Effects of non-nutritive sucking on nutritive sucking, breathing, and behavior during bottle feedings of preterm infants

Effect of premature infant oral motor intervention (PIOMI) and pacifier intervention on the transition to oral feeding in preterm infants: A randomized controlled study

AIM

This study aimed to evaluate the effect of premature infant oral motor intervention (PIOMI) and pacifier intervention on the transition to full oral feeding in preterm infants.

METHODS

This is a randomized controlled trial conducted between January 2021 and April 2023 in a neonatal intensive care unit in Eskişehir, Turkey. Preterm infants born between 29 and 34 weeks of gestation were included in the study. Infants were assigned to the groups by stratified randomization method. The study was completed with a total of 39 infants, 13 infants in each group (PIOMI, pacifier, and control). Data were collected using the "Preterm Infant Demographic Information Form," "Feeding Monitor Form," and "Early Feeding Skills Assessment Tool (EFS)." Statistical analysis used paired sample t-tests, ANOVA, Wilcoxon, Kruskal-Wallis H, and Pearson-χ2 test methods.

RESULTS

In the research findings, it was determined that infants receiving PIOMI and pacifier intervention had a shorter length of stay, transition to full oral feeding compared to infants in the control group, and consumed a higher amount of feed in the first minute (p < .05). The infants in the PIOMI group started full oral feeding on average 3 days earlier than the infants in the pacifier group and were discharged approximately 4 days earlier (p > .05). It was determined that infants in the PIOMI group had significantly higher EFS-total compared to infants in the control group.

CONCLUSIONS

PIOMI intervention and pacifier intervention should be included in nursing care in neonatal intensive care units to improve the oral feeding skills of preterm infants and shorten their discharge time.

Exploration of the Association Between Sucking Measures and Ability to Attain Independent Oral Feeds Among Infants Who Are Born Preterm

IMPORTANCE

Infants who are born preterm often experience difficulty transitioning from full tube to independent oral feeds, which often prolongs their hospital stay. No clinical measures associated with attainment of independent oral feeds are currently available.

OBJECTIVE

To identify specific nutritive sucking measures associated with time to attainment of independent oral feeds among infants who are born preterm.

DESIGN

An observational cohort pilot study was undertaken.

SETTING

A Level 2 to Level 3 neonatal intensive care unit.

PARTICIPANTS

Fourteen infants (7 male, 7 female) born at or less than 34 wk gestation were enrolled.

OUTCOMES AND MEASURES

The monitored suck measures included average suck strength (millimeters of mercury), average sucking burst duration (seconds), average suck count (number of sucks), and average pause duration (seconds). Time to independent oral feeds (days) and baseline characteristics were also monitored. The nutritive sucking measures were recorded once, during the first 5 min of an oral feed, when infants were taking an average of three to four oral feeds per day using a nipple monitoring device.

RESULTS

An inverse relation was found among average suck burst duration (p = .04), gestational age (p = .03), and days to attainment of independent oral feeds.

CONCLUSIONS AND RELEVANCE

Study results suggest that average sucking burst duration, during the first 5 min of an oral feed, is associated with time to attain independent oral feeds. Plain-Language Summary: Sucking burst duration is a simple measure that may be used clinically to identify early on infants who may have trouble transitioning from full tube to independent oral feedings. The results of this study suggest that a suck burst duration in the first 5 min of an oral feeding is inversely associated with the length of time to achieve independent oral feeding. The results highlight the importance of considering an infant's nutritive sucking ability when evaluating their potential to achieve independent oral feedings.

Quantitative non-nutritive sucking measurement as a predictor of oral feeding readiness in newborns

Background and purpose

The purpose of this study is to examine the relationship between the parameters of a silver nanowire-based flexible pressure sensor developed to measure the non-nutritive sucking (NNS) performance and predict the nutritive sucking status in preterm infants.

Methods

Preterm infants who were referred for feeding difficulty during the transition period from tubal feeding to oral feeding were enrolled in our study. A flexible pressure sensor was used to measure the non-nutritive sucking parameters of neonates. The evaluator stimulated the infants' lips and tongue with a pacifier integrated with a sucking pressure sensor, to check whether non-nutritive sucking had occurred. When the sucking reflex was induced, it was measured. The infants' sucking characteristics were subdivided into classifications according to the NOMAS criteria and full oral feeding (FOF) status. Quantitative NNS measurement according to the feeding state was compared between groups.

