they are facing, and evidence-based approaches that facilitate their transition from tube to oral feeding. The field of infant oral feeding research is understudied as the recognition of its importance truly came about with the increased preterm population and the realization that a large number of these infants are not safe and competent oral feeders. It is understandable that this research has taken a “back seat” to the more immediate concerns of saving these babies’ lives. However, the time has now come when these infants make up a large proportion of patients referred to feeding specialists for unresolved oral feeding problems during their stay in neonatal intensive care units (NICUs) as well as post-discharge. Unfortunately, due to the limited research so far conducted in this domain, available therapies are limited and lack evidence-based support. Fortunately, this growing medical concern is stimulating deeper research interests and funding. It is hoped that the information provided will assist the development of systematic differential diagnostic approaches to address infant oral feeding issues.
... It is well recognized that infants' oral feeding performance can be affected not only by their clinical status, but also by the maturity of their feedingrelated functions, e.g., sucking skills, coordination of suck-swallow and swallow-respiration, esophageal immaturity as well as that of their non-feeding related factors, e.g., infants' behavioral state/organization, feeding readiness behaviors, nursery environment (light, sound), caregivers' approach to oral feeding, feeding positions, just to name a few [9,[16][17][18][19][20][21][22][23]. Consequently, our research over the years has centered on developing evidence-based interventions to facilitate infants' transition from tube to oral feeding that focus on both feeding-and non-feeding related functions. ...
Article
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We have shown that the provision of a nonnutritive oral motor therapy (NNOMT) or infant massage therapy (iMT) provided singly and in combination vs. no intervention shortens the number of days from start to independent oral feeding in very low birth weight infants. This study hypothesizes that infants who benefited from NNOMT and/or iMT will demonstrate enhanced maturation of their oral feeding skills (OFS) when compared to control counterparts. OFS levels were monitored using a recently developed scale that takes into account their nutritive sucking skills and endurance at time of assessment. It is a simple method that requires only the additional reading of the volume taken 5 minutes into the start of a feeding and information routinely recorded in patients' medical chart. Four OFS levels were identified, characterized by infant's proficiency (% volume taken during the first 5 min/volume prescribed) and rate of transfer monitored over the entire feeding session (ml/min); OFS level 1 being the most immature and 4 the most mature. In parallel with the benefits provided by NNOMT and/or iMT, we demonstrate the direct positive impact these interventions have on accelerating the maturation of infants' oral feeding skills.
... • Corrected GA > 32 weeks (Hack et al., 1985;Leibel et al., 2020); • Cardiorespiratory stability (Daniels et al., 1990;Wang et al., 2018), including resting respiratory rate < 60 breaths per minute at baseline; • Neurodevelopmental maturation including alertness for oral feeding (Browne & Ross, 2011;Gewolb & Vice, 2006b;White-Traut et al., 2005); • Ability to tolerate bolus feeds (Arvedson et al., 2020, p. 300;Lucas et al., 1986;Senterre, 2014); • Nonnutritive sucking (Kaya & Aytekin, 2017;Lau et al., 2000;Say et al., 2018) • Demonstration of hunger cues (Kirk et al., 2007;Puckett et al., 2008); and • ...
Article
Purpose High-Flow Nasal Cannula (HFNC) has become an increasingly common means of noninvasive respiratory support in pediatrics and is being used in infants and children with respiratory distress both inside and outside of the intensive care units. Despite the widespread use of HFNC, there remains a paucity of data on optimal flow rates and its impact on morbidity, mortality, and desired outcomes. Given the scarcity of information in these critical areas, it is not surprising that guidelines for initiation of oral feeding do not exist. This review article will review HFNC mechanisms of action, its use in specific populations and settings, and finally what is known about initiation of feeding during this therapy. Conclusions The practice of withholding oral feeding solely, because of HFNC, is not supported in the literature at the time of this writing, but in the absence of safety data from clinical trials, clinicians should proceed with caution and consider patient-specific factors while making decisions about oral feeding. Well-controlled prospective clinical trials are needed for development of best practice clinical guidelines and attainment of optimal outcomes.
... The current weights of the infants were not significantly different between the two groups on the assessment day, at which time the infants were physiologically stable and could be evaluated. Researchers have demonstrated that birth weight and gestational age at birth are statistically significant (positive) predictors of feeding readiness behaviors (White-Traut et al., 2005). The rates of maturation and coordination are greatly influenced by the infant's gestational age and PMA. ...
Article
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.
... Infant feeding readiness behavior is an important piece of assessment and researchers have found that these behaviors are predictive of feeding efficiency. 41 Moving away from formal assessment instruments, the following studies examined the use of general clinical assessment and oral feeding readiness. Research found that an increase in number of sucks in an infant's first nutritive suck burst was suggestive of better feeding outcomes. ...
Article
Oral feeding readiness has been described by researchers in the neonatal intensive care unit, and research has continued on this topic for many years. The purpose of this narrative review is to identify research and practice guidelines related to oral feeding readiness in preterm infants that have occurred during the last decade. The introduction and mastery of oral feeding is a major developmental task for the preterm infant that is often a prerequisite for discharge from the neonatal intensive care unit. Having a better understanding of the evidence supporting the development of this skill will help the practicing nurse choose appropriate interventions and the researcher to develop trajectories of research that continue to increase our knowledge in this important practice area.
... As oral feeding problems are multifactorial, there is no good understanding or approach as to how best to feed these infants. Caregivers and researchers have examined a broad range of potential causes, e.g., infant oral feeding skills (Barlow, 2009;Lau and Schanler, 2000), appropriateness of the environment, e.g., light, noise (Lasky and Williams, 2009), optimal infant behavioral states at time of oral feeding (Als et al., 2003;Gill et al., 1992;White-traut et al., 2005), importance of a multidisciplinary approach (Premji et al., 2004). This work has led to a number of emerging clinical practices. ...
Article
Over the last decade, nursing staff and feeding therapists have promoted the upright and sidelying bottle feeding positions as ‘optimal’ for preterm infants. To verify such benefits, very low birth weight infants were randomized to being fed in the customary semi-reclined (control), upright, or sidelying position. The primary outcome was days from start to independent oral feeding. Secondary outcomes included infants' oral feeding skill levels monitored when taking 1,2, 3–5, and 6–8 oral feedings per day. Infants fed in the upright and sidelying groups attained independent oral feeding within the same number of days as control counterparts. There was no difference in the maturation of their oral feeding skills.
... Nurses did not expect to be successful in feeding infants with NAS whose signs were not well under control, and usually collaborated with the medical team to re-evaluate the plan of care. Many experts believe that the infant's neurobehavioral organization plays an important role in successful feeding, [17][18][19] which is reflected by findings describing factors that disrupt feeding in infants with NAS. 5 The informers readily shared their expertise about how to increase success in feeding infants with NAS. We asked them about their most challenging infant to feed so that they would begin thinking about their strategies for success. ...
Article
Full-text available
Purpose: The purpose of this study is to learn how caregivers who are expert in feeding infants with neonatal abstinence syndrome (NAS) successfully feed these infants during withdrawal. Design/sample: Focus group methodology was used to gather information from self-identified experts from three large regional NICUs. Twelve NICU nurses and speech therapists participated in open-ended, recorded discussions. Detailed flip chart notes were taken, reviewed, and verified by the participants before the group ended. Results: Four major themes emerged verified by the participants: (1) optimal medication management, (2) follow the baby's cues, (3) calm and comfortable, and (4) nurture the relationship. Participants reported using both common and creative techniques. Keeping the infant calm was crucial to being successful, as well as maintaining good control of withdrawal signs. Feeding the infant facing away from them to avoid eye contact was used, as well as vertical rocking, continuous butt patting, bundling, "shhing" sound, and a novel feeding position.
