Effects of prefeeding oral stimulation on feeding performance of preterm infants

Objective  

To investigate the effects of a prefeeding oral stimulation program on the feeding performance of preterm infants.     

Interventions to improve the oral feeding performance of preterm infants

Aim: Preterm infants have difficulty oral feeding. We hypothesized that a specific sucking and swallowing exercises vs. no intervention accelerate the attainment of independent oral feeding through a faster maturation of infants’ oral feeding skills (OFS). Methods: Very low birthweight infants were randomized to a control, sucking and swallowing groups. Sucking consisted of active sucking on a pacifier, and swallowing of placing a milk bolus (0.05–0.2 mL) on the tongue where the bolus rests prior to entering the pharynx. Primary outcome was days from start to independent oral feeding (SOF‐IOF). Secondary outcomes included overall transfer (OT, % volume taken/volume prescribed), proficiency (PRO, % volume taken at 5 min/volume prescribed), rate of transfer (RT, mL/min) over the entire feeding and infants’ OFS levels. OFS levels were defined by PRO and RT. Results: Days from SOF to IOF vs controls (21 ± 2) were similar for the sucking group (19 ± 2) and shorter for the swallowing group (15 ± 2; p = 0.019). Only the latter infants demonstrated more mature OFS levels than controls. Conclusion: The swallowing exercise is an efficacious intervention in facilitating the attainment of independent oral feeding, but not the sucking exercise. We speculate that the swallowing benefit resulted from an accelerated maturation of infants’ OFS levels.     

Effects of pre-feeding oral stimulation on oral feeding in preterm infants: A randomized clinical trial

Objective

To evaluate the effect of early oral stimulation before the introduction of oral feeding, over the duration of concomitant tube feeding (“transition period”), the length of hospital stay and the breastfeeding rates upon discharge in preterm infants.

Study design

Preterm infants born between 26 and 33 weeks gestational age (n = 86), were randomized into an intervention and control group. Infants in the intervention group received an oral stimulation program consisting in stimulation of the oral structures for 15 min at least for 10 days, before introduction of oral feeding. Oral feeding was introduced at 34 weeks GA in both groups.

Results

Breastfeeding rates upon discharge were significantly higher in the intervention than in the control group (70% versus 45.6%, p = 0.02). There was no statistical difference between the two groups in terms of the length of the transition period or the length of the hospital stay.The need for prolonged CPAP support (HR = 0.937, p = 0.030) and small size for gestational age at birth (HR = 0.338, p = 0.016) were shown to be risk factors for a prolonged transition period.

Conclusion

A pre-feeding oral stimulation program improves breastfeeding rates in preterm infants. The study results suggest that oral stimulation, as used in our specific population, does not shorten the transition period to full oral feeding neither the length of hospital stay.     

Decreased ventilation in preterm infants during oral feeding

As respiratory difficulty may accompany nipple feeding in preterm neonates, we studied the effect of oral feeding on ventilation in 23 preterm infants. The infants composed two groups based on their postconceptional age at the time of study: Group A comprised 12 infants 34 to 35.9 weeks of age, and group B, 11 infants 36 to 38 weeks. Ventilation was measured via a nasal mask pneumotachometer, and sucking pressure via a nipple that also permitted milk delivery; transcutaneous PO2 and PCO2 were continuously monitored. The feeding pattern comprised an initial period of continuous sucking of at least 30 seconds, followed by intermittent sucking bursts for the remainder of the feed. When compared with an initial semi-upright control period, minute ventilation (V1) during continuous sucking fell by 52 +/- 6% (P less than 0.001) and 40 +/- 2% (P less than 0.001) in groups A and B, respectively. This was the result of a decrease in respiratory frequency and tidal volume and was associated with a fall in TcPO2 of 13 +/- 4 mm Hg (P less than 0.01) in group A and 10 +/- 2 mm Hg (P less than 0.01) in group B. During intermittent sucking, V1 and TcPO2 recovered partially only in the more mature infants (group B). At the end of the feed, TcPCO2 have risen by 3 +/- 1 mm Hg (P less than 0.001) in group A and by 2 +/- 2 mm Hg (P less than 0.05) in group B. Thus oral feeding results in an impairment of ventilation during continuous sucking and the subsequent recovery during intermittent sucking is dependent on postconceptional age.     