Results

When comparing the quantitative NNS measurement by feeding characteristics, the average sucking pressure was significantly higher in infants in the FOF capable group than those in the incomplete FOF group. In addition, the maximum and average sucking pressure was significantly higher in infants with a normal sucking pattern compared to those with a disorganized sucking pattern. The average NNS pressure was divided over the range of 0-3 kPa and the same weight was assigned to each item. When the optimal cut-off value for the sensitivity and specificity of the average NNS pressure to estimate the FOF was set, a pressure of 1.5 kPa yielded the highest sensitivity (84.62%) and specificity (67.65%) on the receiver operating characteristic (ROC) curve. The area under the curve (AUC) was 0.786, and this result was statistically significant.

Conclusions

This study presents a quantitative parameter for non-nutritive sucking in preterm infants with the use of a flexible pressure sensor. Results show possible quantitative indicators that can aid in predicting when preterm infants can transition to oral feeding and their prognosis. This will serve as a basis for future research on determining the feeding transition period of newborns with health conditions that affect oral feeding.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' post-menstrual age (PMA)) 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. This is an update of our 2016 review.

OBJECTIVES

To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA.

SEARCH METHODS

Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis.

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 (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

Following the updated search, two review authors screened the titles and abstracts of studies and full-text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided 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

We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) -4.07 days, 95% confidence interval (CI) -4.81 to -3.32 days, 6 studies, 292 infants; I2 =85%, very low-certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD -4.33, 95% CI -5.97 to -2.68 days, 5 studies, 249 infants; i2 =68%, very low-certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non-oral intervention Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non-oral intervention (MD -7.17, 95% CI -8.04 to -6.29 days, 10 studies, 574 infants; I2 =80%, very low-certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD -6.15, 95% CI -8.63 to -3.66 days, 10 studies, 591 infants; I2 =0%, low-certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD -2.85, 95% CI -6.13 to 0.42, 3 studies, 268 infants; very low-certainty evidence due to serious risk of bias, inconsistency and imprecision).

AUTHORS' CONCLUSIONS

There remains uncertainty about the effects of oral stimulation (versus either standard care or a non-oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta-analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions.

Non-Pharmacological and Non-Surgical Feeding Interventions for Hospitalized Infants with Pediatric Feeding Disorder: A Scoping Review

Infants born prematurely or with complex medical conditions often require treatment to facilitate safe and efficient feeding. Practice is based on evidence, so frontline clinicians look to the literature to make informed clinical decisions. The aim of this scoping review was to map and describe the literature base for infant feeding and swallowing interventions and to identify areas for further research. Four electronic databases were searched from the sources' inceptions through April 2020 using a search strategy designed by a health sciences research librarian. Thirteen grey literature sources were searched and forward and backward citation chasing was performed. Inclusion criteria were English-language studies reporting non-pharmacological and non-surgical interventions for hospitalized infants. Exclusion criteria included interventions exclusively for infants with cleft lip or palate or for infants being fed exclusively though enteral feeding. Data were extracted using a form created a priori and data were reported descriptively. We reviewed 6654 abstracts: 725 were chosen for full-text review and 136 met inclusion. Most studies explored interventions for infants born prematurely (n = 128). Studies were stratified by intervention domain: bridging (n = 91) and feeding/swallowing (n = 45); intervention approach: direct (n = 72), indirect (n = 31), or combination (n = 33); and outcome: feeding performance (n = 125), physiologic stability (n = 40), and swallowing physiology (n = 12). The body of research in infant feeding has grown; however, a need remains for research focused on populations of infants with various medical complexities and for frequently used interventions that lack supporting evidence.

Nonnutritive Sucking Before Oral Feeding of Preterm Infants in Turkey: A Randomized Controlled Study

BACKGROUND

The use of a pacifier is recommended to support sucking reflex during transition from gavage feeding to oral feeding and ensure readiness for feeding.