... The experimental session began by having the infant suck on the examiner's gloved finger (about 30-60 s) to increase alert state and ready the infant for feeding (White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005). This was followed by nonnutritive suck (NNS) on the instrumented pacifier while in their typical feeding position (held by mother) (Fig. 3A). ...
Article
Background: Independent oral feeding requires coordination of suck, swallow and breathe and the lingual musculature plays a signficant role in this coordinative action. However, clinical benchmarks of lingual function fundamental to successful feeding have not been explored. Aims: The present study tests our model for quantifying infant lingual force and size and compares the muscle measures of interest in two cohorts: healthy full-term infants (FT) (N=5) and healthy preterm infants (PT) (N=6). Method: Using an instrumented pacifier and a bottle nipple, we determined the resultant compressive forces applied to the nipple by the tongue during nutritive (NS) and nonnutritive sucking (NNS). Muscle size was estimated from measures of posterior tongue thickness using ultrasonography. Results: After controlling for weight and post menstrual age, statistically significant differences were found between FT and PT infants beginning to feed for NNS frequency and NS tongue force. Clinically significant differences were detected for NNS tongue force and posterior tongue thickness. Additionally, PT infants demonstrated a significant difference in mean frequency between NS and NNS and PT infants did not. Linear regression indicated that mean posterior tongue thickness alone predicted 55% of the variance in NS force. Conclusions: Results demonstrate the feasilbility of our approach and suggest that infant tongue muscle characteristics necessary for successful feeding differ between healthy full term infants and preterm infants who are beginning oral feeding.
... Filters used: English, full text, humans, and infant (birth to 23 months). As oral feeding is multifactorial, there were several factors that may have affected the outcomes of this study, including feeding techniques used by caregivers, 13 types of bottle nipple, 14 infants' behavioral states before and during feeding, 15,16 and environmental stimulations. 17,18 These factors need to be controlled appropriately so that outcome effects can be attributed to the feeding position. ...
Article
Background: Side-lying position is an increasingly common feeding strategy used by parents, nurses, and feeding therapists to support oral feeding in preterm infants. Better understanding of the research evidence on the effect of the side-lying position will help clinicians make informed decisions and guide future research in this important area. Purpose: To identify and summarize the available evidence on the effect of side-lying position on oral feeding outcomes in preterm infants. Methods/search strategy: PubMed, CINAHL, Web of Science and PsycINFO were searched for ("preterm" OR "premature") AND "feed*" AND "position*". The full text of 47 articles was reviewed to identify eligible studies that use a quasi-experimental or experimental design to examine the intervention effectiveness; 4 studies met criteria. Findings/results: Four studies compared the effect of the side-lying position with either the semi-upright, cradle-hold, or semi-reclined positions on various feeding outcomes. The findings were conflicting: 2 studies found the side-lying position to be beneficial for supporting physiologic stability during feeding compared with the semi-upright position whereas 2 studies did not find significant differences in any of their outcomes between the side-lying position and other feeding positions. However, this finding should be interpreted cautiously because of various methodological weaknesses and limited generalizability. Implications for practice: This review does not provide strong or consistent evidence that the side-lying position improves preterm infants' oral feeding outcomes. Implications for research: A large randomized controlled trial with a diverse group of preterm infants is needed to determine the effects of the side-lying position and identify infants who would receive the most benefit.Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.
... Specifically, infants born prematurely with significant respiratory problems often have increased respiratory rates, with a less rhythmic coordination of swallowing and respiration during feeding, leading to risk of aspiration [14]. As the infant matures, they develop a wider range of infant states, including oral readiness signs although these may be variable when beginning the process of oral feeding [16]. ...
Article
Non-nutritive sucking is often used with premature infants by either using a pacifier or an expressed breast nipple to support the introduction and development of early oral feeding. The pattern of non-nutritive sucking is distinct in that it involves two sucks per second in contrast to nutritive sucking which is one suck per second. Although some literature has identified that non-nutritive sucking has some benefit for the premature infant's feeding development, it is not entirely clear why such an approach is helpful as neurologically, activation of non-nutritive and nutritive skills are different. A summary is presented of the main approaches that use non-nutritive sucking with reference to the literature. This paper also considers other factors and beneficial approaches to managing the introduction of infant feeding. These are: the infant's toleration of enteral feeds pre oral trials, overall development and gestational age when introducing oral experiences, developing swallowing skills before sucking, physiological stability, health status, as well as the development and interpretation of infant oral readiness signs and early communication.
... Their clinical status, behavioral states, infant's organization, and environmental conditions at feeding time are well-known contributors to a successful feeding (6). Oral feeding is optimized when infants are in drowsy/alert inactive, quiet awake, and/or alert state as defined by the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) (78)(79)(80). As mentioned earlier, environmental conditions such as bright light, loud surroundings, fluctuating temperatures, infant unsupported posture are disruptive (10,81). ...
Article
Full-text available
The increase in preterm infants' survival over the last 30 years has shed light over their inability to feed by mouth safely and efficiently. With adverse events such as increased risks for oxygen desaturation, bradycardia, penetration/aspiration, infants' hospitalization in neonatal intensive care units (NICUs) are understandably prolonged. Unfortunately, this leads to delayed mother-infant reunion, maternal stress, breastfeeding obstacles, and increased medical costs. Such impediments have stimulated clinicians and researchers to better understand the underlying causes and develop evidence-based solutions to assist these infants. However, it is notable that the research-to-practice translation of this knowledge has been limited as there are still no validated guidelines or protocols as how to best diagnose and care for these infants. This report revisits the immature physiologic functions at the root of these infants' oral feeding difficulties, the current practices, and the recent availability of evidence-based efficacious tools and interventions. Taking advantage of the latter, it presents a renewed perspective of how management strategies can be tailored to the specific needs of individual patients.
... Behavioral state is an important clinical parameter for assessing oral feeding readiness and performance [57,58]. Several studies have shown that sucking on pacifiers helped infants achieve and sustain a quiet alert state prior to and during oral feeding and improved their feeding readiness and efficiency [59][60][61][62][63]. Time to transition from gavage to FOF is a commonly used outcome in studies of infant feeding [4,19,26]. ...