Maturation of oral feeding skills in preterm infants

AIM: Safe and successful oral feeding requires proper maturation of sucking, swallowing and respiration. We hypothesized that oral feeding difficulties result from different temporal development of the musculatures implicated in these functions. METHODS: Sixteen medically stable preterm infants (26 to 29 weeks gestation, GA) were recruited. Specific feeding skills were monitored as indirect markers for the maturational process of oral feeding musculatures: rate of milk intake (mL/min); percent milk leakage (lip seal); sucking stage, rate (#/s) and suction/expression ratio; suction amplitude (mmHg), rate and slope (mmHg/s); sucking/swallowing ratio; percent occurrence of swallows at specific phases of respiration. Coefficients of variation (COV) were used as indices of functional stability. Infants, born at 26/27- and 28/29-week GA, were at similar postmenstrual ages (PMA) when taking 1-2 and 6-8 oral feedings per day. RESULTS: Over time, feeding efficiency and several skills improved, some decreased and others remained unchanged. Differences in COVs between the two GA groups demonstrated that, despite similar oral feeding outcomes, maturation levels of certain skills differed. CONCLUSIONS: Components of sucking, swallowing, respiration and their coordinated activity matured at different times and rates. Differences in functional stability of particular outcomes confirm that maturation levels depend on infants' gestational rather than PMA.     

A feeding protocol for healthy preterm infants that shortens time to oral feeding

OBJECTIVE: To test the hypothesis that healthy preterm infants randomly assigned to a semi-demand feeding protocol would require fewer days to attain oral feeding and have a satisfactory weight gain compared with control infants receiving standard care. STUDY DESIGN: In 2 neonatal intensive care nurseries, 81 infants 32 to < or = 34 weeks' postconceptional age were randomly assigned to the control (n = 41) or experimental (n = 40) protocol for transition from gavage to oral feedings. The control protocol followed the standard practice of gradually increasing scheduled oral feedings, whereas the experimental protocol used a semi-demand feeding method contingent on infant behavior. Analysis of variance techniques were used to compare the study groups for number of days to attain oral feeding and weight gain. RESULTS: The semi-demand method shortened the time for infants to achieve oral feeding by 5 days (P < .001). There were no differences in weight gain between the study groups, and both groups had satisfactory weight gain. CONCLUSION: The semi-demand method for the transition from gavage to oral feeding in healthy, preterm infants 32 to < or = 34 weeks postconceptional age promotes faster attainment of oral feeding and does not compromise their weight gain.     

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

The ability of a preterm infant to make the transition from gavage to oral nipple feeding depends on the infant's neurodevelopment in relation to behavioral organization, to a rhythmic suck-swallow-breathe pattern, and to cardiorespiratory regulation. Research-based knowledge about infant neurodevelopment in these three areas has led to the creation of a semidemand feeding method to aid in this transition. The method combines the use of nonnutritive sucking to promote awake behavior for feeding, use of behavioral assessment to identify readiness for feeding, and systematic observation of and response to infant behavior cues to regulate frequency, length, and volume of oral feedings. Semidemand feeding may be individualized for healthy preterm infants. This article discusses both the relevant knowledge about neurodevelopment and the semidemand feeding method itself.     

Alae nasi activation in preterm infants during oral feeding.

Preterm infants may demonstrate impaired ventilation during oral feeding with resultant hypoxemia and hypercarbia. This study was designed to determine whether infants activate a representative upper airway muscle, the ala nasi, in response to these ventilatory changes. Ten preterm infants (postconceptional age at study 35 +/- 4 wk, weight 2.2 +/- 0.1 kg) were studied during a control period, continuous feeding, subsequent intermittent feeding, and a period of nonnutritive sucking. Nasal airflow was measured with a pneumotachometer to quantify minute ventilation. The alae nasi electromyogram (EMGAN) was recorded with surface electrodes, and sucking pressure was detected by a catheter in the feeding nipple. End-tidal CO2 and O2 saturation were also recorded during each period. The percentage of breaths associated with EMGAN activity increased from 41 +/- 13% during the control period to 95 +/- 5% and 93 +/- 7% during continuous and intermittent sucking, respectively (p < 0.05). Eighty-seven +/- 5% of EMGAN activity occurred during inspiration. During continuous and intermittent sucking, the amplitude of EMGAN activity also increased (6.8 +/- 5.2 and 6.7 +/- 4.0 arbitrary units/breath, respectively) compared with the control period (2.4 +/- 2.8 units/breath, p < 0.05). In association with the increase in EMGAN activity, O2 saturation fell from 98 +/- 1% in the control period to 95 +/- 1% during both continuous and intermittent feeding (p < 0.05), and minute ventilation fell from 274 +/- 80 mL/min/kg during the control period to 190 +/- 81 and 208 +/- 57 mL/min/kg during continuous and intermittent feeding, respectively (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Aseptic sialadenitis in preterm infants associated with long-term oro-gastric tube feeding

Sialadenitis is a rare disease in the newborn and the pathogenesis in this age group is not fully understood. We report five cases of neonatal sialadenitis in stable preterm, gavage-fed infants at 2 to 6 weeks postnatal age. The occurrence of sialadenitis was observed in temporal relation to changes in enteral feeding routines in the unit which were initiated with the objective of promoting full breast feeding at discharge. Clinical presentation consisted of a tender palpable mass over one of the salivary glands, low-grade (37.5–38.3°C) fever in conjunction with clinical malaise. C-reactive protein and white blood cell count were only moderately elevated. No suppuration from salivary ducts was present. Bacterial cultures were invariably negative. Viral investigations were not carried out. Aseptic sialadenitis was suggested as the cause of the symptoms. The clinical course was benign and the local tender mass over the salivary gland vanished shortly after intravenous fluids and antibiotics were started. Conclusion Long-term exclusive oro-gastric feeding may result in reduced reflex salivary gland stimulation, saliva production and hence ductal clearance of mucoid saliva, leading to functional ductal obstruction and local inflammation.     