PURPOSE

A randomized controlled experimental design was used to determine the effect of a pacifier given before feeding on physiological characteristics and feeding performance in preterm infants initially fed orally.

DESIGN AND METHODS

The data were obtained from preterm infants (N = 72) born before 31st gestational week, who were admitted to Newborn Intensive Care Unit of a training and research hospital affiliated with Ministry of Health between January 2017-July 2018 and met the case selection criteria. Heart rates, oxygen saturation levels and feeding performances of preterm infants in both groups before, during, and after feeding were compared.

RESULTS

Heart rates of preterm infants in the experimental group were statistically significantly lower (Experimental: 139.64 ± 10.16; Control: 149.31 ± 8.40; p < 0.01) and their oxygen saturation levels were higher (Experimental: 97.22 ± 2.22; Control: 96.33 ± 1.93; p < 0.05). Feeding efficiency rates (Experimental: 1.94 ± 1.19; Control: 0.69 ± 0.34; p < 0.01) and the percentage of food intake (Experimental: 89.5 ± 23.93; Control: 70.86 ± 27.41; p < 0.01) of newborns in the experimental group were statistically significantly higher and their feeding duration was shorter (Experimental: 10.58 ± 8.29; Control: 16.14 ± 8.31; p < 0.01).

CONCLUSIONS

It was determined that a pacifier given before feeding is effective on regulating physiological parameters and supporting feeding performance in preterm infants.

PRACTICE IMPLICATIONS

The use of a pacifier in the first transition to oral feeding in preterm infants supports their sucking reflex, calms them down, and ensures the readiness for feeding.

Abnormal Nutritive Sucking as an Indicator of Neonatal Brain Injury

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

A silver nanowire-based flexible pressure sensor to measure the non-nutritive sucking power of neonates

Preterm infants are prone to have higher risks of morbidity, disability and developmental delay compared to term infants. The primitive reflexes, inborn behaviors found in early life development, are shown to be a good tool to assess the integrity of the central nervous system of infants and to predict potential malfunctions. Among these reflexes, the non-nutritive sucking reflex plays an important role in indicating congenital abnormalities in brain development and feeding readiness, especially for premature infants. Conventionally, pediatricians evaluate the oral sucking power qualitatively based on their experiences, by using a gloved finger put inside the infant’s mouth. Thus, more quantitative solutions to assess the sucking power of preterm infants are necessary to support healthcare professionals in their evaluation procedures. Here, we developed a silver nanowire (AgNW)-based flexible pressure sensor to measure the non-nutritive sucking power of infants. The flexible sensor was fabricated using silver nanowires deposited on polydimethylsiloxane (PDMS) in a sandwich-like structure. The sensor based on the principle of strain gauge was attached to a ring-shaped connecting module, and then to a pacifier. The negative sucking pressure exerted by the infant deformed the sensor membrane, causing its electrical resistance to change without any contact between the infant’s mouth and the sensing element. The fabricated sensor was characterized and optimized to achieve both the suitable sensitivity and stability. Thanks to the excellent long-term electro-mechanical stability and high sensitivity, the developed sensor is expected to provide the means to quantitatively assess the non-nutritive sucking of infants, with a portable, low-cost, non-invasive and light-weight solution.

A Multidisciplinary Approach to Pediatric Feeding Disorders: Roles of the Speech-Language Pathologist and Behavioral Psychologist

Purpose Pediatric feeding disorders (PFDs) present as a complex clinical challenge because of the heterogeneous underlying etiologies and their impact on health, safety, growth, and psychosocial development. A multidisciplinary team approach is essential for accurate diagnosis and prompt interventions to lessen the burdens associated with PFDs. The role of the speech-language pathologist (SLP) as a member of the multidisciplinary team will be highlighted. Method This clinical focus article reviews the definition of PFDs and pertinent literature on factors that contribute to the development of PFDs, the accurate diagnosis, and current interventions for infants and children. As part of the multidisciplinary team, the SLP has an integral role in determining whether a child cannot or will not eat and working with the team to identify and carryout appropriate interventions. Collaboration between SLPs and psychologists/behavioral specialists in conjunction with the parents/caregivers as part of the multidisciplinary team is essential to the advancement of therapeutic goals. Conclusions Due to their complex nature, the successful management of PFDs is only possible with the care and expertise of a multidisciplinary team, which includes parents/caregivers. SLPs are important members of these multidisciplinary teams and provide valuable input for the accurate identification and effective remediation of PFDs.