Article
Full-text available
Objective To evaluate the effect of patterned, frequency-modulated oro-somatosensory stimulation on time to full oral feeds in preterm infants born 26–30 weeks gestation. Study design This is a multicenter randomized controlled trial. The experimental group (n = 109) received patterned, frequency-modulated oral stimulation via the NTrainer system through a pulsatile pacifier and the control group (n = 101) received a non-pulsatile pacifier. Intent-to-treat analysis (n = 210) was performed to compare the experimental and control groups and the outcomes were analyzed using generalized estimating equations. Time-to-event analyses for time to reach full oral feeds and length of hospital stay were conducted using Cox proportional hazards models. Results The experimental group had reduction in time to full oral feeds compared to the control group (-4.1 days, HR 1.37 (1.03, 1.82) p = 0.03). In the 29–30 weeks subgroup, infants in the experimental group had a significant reduction in time to discharge (-10 days, HR 1.87 (1.23, 2.84) p < 0.01). This difference was not observed in the 26–28 weeks subgroup. There was no difference in growth, mortality or morbidities between the two groups. Conclusions Patterned, frequency-modulated oro-somatosensory stimulation improves feeding development in premature infants and reduces their length of hospitalization. Trial registration ClinicalTrials.gov NCT01158391
... From a clinical perspective, the ability to feed depends upon a coordinated suck, swallow, and breathing pattern. Often, premature infants have delayed or uncoordinated pattern of suck-swallow-breath and poor state control (Mizuno & Ueda, 2006;Tosh, McGuire, 2006;Barlow et al., 2001;Pinelli & Symington, 2005;Cevasco & Grant, 2005;Lau & Kusnierczyk, 2001;White-Traut, et al., 2005;Stumm et al., 2008). These conditions significantly affect their abilities to sustain full oral feedings. ...
Article
Infants in the Neonatal Intensive Care Unit (NICU) frequently experience a delay in the initiation of oral feedings, related either to illness or prematurity, and demonstrate greater difficulties transitioning from gavage to oral feedings. Given the demonstration of physiologic stability, these infants would benefit from a shorter length of stay which would minimize parental-infant separation and exposure to possible hospital-acquired infections. However, current practice is inconsistent, at best, and is based largely on both prior experiences and NICU culture rather than on evidence-based practices. A systematic review of the literature pertaining to a “cue-based” feeding approach that initiates and advances oral feedings in the premature population and the impact it has on length of stay, weight gain, and caregiver satisfaction was performed.
Article
To identify infant and maternal characteristics associated with the pace of progression from the first oral feeding to complete oral feeding. One hundred forty-two stable premature infants who were fully or partially gavage feeding immediately after birth (29 to 34 weeks gestational age at birth). Exploratory secondary analysis. Data are from an ongoing randomized clinical trial of a developmental maternally administered intervention (Hospital to Home Transition-Optimizing Premature Infant's Environment) for mother-infant dyads at high social-environmental risk. Oral feeding progression (transition time from the first attempt to complete oral feeding). The convenience sample of preterm infants consisted of 48.6% male infants; the mean gestational age at birth was 32.4 weeks and mean birth weight 1787 g; and African American mothers (47.9%; n = 80) and Latina mothers (52.1%; n = 83). Multivariable linear regression results showed that, on average, the number of days for infants of Latina mothers to achieve complete oral feeding was 2.43 days more than for infants of African American mothers. In addition, lower birth weight and lower postmenstrual age at first oral feeding were associated with longer feeding progression. Higher infant morbidity was correlated with longer feeding progression. Infants with Latina mothers, lower birth weight, lower postmenstrual age at first oral feeding, and higher morbidity scores had a longer transition from first to complete oral feeding. Identification of infants at risk for delayed transition from first to complete oral feeding may allow for the development and testing of appropriate interventions that support the transition from gavage to complete oral feeding.
To assess how non-nutritive sucking (NNS) using a pacifier affected physiological and behavioral outcomes of preterm infants. Short-term longitudinal, experimental design. The study took place at the neonatal intensive care unit at Al-Mansoura, Egypt. Forty-seven preterm infants were divided into intervention and control groups. Preterm infants in the intervention group received NNS during nasogastric tube feeding while infants in the control group never received NNS. During 10 days, behavioral responses were videotaped and physiological responses were monitored. Significantly higher oxygen saturation occurred during and after nasogastric feeding for the intervention infants as compared to the control group. No significant group differences occurred in heart rate. The NNS group showed an accelerated transition to nipple feeding and had better weight gain and earlier discharge. Non-nutritive sucking was found to improve physiological and behavioral responses of preterm infants.
Article
For many preterm and convalescing infants in the neonatal intensive care unit, often one of the last barriers to going home is being able to successfully feed from the breast or bottle. Parents frequently ask staff: when will my baby be ready to go to breast or start taking a bottle? In the past, the answer was based on the infant’s medical condition and age alone. However, this approach to infant feeding readiness is changing and it is now acknowledged as a dynamic and multifactorial process.
Article
Preterm infants often display difficulty establishing oral feeding in the weeks following birth. This article aims to provide an overview of the literature investigating the development of feeding skills in preterm infants, as well as of interventions aimed at assisting preterm infants to develop their feeding skills. Available research suggests that preterm infants born at a lower gestational age and/or with a greater degree of morbidity are most at risk of early feeding difficulties. Respiratory disease was identified as a particular risk factor. Mechanisms for feeding difficulty identified in the literature include immature or dysfunctional sucking skills and poor suck–swallow–breath coordination. Available evidence provides some support for therapy interventions aimed at improving feeding skills, as well as the use of restricted milk flow to assist with maintaining appropriate ventilation during feeds. Further research is needed to confirm these findings, as well as to answer remaining clinical questions.
Article
Purpose The purpose of this study was to compare student knowledge and confidence, related to the assessment and management of oral feeding readiness in medically complex infants, following a written case study versus a high-fidelity human patient simulation (HPS). Method A sequential, two-phase, embedded mixed methods design was conducted. Participants were two sequential cohorts of second-year speech-language pathology graduate students enrolled in a didactic Pediatric Dysphagia course. At the end of the course, students completed the same case scenario presented as a written case study (control group; N = 28) or as an HPS (experimental group; N = 24). Pre– and post–knowledge assessment results and self-assessments of confidence conducted at three time points were compared. Results All students made gains in knowledge, regardless of intervention (written case study or HPS). Despite different baselines, the percent change in knowledge was significant with the control group improving 33% and the experimental group improving 76% from baseline. Students in the experimental group demonstrated significantly greater gains in confidence with skills enhanced by the hands-on, immersive experience of HPS. Qualitative analysis further identified factors contributing to increased confidence with all students reporting that experience significantly contributes to their confidence in their ability to treat patients. Conclusions While knowledge outcomes were similar between the groups, the confidence that the experimental group gained through the hands-on experiences of HPS fosters student development as confident professionals in assessing feeding readiness and managing medically complex infants. Results support integration of simulation into the graduate curriculum to support student learning. Supplemental Material https://doi.org/10.23641/asha.19233504
Article
Background: Preterm infants (< 37 weeks' postmenstrual age) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. Objectives: To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' postmenstrual age (PMA).To conduct subgroup analyses for the following prespecified subgroups.? Extremely preterm infants born at < 28 weeks' PMA.? Very preterm infants born from 28 to < 32 weeks' PMA.? Infants breast-fed exclusively.? Infants bottle-fed exclusively.? Infants who were both breast-fed and bottle-fed. Search methods: We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 25 February 2016). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles. Selection criteria: Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention in preterm infants and reporting at least one of the specified outcomes. Data collection and analysis: One review author searched the databases and identified studies for screening. Two review authors screened the abstracts of these studies and full-text copies when needed to identify trials for inclusion in the review. All review authors independently extracted the data and analysed each study for risk of bias across the five domains of bias. All review authors discussed and analysed the data and used the GRADE system to rate the quality of the evidence. Review authors divided studies into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model. Main results: This review included 19 randomised trials with a total of 823 participants. Almost all included trials had several methodological weaknesses. Meta-analysis showed that oral stimulation reduced the time to transition to oral feeding compared with standard care (mean difference (MD) -4.81, 95% confidence interval (CI) -5.56 to -4.06 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days), as well as the duration of initial hospitalisation compared with standard care (MD -5.26, 95% CI -7.34 to -3.19 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days).Investigators reported shorter duration of parenteral nutrition for infants compared with standard care (MD -5.30, 95% CI -9.73 to -0.87 days) and compared with another non-oral intervention (MD -8.70, 95% CI -15.46 to -1.94 days). They could identify no effect on breast-feeding outcomes nor on weight gain. Authors' conclusions: Although the included studies suggest that oral stimulation shortens hospital stay, days to exclusive oral feeding and duration of parenteral nutrition, one must interpret results of these studies with caution, as risk of bias and poor methodological quality are high overall. Well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should use reliable methods of randomisation while concealing treatment allocation, blinding caregivers to treatment when possible and paying particular attention to blinding of outcome assessors.