Preterm oral feeding scale to assist in deciding initial oral feeding of preterm infants in neonatal intensive care units

BackgroundThe inconsistency in decisions to commence oral feeding indicates that health professionals require clearer guidelines to determine when to initiate oral feeding in preterm infants. This study applied the Taiwan version of Preterm Oral Feeding Readiness Assessment Scale (TW-POFRAS) to clinical decision-making, especially for preterm infants with a birth weight less than 1,500 g or gestational age (GA) less than 32 weeks.MethodsThis was a single-center observational cross-sectional study and 81 preterm infants were recruited. Lengths of stay from admission to initial one-meal oral feeding, to one-day all-meal oral feeding, and to discharge were analyzed. Scale scores, physician orders, and smooth oral intake of 5 mL of milk were analyzed. Kappa coefficients were examined to determine concordances within the results.ResultsAt least moderate concordance was evident (k = 0.492). Most preterm infants can begin to consume one meal of the least 5 mL of milk smoothly and proceed to consume a full day of meals with a week; they are typically discharged from the hospital within a month, except for those with a birth weight less than 1,500 g or a GA less than 32 weeks. For 17 of 81 participants, assessment results for physician orders, 5-mL milk consumption, and scale scores were inconsistent. Participants with a birth weight less than 1,500 g or GA less than 32 weeks were able to meet the 5-mL standard by the postmenstrual age of 35 weeks, at latest.ConclusionWe recommend that TW-POFRAS should be used in conjunction with physicians’ clinical decision-making for oral feeding readiness for preterm infants in the NICU.     

Patterned orocutaneous therapy improves sucking and oral feeding in preterm infants

AIM: To determine whether NTrainer patterned orocutaneous therapy affects preterm infants' non-nutritive suck and/or oral feeding success. SUBJECTS: Thirty-one preterm infants (mean gestational age 29.3 weeks) who demonstrated minimal non-nutritive suck output and delayed transition to oral feeds at 34 weeks post-menstrual age. INTERVENTION: NTrainer treatment was provided to 21 infants. The NTrainer promotes non-nutritive suck output by providing patterned orocutaneous stimulation through a silicone pacifier that mimics the temporal organization of suck. METHOD: Infants' non-nutritive suck pressure signals were digitized in the NICU before and after NTrainer therapy and compared to matched controls. Non-nutritive suck motor pattern stability was calculated based on infants' time- and amplitude-normalized digital suck pressure signals, producing a single value termed the Non-Nutritive Suck Spatiotemporal Index. Percent oral feeding was the other outcome of interest, and revealed the NTrainer's ability to advance the infant from gavage to oral feeding. RESULTS: Multilevel regression analyses revealed that treated infants manifest a disproportionate increase in suck pattern stability and percent oral feeding, beyond that attributed to maturational effects alone. CONCLUSION: The NTrainer patterned orocutaneous therapy effectively accelerates non-nutritive suck development and oral feeding success in preterm infants who are at risk for oromotor dysfunction.     

Systematic review of transpyloric versus gastric tube feeding for preterm infants

AIM: To determine if enteral tube feeding by the transpyloric versus the gastric route improves feeding tolerance, and growth and development, without increasing adverse events, in preterm infants. METHODS: Systematic review of randomised controlled trials. A search was made of the Cochrane Controlled Trials Register (CCTR; 2003, issue 1), Medline (1966 to April 2003), and Embase (1980 to April 2003), and references in previous reviews. The data were extracted, analysed, and synthesised using the standard methods of the Cochrane Neonatal Collaborative Review Group. RESULTS: Data were found from eight trials. No evidence of an effect on growth or development was found, but transpyloric feeding was associated with a greater incidence of gastrointestinal disturbance: relative risk (RR) 1.45, 95% confidence interval (CI) 1.05 to 2.09. Transpyloric feeding was also associated with increased mortality: RR 2.46, 95% CI 1.36 to 4.46. However, the trial that contributed most to this finding may have been affected by allocation bias. No significant differences were detected in the incidence of other adverse events, including necrotising enterocolitis, intestinal perforation, and aspiration pneumonia. CONCLUSIONS: No evidence of benefit was found, but evidence of harm was found. Feeding by the transpyloric route cannot be recommended for preterm infants.