Early Intervention to Improve Sucking in Preterm Newborns: A Systematic Review of Quantitative Studies

BACKGROUND

Premature birth is associated with feeding difficulties due to inadequate coordination of sucking, swallowing, and breathing. Nonnutritive sucking (NNS) and oral stimulation interventions may be effective for oral feeding promotion, but the mechanisms of the intervention effects need further clarifications.

PURPOSE

We reviewed preterm infant intervention studies with quantitative outcomes of sucking performance to summarize the evidence of the effect of interventions on specific components of sucking.

METHODS

PubMed, CINAHL, MEDLINE, EMBASE, and PSYCOLIST databases were searched for English language publications through August 2017. Studies were selected if they involved preterm infants, tested experimental interventions to improve sucking or oral feeding skills, and included outcome as an objective measure of sucking performance. Specific Medical Subject Headings (MeSH) terms were utilized.

RESULTS

Nineteen studies were included in this review: 15 randomized, 1 quasi-randomized, and 3 crossover randomized controlled trials. Intervention types were grouped into 6 categories (i) NNS, (ii) NNS with auditory reinforcement, (iii) sensorimotor stimulation, (iv) oral support, (v) combined training, and (vi) nutritive sucking. Efficiency parameters were positively influenced by most types of interventions, though appear to be less affected by trainings based on NNS alone.

IMPLICATIONS FOR PRACTICE

These findings may be useful in the clinical care of infants requiring support to achieve efficient sucking skills through NNS and oral stimulation interventions.

IMPLICATIONS FOR RESEARCH

Further studies including quantitative measures of sucking performance outcome measures are needed in order to best understand the needs and provide more tailored interventions to preterm infants.

Effect of Unimodal and Multimodal Sensorimotor Interventions on Oral Feeding Outcomes in Preterm Infants: An Evidence-Based Systematic Review

BACKGROUND

Preterm infants often experience difficulty with the transition from tube to oral feeding. While many unimodal and multimodal sensorimotor interventions have been generated to optimize oral feeding skills, there has been little cohesion between interventions.

PURPOSE

The aims of this systematic review were to examine the effect of sensorimotor interventions on oral feeding outcomes and to determine whether multimodal interventions lead to better oral feeding performances than unimodal interventions.

SEARCH STRATEGY

A systematic search of CINAHL, Embase, MEDLINE, and PsycINFO databases was conducted. Studies were reviewed to assess the types of interventions used to improve transition to full oral feeding, volume intake, weight gain, and length of hospital stay.

RESULTS

The search identified 35 articles. Twenty-six studies examined a unimodal intervention, with the majority focusing on oral sensorimotor input and the others on tactile, auditory, and olfactory input. Nine studies assessed multimodal interventions, with the combination of tactile and kinesthetic stimulation being most common. Results varied across studies due to large differences in methodology, and caution is warranted when interpreting results across studies. The heterogeneity in the studies made it difficult to make any firm conclusions about the effects of sensorimotor interventions on feeding outcomes. Overall, evidence on whether multimodal approaches can lead to better oral feeding outcomes than a unimodal approach was insufficient.

IMPLICATIONS FOR PRACTICE

The use of sensorimotor interventions to optimize feeding outcomes in preterm infants varies based on methods used and modalities. These factors warrant caution by clinicians who use sensorimotor interventions in the neonatal intensive care unit.

IMPLICATIONS FOR RESEARCH

Large randomized clinical trials using a standardized approach for the administration of sensorimotor input are needed to further establish the effects on feeding outcomes in preterm infants.

The Relationship Between Behavioral States and Oral Feeding Efficiency in Preterm Infants

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 (β = .76, F = 11.29, P ≤ .05), sleep states (β = -1.08, F = 25.26, P ≤ .05), and crying (β = 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.