Article
We examined the effects of breast milk smell on transition time from gavage to oral feeding and hospital stay in premature infants. There were 92 premature infants younger than 33 weeks who were randomly selected and sequentially allocated to the following groups: control (n = 46) and intervention (n = 46). This experimental study was undertaken in 2 neonatal intensive care units located in Vali Asr and Jamee Zanan educational hospitals in Tehran, Iran. We collected data from April 6 until September 6, 2013, over 4.5 months. Participants’ demographic data were extracted from their medical records. The findings of the study indicated that the use of an impregnated pad with breast milk, which was used for olfactory stimulation, reduced premature infants’ transition feeding time by 10 days in the intervention group compared with the control group. The length of hospitalization was also reduced by 12 days in the intervention group compared with the control group. The study results suggested that neonatal intensive care unit nurses should train mothers in the performance of this simple, inexpensive method to improve the quality of care provided to premature infants and reduce feeding transition time from gavage to oral feeding.
Article
Based on the evidence for its short and long term benefits, full breastfeeding is the optimal aim for the preterm infant-mother dyad. The preterm infant's transition to full oral feeding is frequently complicated by neurological and developmental immaturity as well as accompanying co-morbidities. Currently there is limited evidence available to guide feeding strategies for these infants, and few validated diagnostic tools available to assist health professionals in assessing feeding progress for these infants. The current knowledge of breastfeeding the preterm infant is summarised in this chapter. We look forward to more research elucidating the most effective means of achieving and sustaining full breastfeeding in this population. © 2013 Springer Science+Business Media Dordrecht. All rights reserved.
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Objective: To test the effects of kangaroo care (KC) on breastfeeding outcomes in preterm infants compared with two control groups and to explore whether maternal-infant characteristics and the mother's choice to use KC were related to breastfeeding measures. Design: Secondary analysis of a multisite, stratified, randomized three-arm trial. The treatment groups used KC, auditory-tactile-visual-vestibular (ATVV) intervention, or received preterm infant care information. Setting: Neonatal intensive care units from 4 hospitals in the United States from 2006 to 2011. Participants: Racially diverse mothers (N = 231) and their preterm infants born weighing less than 1,750 g. Methods: Mothers and their infants were enrolled once the infants were no longer critically ill, weighed at least 1,000 g, and could be safely held outside the incubator by parents. Participants were instructed by study nurses; those allocated to the KC or ATVV groups were asked to engage in these interactions with their infants for a minimum of 3 times a week in the hospital and at home until their infants reached age 2 months adjusted for prematurity. Results: Feeding at the breast during hospitalization, the duration of postdischarge breastfeeding, and breastfeeding exclusivity after hospital discharge did not differ statistically among the treatment groups. Regardless of group assignment, married, older, and more educated women were more likely to feed at the breast during hospitalization. Mothers who practiced KC, regardless of randomly allocated group, were more likely to provide their milk than those who did not practice KC. Breastfeeding duration was greatest among more educated women. Conclusion: As implemented in this study, assignment to the KC group did not appear to influence the measured breastfeeding outcomes.
Article
Even though direct breastfeeding holds many benefits for preterm infants, the transition from gavage to direct breastfeeding remains suboptimal in this population. Failing this transition can contribute to an early cessation of direct breastfeeding and jeopardize the preterm infants’ growth and development. Preterm infants could benefit from interventions that promote the transition to direct breastfeeding and thus, facilitate this challenging step. This review identifies and analyzes interventions classified in four categories: non-nutritive sucking (NNS) and oral stimulation, promotion of direct breastfeeding experience and avoidance of bottles, cue-based feeding approach, and exposure to human milk odor. All of these interventions improved the preterm infants’ sucking competency, decreased their hospitalization length or increased the breastfeeding rates at discharge. NNS and oral stimulation, and promotion of direct breastfeeding experience and avoidance of bottles are the interventions with the highest evidence level, with the most potential for NICU implementation.
Article
Background: One of the most challenging milestones for preterm infants is the acquisition of safe and efficient feeding skills. The majority of healthy full term infants are born with skills to coordinate their suck, swallow and respiration. However, this is not the case for preterm infants who develop these skills gradually as they transition from tube feeding to suck feeds. For preterm infants the ability to engage in oral feeding behaviour is dependent on many factors. The complexity of factors influencing feeding readiness has led some researchers to investigate the use of an individualised assessment of an infant's abilities. A limited number of instruments that aim to indicate an individual infant's readiness to commence either breast or bottle feeding have been developed. Objectives: To determine the effects of using a feeding readiness instrument when compared to no instrument or another instrument on the outcomes of time to establish full oral feeding and duration of hospitalisations. Search methods: We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 22 February 2016), EMBASE (1980 to 22 February 2016), and CINAHL (1982 to 22 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Selection criteria: Randomised and quasi-randomised trials comparing a formal instrument to assess a preterm infant's readiness to commence suck feeds with either no instrument (usual practice) or another feeding readiness instrument. Data collection and analysis: The standard methods of Cochrane Neonatal were used. Two authors independently screened potential studies for inclusion. No studies were found that met our inclusion criteria. Main results: No studies met the inclusion criteria. Authors' conclusions: There is currently no evidence to inform clinical practice, with no studies meeting the inclusion criteria for this review. Research is needed in this area to establish an evidence base for the clinical utility of implementing the use of an instrument to assess feeding readiness in the preterm infant population.
Article
Rationale, aims and objectives: This article aims to provide evidence to guide multidisciplinary clinical practitioners towards successful initiation and long-term maintenance of oral feeding in preterm infants, directed by the individual infant maturity. Method: A comprehensive review of primary research, explorative work, existing guidelines, and evidence-based opinions regarding the transition to oral feeding in preterm infants was studied to compile this document. Results: Current clinical hospital practices are described and challenged and the principles of cue-based feeding are explored. "Traditional" feeding regimes use criteria, such as the infant's weight, gestational age and being free of illness, and even caregiver intuition to initiate or delay oral feeding. However, these criteria could compromise the infant and increase anxiety levels and frustration for parents and caregivers. Cue-based feeding, opposed to volume-driven feeding, lead to improved feeding success, including increased weight gain, shorter hospital stay, fewer adverse events, without increasing staff workload while simultaneously improving parents' skills regarding infant feeding. Although research is available on cue-based feeding, an easy-to-use clinical guide for practitioners could not be found. A cue-based infant feeding regime, for clinical decision making on providing opportunities to support feeding success in preterm infants, is provided in this article as a framework for clinical reasoning. Conclusions: Cue-based feeding of preterm infants requires care providers who are trained in and sensitive to infant cues, to ensure optimal feeding success. An easy-to-use clinical guideline is presented for implementation by multidisciplinary team members. This evidence-based guideline aims to improve feeding outcomes for the newborn infant and to facilitate the tasks of nurses and caregivers.
Article
Non-nutritive sucking is often used with premature infants by either using a pacifier or an expressed breast nipple to support the introduction and development of early oral feeding. The pattern of non-nutritive sucking is distinct in that it involves two sucks per second in contrast to nutritive sucking which is one suck per second. Although some literature has identified that non-nutritive sucking has some benefit for the premature infant's feeding development, it is not entirely clear why such an approach is helpful as neurologically, activation of non-nutritive and nutritive skills are different. A summary is presented of the main approaches that use non-nutritive sucking with reference to the literature. This paper also considers other factors and beneficial approaches to managing the introduction of infant feeding. These are: the infant's toleration of enteral feeds pre oral trials, overall development and gestational age when introducing oral experiences, developing swallowing skills before sucking, physiological stability, health status, as well as the development and interpretation of infant oral readiness signs and early communication.
Article
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Objective: Objective: The aim of the study was to compare the advantages of semi-elevated and side-lying positioning during bottle-feeding of preterm infants ≤ 34 weeks gestational age (34+0/7). Patients and methods: Material and methods: The study included six neonates (n=6) born ≤ 34 weeks gestational age who reached the age ≥ 32 weeks of postmenstrual age on the day when the study began and were hospitalized in the neonatology ward. Four bottle-feeding sessions were tested in each of the newborns: two in the side-lying and two in the semi-elevated position. The position for the first test was chosen randomly. For each of the positions twelve feeding sessions were examined and each preterm infant had bottle-feeding sessions analyzed both in the semi-elevated and side-lying positions. The level of saturation and heart rate were measured as the parameters indicative of the newborn's physiological stability. The factors determining the qualitative aspect of feeding included the level of the newborn's alertness and the occurrence of choking episodes. The amount of food consumed and the duration of the feeding were also recorded. Results: Results: The side-lying position was more effective with regard to the total amount of sustenance consumed as compared to the semi-elevated feeding position and the study result was statistically significant (p=0.007). The difference in the number of chokes between the study groups was not statistically significant, although a trend towards a reduced number of choking episodes was observed among infants fed in the side-lying position (p=0.090). There were no significant differences in oxygen saturation, heart rate and level of activity between the study groups. Conclusion: Conclusions: The effects of this pilot study demonstrate the efficacy of the side-lying feeding position regarding the final amount of milk intake. The side-lying position may also reduce the number of choking episodes during the feeding. The results suggest the need to extend the study in order to confirm the potential benefits of using the side-lying position.
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Background Multi-sensory behavioral interventions for preterm infants have the potential to accelerate feeding, growth, and optimize developmental trajectories and increase parents’ interactive engagement with their infants. However, few neonatal intensive care units (NICUs) provide evidence-based standardized early behavioral interventions as routine care. Lack of implementation is a major gap between research and clinical practice. H-HOPE, is a standardized behavioral intervention with an infant- directed component (Massage+) and a parent-directed component (four participatory guidance sessions that focus on preterm infants’ behaviors and appropriate responses). H-HOPE has well documented efficacy. The purpose of this implementation study is to establish H-HOPE as the standard of care in 5 NICUs. Methods The study employs a Type 3 Hybrid design to simultaneously examine the implementation process and effectiveness in five NICUs. To stagger implementation across the clinical sites, we use an incomplete stepped wedge design. The five participating NICUs were purposively selected to represent different acuity levels, number of beds, locations and populations served. Our implementation strategy integrates our experience conducting H-HOPE and a well-established implementation model, the Consolidated Framework for Implementation Research (CFIR). The CFIR identifies influences (facilitators and barriers) that affect successful implementation within five domains: intervention characteristics, outer setting (the hospital and external events and stakeholders), inner setting (NICU), implementers’ individual characteristics, and the implementation process. NICUs will use the CFIR process, which includes three phases: Planning and Engaging, Executing, and Reflecting and Evaluating. Because sustaining is a critical goal of implementation, we modify the CFIR implementation process by adding a final phase of Sustaining.DiscussionThis study builds on the CFIR, adding Sustaining H-HOPE to observe what happens when sites begin to maintain implementation without outside support, and extends its use to the NICU acute care setting. Our mixed methods analysis systematically identifies key facilitators and barriers of implementation success and effectiveness across the five domains of the CFIR. Long term benefits have not yet been studied but may include substantial health and developmental outcome for infants, more optimal parent-child relationships, reduced stress and costs for families, and substantial indirect societal benefits including reduced health care and special education costs.Trial registrationClinicalTrials.gov registration number NCT04555590, Registered on 8/19/2020
Article
Full-text available
Background Multi-sensory behavioral interventions for preterm infants have the potential to accelerate feeding, growth, and optimize developmental trajectories and increase parents’ interactive engagement with their infants. However, few neonatal intensive care units (NICUs) provide evidence-based standardized early behavioral interventions as routine care. Lack of implementation is a major gap between research and clinical practice. H-HOPE, is a standardized behavioral intervention with an infant- directed component (Massage+) and a parent-directed component (four participatory guidance sessions that focus on preterm infants’ behaviors and appropriate responses). H-HOPE has well documented efficacy. The purpose of this implementation study is to establish H-HOPE as the standard of care in 5 NICUs. Methods The study employs a Type 3 Hybrid design to simultaneously examine the implementation process and effectiveness in five NICUs. To stagger implementation across the clinical sites, we use an incomplete stepped wedge design. The five participating NICUs were purposively selected to represent different acuity levels, number of beds, locations and populations served. Our implementation strategy integrates our experience conducting H-HOPE and a well-established implementation model, the Consolidated Framework for Implementation Research (CFIR). The CFIR identifies influences (facilitators and barriers) that affect successful implementation within five domains: intervention characteristics, outer setting (the hospital and external events and stakeholders), inner setting (NICU), implementers’ individual characteristics, and the implementation process. NICUs will use the CFIR process, which includes three phases: Planning and Engaging, Executing, and Reflecting and Evaluating. Because sustaining is a critical goal of implementation, we modify the CFIR implementation process by adding a final phase of Sustaining. Discussion This study builds on the CFIR, adding Sustaining H-HOPE to observe what happens when sites begin to maintain implementation without outside support, and extends its use to the NICU acute care setting. Our mixed methods analysis systematically identifies key facilitators and barriers of implementation success and effectiveness across the five domains of the CFIR. Long term benefits have not yet been studied but may include substantial health and developmental outcomes for infants, more optimal parent-child relationships, reduced stress and costs for families, and substantial indirect societal benefits including reduced health care and special education costs. Trial registration ClinicalTrials.gov registration number NCT04555590 , Registered on 8/19/2020.
Article
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Background The aim of this study was to determine the impact of umbilical cord arterial pH, gestational age, and birth weight on neurodevelopmental outcomes for preterm neonates. Methods We examined 112 neonates. Inclusion criteria were: Saturations greater than 88%, and heart rates between 100–205 beats per minute. Measurements We assessed several neurodevelopmental factors as part of the Brazelton Neonatal Behavioral Assessment Scale (NBAS), 4th edition, such as asymmetric tonic neck reflex (ATNR), motor maturity, response to sensory stimuli, habituation, and state regulation. Initial assessment parameters such as APGAR score and umbilical cord arterial pH were used to assess neonates. Results We found a strong correlation between the presence of the sucking reflex and umbilical cord arterial pH ( r = 0.32; p = 0.018981). Umbilical cord arterial pH was also correlated with the presence of asymmetric tonic neck reflex ( r = 0.27; p = 0.047124), cost of attention ( r = 0.31; p = 0.025381) and general motor maturity ( r = 0.34; p = 0.011741). Conclusions We found that the sucking reflex may be affected in infants with low umbilical cord arterial pH values. Practitioners and parents can use the NBAS to help determine neurodevelopmental factors and outcomes in preterm infants, possibly leading to safer and more effective feeding practices and interventions.
Article
Introduction and management of oral feeding for preterm infants is a major challenge for clinicians in the neonatal intensive care unit (NICU). Feeding practices are often inconsistent and contradictory among clinicians and NICUs and based on custom rather than evidence. There is a need to establish a systematic approach, which is evidence based to facilitate decision making and clinical practice. Assisting the preterm infant to achieve the ability to fully orally feed takes time and is often a requirement for discharge. To be discharged from hospital, an infant must have a safe and efficient feeding method, ideally by breast or bottle. If sucking and oral feeding are developmentally programmed in infants, then maturation to a certain gestational age would be all that is needed. Early introduction of oral feeding and interventions to facilitate bottle or breast would be unnecessary. However, if practice or experience plays a significant role, then a systematic approach to timing of introduction and transition to oral feeding would be beneficial. Determining the optimal time to introduce oral feeds and strategies for progression would perhaps lead to earlier attainment and discharge from hospital especially in the “healthy” preterm population. The purpose of this article is to review the current research to (1) identify best practices related to (i) timing of introduction of oral feeds and (ii) transition to full oral and to (2) provide support for evidence-based practice and decision making for clinicians working with premature infants in the NICU.
Article
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Fourteen newborn babies of different gestational ages (33 to 40 weeks) but similar postnatal age (four to 19 days) were studied during bottle-feeding using real-time ultrasonography, combined with respiratory monitoring. Previously undescribed tongue movements and graded changes in the temporal relationships between tongue movements, swallowing and breathing were observed among infants of differing maturity. These were most marked in the least mature infants, but were occasionally seen in term infants. The results suggest that adequate neuromuscular co-ordination is more a function of gestational maturity than of postnatal sucking experience. The pattern of intraoral events for infants of differing maturity described in this study provides a framework for the study of feeding problems of term and preterm infants.
Article
Survival rates have improved dramatically among premature infants admitted to a neonatal intensive care unit. Yet, nutrition and feeding remains a challenge. As the infant grows and enteral feeding are contemplated, one still has to question what facts impact feeding readiness or competence. A study was undertaken to examine the relationship between the maturation of alertness and the acquisition of nutritive sucking competence during the transition to all oral nipple feedings in the neonatal intensive care unit. Copyright 2002, Elsevier Science (USA). All rights reserved.
Article
A prospective clinical random design was used to assess the effects of prefeeding auditory, tactile, visual and vestibular (ATVV) intervention on the behavioral state, frequency of feeding readiness behaviors, and oral feeding efficiency in 22 stable, premature infants. Experimental infants (group E) received 15 minutes of ATVV intervention immediately prior to their first 3 oral feedings, while the controls received normal nursery care. FRBs and behavioral states were recorded and later scored via videotape. Feeding efficiency was determined by feeding volume and feeding duration. Group E infants were more alert after the intervention (P < .0001) and showed more FRBS during the intervention for 5 of the 8 behaviors (P < .05). A trend toward decreased feeding time was noted for group E infants. The present findings support the use of ATVV intervention prior to feeding as a means of modulating behavioral states and increasing the frequency of FRBs. Copyright 2002, Elsevier Science (USA). All rights reserved.
Objective To describe criteria used to determine readiness for oral feedings in stable, preterm infants. Design A 25‐item survey questionnaire was mailed to hospitals having level II or level III NICUs. Setting Nurseries identified in the 1987 National Perinatal Directory (576 in all) as level II or level III NICUs. Participants Head nurses (HN) and staff nurses (SN) at 420 hospitals comprised 73% of the sample surveyed. Procedures: Survey items were predominantly multiple choice and included an “other” option to encourage comments. Main Outcome Measures Respondents described clinical practice in their nurseries relative to feeding policies, use of traditional decision criteria, or behavioral cues and related interventions. Results/Conclusions Fewer than 50% of nurseries identified a specific feeding policy for the initiation of oral feedings. Seventy‐five percent used either gestational age or weight criteria in deciding when to start oral feedings. Eighty‐six percent considered infant behavior as well when determining feeding readiness. Findings suggest an emerging emphasis on infant behavioral cues in addition to gestational age and weight criteria when making feeding decisions.
Article
Describes the influence of several sleeping and waking states and of hunger on the neonate's behavior. It is noted that differences among infants are purely a function of momentary states rather than their individuality. General effects of interventions will be obscured unless the infants are observed in comparable states. Illustrations are included from sleep research as well as distinctness of state, range, predictability, and alterability of states as these may affect mother-infant relationships and normal and pathological development. The states of crying and of alert inactivity are included under the heading of state as variable and as mediator of stimulation. (42 ref.) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
This study examined the development of sleeping and waking states in high-risk preterm infants. Thirty-seven preterm infants were observed from 7 p.m. to 11 p.m. weekly from the time their conditions were no longer critical until term age or hospital discharge. An average of 3.6 observations was conducted on each infant between 29 and 39 weeks conceptional age (CA). During the observations, the occurrence of eight sleep-wake states was recorded every 10 s. The intensity of rapid eye movements in active sleep and the regularity of respiration in quiet sleep were also rated. Similar state patterns were found at all ages, with active sleep the most frequent state, quiet sleep the second most frequent, and drowsiness and sleep-wake transition third and fourth. Waking states made up only small percentages of the observations at every age. Despite these similarities, four states exhibited significant changes over age: the amount of active sleep decreased, and fuss, cry, and quiet sleep increased. The organization of the sleep states also increased, as evidenced by an increase in the percent of active sleep with rapid eye movements and an increase in the regularity of respiration in quiet sleep. The severity of illness experienced by the infants had only minor effects on these patterns. These findings demonstrate that even high-risk infants show behavioral states by 29 weeks CA and that considerable state development occurs over the preterm period. Additional research is needed to determine the effects of time of day, caregiving environments, and specific insults on state development.
Article
Attempts to correlate developmental outcome with medical complications affecting the fetus and infant have focused on the prenatal, intrapartum, and postnatal periods. The time beyond the newborn stage has not been explored in detail. The aim of this study was to relate events occurring during the gestational and neonatal periods as well as the infancy periods to later performance by the use of four medical scales. A total of 126 preterm infants were followed up prospectively from birth to 2 years of age. Medical complications occurring during the prenatal, intrapartum, and postnatal periods as well as the first nine months of life were recovered. No relationship was found between obstetric and neonatal events and developmental outcome. Significant correlations were seen between medical events of later infancy and development at 2 years of age.
Article
Forty-two pre-term infants were studied to determine the effect of nonnutritive sucking pre-feeding on behavioral state. Infants were randomly assigned to pacifier or rest groups. Pacifiers or rest were given for 5 minutes following routine caregiving and before each of the first 16 bottle feedings. A 12-category scale was used to measure state immediately before the 5-minutes and after. Frequencies of states that precede optimal feedings changed for infants given pacifiers versus rest: alert inactivity (+6 vs. -2), quiet awake (+19 vs. -6), and active awake (-24 vs. +12); infants given pacifiers had more sleep and fewer restless states. Group differences were non-significant before nonnutritive sucking (p = 0.16) but significant after (p = 0.00001). When self-regulatory feeding policies based on early hunger cues are not allowed, nonnutritive sucking for 5 minutes pre-feeding is simple, brief, and appropriate for busy intensive care units. These findings confirm those from earlier less conclusive research and indicate that nonnutritive sucking modulates behavioral state.
Article
Inactive awake behavioral states have been associated with reduced heart rates and more successful feeding in preterm infants. The purpose of this study was to test the efficacy of three different interventions to facilitate these optimal feeding states. Twenty preterm infants (gestational ages 27-33 weeks, M = 31.6, SD = 1.7; birth weights 931-2,140 grams, M = 34, SD = 373) serving as their own controls were randomly administered nonnutritive sucking, nonnutritive sucking plus rocking, and stroking interventions; and a control condition. There were significantly more inactive awake states with the nonnutritive sucking and nonnutritive sucking plus rocking interventions than with the stroking intervention and the control conditions. The results suggest that there are interventions that can help preterm infants in the transition from gavage to oral feeding and potentially shorten their hospital stays.
Article
We investigated the effects of gestational age at birth on behavioral and electrophysiological measures of 135 medically healthy infants, studied at 42 weeks postconception, and stratified into 3 groups--early-born preterms, 26-32 weeks (n = 55); middle-group preterms, 33-37 weeks (n = 43); and fullterms, 38-41 weeks (n = 37). Subjects were studied behaviorally with the Assessment of Preterm Infants' Behavior (APIB) and electrophysiologically with brain electrical activity mapping (BEAM). Fullterms showed significantly better behavioral function than both preterm groups. Less difference was found between the preterm groups. EEG spectral and photic evoked response were of significantly less amplitude for the preterms than the fullterms. Path analysis showed gestational age effects on behavioral (3 of 6) and electrophysiological (13 of 17) variables due to postnatal complications. We conclude that some differences attributable to gestational age at birth are explained by the cumulative effect of minor but unavoidable complications associated with premature birth. We speculate that remaining effects may result from developmentally inappropriate sensorimotor stimulation consequent to the premature experience of an extrauterine environment.
Article
To describe the effect of nonnutritive sucking (NNS) on behavioral state (BSt) in preterm infants before feedings 24 preterm infants were randomly assigned and studied before each of their first 16 bottle feedings. Twelve received NNS by pacifier for 5 minutes; 12 did not receive a pacifier. BSt was measured with a 12-category scale for 30 seconds before the 5-minute period (BSt1) and for 30 seconds after (BSt2). Sleep states decreased for both groups. BSts considered more optimal for feeding increased more during NNS (86 vs. 46). Restless states were three times less frequent after NNS (23 vs. 68). Differences between groups were nonsignificant at BSt1, but were significant at BSt2, p less than .001. In the absence of self-regulatory feeding policies based on early hunger cues, NNS for 5 minutes prefeeding is simple, brief, and suitable for implementation in busy neonatal intensive care units. Nonnutritive sucking was an effective modulator of behavioral state for this sample.
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
Transition of preterm infants from enteral to nipple feeding is a necessary milestone for hospital discharge. This study tested the efficacy of one potential intervention to facilitate the transition process. Ten minutes of nonnutritive sucking (NNS) and a control condition were administered randomly before first nipple feedings. The sample consisted of 20 preterm infants (gestational ages 27-33 weeks, M = 31.6, SD = 1.7; birth weights 931-2, 140 g, M = 1,649, SD = 373) who served as their own controls. NNS resulted in fewer behavioral state changes during feedings and produced quiet, awake states more frequently during feedings. Heart rates did not differ between feedings following NNS compared with those in the control condition.
Article
Behavioral and physiologic responsivity to nasogastric gavage feeding was assessed in 36 preterm infants on 2 consecutive d. On one of these days, a pacifier was provided during and after the gavage segment of the standardized protocol. The protocol was divided into segments that included baseline, preparatory handling, pregavage, gavage, and postgavage periods. Patterns of cardiac (heart period and vagal tone), oxygen saturation, behavioral state, and defensive behavioral responses to gavage were quantified. These stable preterm infants responded to handling and gavage feeding with reduction in heart period, vagal tone, and oxygen saturation. These responses were not altered by provision of a pacifier, although there was a tendency for fewer episodes of bradycardia and oxygen desaturation. Conversely, behavioral state was affected significantly by nonnutritive sucking: when provided with a pacifier, infants exhibited less behavioral distress, spent less time in fussy and active awake states during and after feeding, and returned to a sleep state significantly faster. There is converging evidence to suggest that nonnutritive sucking lessens behavioral distress to iatrogenic stressors but does not alter physiologic responsiveness.
Article
To examine the effects of nonnutritive sucking on the physiologic and behavioral stress reactions of preterm infants at early bottle feedings and to examine the effect of nonnutritive sucking on the feeding performance of preterm infants at early bottle feedings. Quasi-experimental with a matched sample. A level III neonatal intensive-care unit in a large medical center. Twenty preterm infants whose gestational ages at birth ranged from 26 to 34 weeks. Ten infants were provided nonnutritive sucking for 5 minutes before and 5 minutes after an early bottle feeding. Ten infants served as controls. Physiologic stress was measured by heart rate and oxygen saturation rate. Behavioral stress was measured by observation of behavioral state. Feeding performance was measured by duration, percentage of formula taken by bottle, and behavioral state after feeding. Infants who received nonnutritive sucking before and after bottle feedings were more likely to be in a quiescent behavior state 5 minutes after the feeding (p = .01) and had higher feeding performance scores (p = .01) than infants who did not receive nonnutritive sucking.
Article
The purpose of this study was to examine the effects of nonnutritive sucking (NNS) on behavioral organization and feeding performance in preterm infants. Thirteen preterm infants were observed at four bottle-feedings, two of which involved treatment with prefeeding NNS. NNS had a positive effect on oxygen saturation and behavior state, as well as on the initiation and duration of the first nutritive suck burst.
Article
A feeding bottle equipped with micro-video-camera and pressure sensor was devised to show the inside of the mouth and record sucking pressure. Activities of the temporal (TM), masseter muscle (MM), orbicular muscle of the mouth (OM) and suprahyoid muscles (SM) of 25 healthy infants were examined. Tongue and jaw movements, EMGs and sucking waves were scanned simultaneously. The tongue movements included elevation of the medial part of the tongue in a backward-moving peristaltic wave; significant correlations were found between jaw motion, tongue movement and sucking pressure. The TM, MM and OM were most active when the sucking pressure became positive and the jaw was closing, the SM showing highest activity in the negative-pressure phase. These findings show that each suckling cycle is biphasic, with sucking pressure, peri-oral muscle activities and jaw motion all closely correlated.
Article
The purpose of this research was to examine the effect of behavioral state activity during nipple feeding on feeding success for a group of 20 preterm infants. The infants, fed per hospital policy at scheduled three-hour intervals, were observed during four early nipple feedings. Nine of the 20 infants were able to successfully nipple their four nipple feedings; the other 11 infants were unable to successfully complete their nipple feedings. The 9 successful feeders exhibited significantly more awake behavior during feeding than unsuccessful feeders (F = 7.82; p = .012). The unsuccessful feeders spent 53 percent of their feeding in sleep states; successful feeders were in sleep states only 30 percent of their feeding time. Along with other research, these findings suggest that infant behavioral state may be a key consideration for nipple feeding success in preterm infants.
Article
The purpose of this paper is to demonstrate the use of the mixed general linear model (MixMod) for modeling development of sleep-wake behaviors in preterm infants. The mixed general linear model allows the concurrent identification of both group and individual developmental patterns in longitudinal data sets with inconsistently timed data, irregularly timed data, and randomly missing values. This statistical technique is well suited to data from preterm infants because these infants enter and leave longitudinal studies at varying times depending on their health status. One sleep organizational variable--the regularity of respiration in quiet sleep--obtained from a study of 37 preterm infants was used as an example. Seven infant characteristics were used as covariates. The various steps involved in conducting a mixed model analysis of this variable are illustrated. The strengths and limitations of this technique are discussed.
Article
To investigate changes in nutritive sucking patterns, behavioral state, and neurobehavioral development of preterm infants from the 34 weeks postconceptional age (PCA) to term. Nonexperimental descriptive correlational design was used. A convenience sample included 66 preterm infants with a gestational age between 24 and 34 weeks at birth. Mean gestational age was 29.7 weeks, with a mean birthweight of 1379 grams. Instruments included the Kron Nutritive Sucking Apparatus, the Anderson Behavioral State Scale (ABSS), and the Brazelton Neonatal Behavioral Assessment Scale (BNBAS). A feeding procedure was administered at 34 and 40 weeks PCA with BNBAS administered at 40 weeks PCA. Data analysis strategies included t-tests, Spearman rho correlations, Wilcoxon matched-pairs signed-ranks test, and a Random Coefficients Model. There were significant differences in number of sucks (p < 0.001), intensity of sucking pressures (p < 0.001), average time between sucks (p < 0.001), and average time between bursts (p < 0.001) from 34 weeks PCA to term. With maturation, it was noted that the preterm infants were significantly more alert during the sucking protocol from 34 weeks to term (p < 0.001). Yet, infant sucking parameters at 34 weeks PCA and term were not significantly related to the BNBAS or to the infant's state. These results demonstrate that high risk preterm infants mature significantly in their sucking behaviors and in their ability to maintain a more alert behavioral state from 34 weeks PCA to term. However, unlike full term infants--where state is positively correlated to feeding (sucking) success--the preterm infant state of alertness may not enhance sucking skills at 34 weeks PCA. These infants may be too stressed to manage both feeding and stimulation from the environment that is unavoidable when alert. However, this relationship does appear to change by 40 weeks PCA.
Article
An earlier study demonstrated that oral feeding of premature infants (<30 wk gestation) was enhanced when milk was delivered through a self-paced flow system. The aims of this study were to identify the principle(s) by which this occurred and to develop a practical method to implement the self-paced system in neonatal nurseries. Feeding performance, measured by overall transfer, duration of oral feedings, efficiency, and percentage of successful feedings, was assessed at three time periods, when infants were taking 1-2, 3-5, and 6-8 oral feedings/day. At each time period, infants were fed, sequentially and in a random order, with a self-paced system, a standard bottle, and a test bottle, the shape of which allowed the elimination of the internal hydrostatic pressure. In a second study, infants were similarly fed with the self-paced system and a vacuum-free bottle which eliminated both hydrostatic pressure and vacuum within the bottle. The duration of oral feedings, efficiency, and percentage of successful feedings were improved with the self-paced system as compared to the standard and test bottles. The results were similar in the comparison between the self-paced system and the vacuum-free bottle. Elimination of the vacuum build-up naturally occurring in bottles enhances the feeding performance of infants born <30 wk gestation as they are transitioned from tube to oral feeding. The vacuum-free bottle is a tool which caretakers can readily use in neonatal nurseries.
Article
Little information is available regarding the behavioral repertoire of healthy, yet prematurely born, infants. To address this problem, the Assessment of Preterm Infants' Behavior (APIB) was used 10 to 14 days after birth in a cross-sectional comparison of 42 healthy newborn infants: 16 full-term infants (gestational age at birth [GA] = 40 weeks), 13 close to full-term infants (GA = 37 weeks), and 13 preterm infants (GA = 34 weeks). Groups differed on four background variables that were used as covariates in subsequent analyses. Significant group differences were found on 12 of 29 outcome variables, including measures of autonomic, motor, state, attention/interaction, and self-regulatory systems, as well as a measure of overall behavioral organization. Pairwise comparison showed that preterm and full-term infants differed on all 12 variables whereas preterm and close to full-term infants differed on 11 of the 12 variables. Furthermore, full-term and close to full-term infants differed on 4 of the 12 variables, including measures of the autonomic, motor, and state systems. Full-term and close to full-term infants were behaviorally more similar to one another than either group was to the preterm infants, yet there were important differences even between full-term and close to full-term infants.
Article
In this exploratory study we examined the contribution of biologic and experiential conditions to the pattern of growth in weight for premature and full-term infants. The three components of the pattern were: (a) the infant's weight level; (b) the linear growth rate; and (c) the quadratic growth rate. Biologic conditions were maturity at birth and gender. Experiential conditions included variables in the mother's caregiving and the infant's feeding behavior, nutrient intake, and acuity of illness. At 1, 4, 8, and 12 months, premature infants (n = 61) weighed significantly less than full-term infants (n = 53), but neither linear nor quadratic rates of weight gain were significantly different from the rates for the full-term infants. Multilevel analytic models showed that female gender significantly affected weight level and linear and quadratic growth rates. Negative affect and behavior in both the mother and the infant significantly increased the linear rate of weight gain. The interaction of several experiential conditions with the two biologic conditions, birth maturity and gender, affected growth outcomes. Further exploration of the model with a larger sample is indicated to enable simultaneous testing of biologic and experiential conditions.
Article
This study determined whether an auditory, tactile, visual, and vestibular intervention (ATVV) reduced the length of hospitalization of 37 preterm infants by increasing the proportion of alert behavioral states, thereby improving their feeding progression. Participants comprised 12 infants born between 23 and 26 weeks' gestation with normal head ultrasounds and 25 CNS-injured infants born between 23 and 31 weeks' gestation. Infants were randomly assigned to the control group (11 males, five females) or study group (seven males, 14 females) at 32 weeks' postconceptional age. ATVV intervention was administered to the study group for 15 minutes, twice daily, 5 days per week, from 33 weeks of age until discharge. The study group demonstrated increased alertness during the first 5 minutes of intervention, which was significantly correlated to length of stay (p<0.05). The proportion of nippled (teat) intake increased significantly faster for the study group (p=0.0001). Infants in the study group were discharged at a mean of 36.54 weeks, 1.6 weeks earlier than control infants (p<0.05). ATVV intervention facilitated increased alertness, faster transition to complete nipple feeding, and decreased length of hospitalization.
Feeding readiness behavior in preterm infants (Abstract)
  • J Cagan
Cagan, J. (1995). Feeding readiness behavior in preterm infants (Abstract). Neonatal Network, 14(2), 82.