Effects of pacifier use on transition to full breastfeeding and sucking skills in preterm infants: a randomised controlled trial

AIMS AND OBJECTIVES

To determine the effects of pacifier use on transition to full breastfeeding and sucking skills in preterm infants.

BACKGROUND

Feeding problems in preterm infants cause delays in hospital discharge, extend mother-infant reunification and increase medical cost. Nutritive sucking skills of preterm infants may develop by improving non-nutritive sucking skills and increasing sucking experiences.

DESIGN

A prospective, randomised controlled trial conducted in the Eastern Turkey.

METHODS

Seventy infants were randomised into two groups: a pacifier group (n = 34) and a control group (n = 36). Pacifier use was applied in the preterm infants in the pacifier group, up to switching to full breastfeeding. The infants in the control group did not use pacifiers. Data were collected by a researcher using the Preterm Infant Introductory Information Form, the Preterm Infant Monitoring Form and the LATCH Breastfeeding Assessment Tool. For the study, ethics committee approval, official permission and written informed consents of the families were obtained.

RESULTS

The time to transition to full breastfeeding (123·06 ± 66·56 hours) and the time to discharge (434·50 ± 133·29 hours) in the pacifier group were significantly shorter compared to the control group (167·78 ± 91·77 and 593·63 ± 385·32 hours, respectively) (p < 0·05). The weight at transition to full breastfeeding (1944·12 ± 275·67 g) and the weight of discharge (1956·45 ± 268·04 g) in the pacifier group were significantly lower compared to the control group (2155·58 ± 345·57 and 2159·75 ± 341·22 g, respectively) (p < 0·05). Sucking skills of the infants in the pacifier group at 48 hours after transition to oral feeding and before the discharge was better than in the control group (p < 0·05).

CONCLUSION

Pacifier use improved the sucking skills and shortened the time to transition to full breastfeeding and to discharge in preterm infants receiving complementary feeding.

RELEVANCE TO CLINICAL PRACTICE

Pacifier use may be recommended to accelerate transition to full breastfeeding and to improve the sucking skills in preterm infants who were fed by both oral route and complementary feeding in the neonatal intensive care units.

Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants

BACKGROUND

Non-nutritive sucking (NNS) is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants to improve the development of sucking behavior and the digestion of enteral feedings.

OBJECTIVES

To assess the effects of non-nutritive sucking on physiologic stability and nutrition in preterm infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016), and CINAHL (1982 to 25 February 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials that compared non-nutritive sucking versus no provision of non-nutritive sucking in preterm infants. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported mean differences (MD) for continuous data, with 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses. We did not perform subgroup analyses because of the small number of studies related to the relevant outcomes. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We identified 12 eligible trials enrolling a total of 746 preterm infants. Meta-analysis, though limited by data quality, demonstrated a significant effect of NNS on transition from gavage to full oral feeding (MD -5.51 days, 95% CI -8.20 to -2.82; N = 87), transition from start of oral feeding to full oral feeding (MD -2.15 days, 95% CI -3.12 to -1.17; N = 100), and the length of hospital stay (MD -4.59 days, 95% CI -8.07 to -1.11; N = 501). Meta-analysis revealed no significant effect of NNS on weight gain. One study found that the NNS group had a significantly shorter intestinal transit time during gavage feeding compared to the control group (MD -10.50 h, 95% CI -13.74 to -7.26; N = 30). Other individual studies demonstrated no clear positive effect of NNS on age of infant at full oral feeds, days from birth to full breastfeeding, rates and proportion of infants fully breastfeeding at discharge, episodes of bradycardia, or episodes of oxygen desaturation. None of the studies reported any negative outcomes. These trials were generally small and contained various methodological weaknesses including lack of blinding of intervention and outcome assessors and variability on outcome measures. The quality of the evidence on outcomes assessed according to GRADE was low to very low.

AUTHORS' CONCLUSIONS

Meta-analysis demonstrated a significant effect of NNS on the transition from gavage to full oral feeding, transition from start of oral feeding to full oral feeding, and length of hospital stay. None of the trials reported any adverse effects. Well-designed, adequately powered studies using reliable methods of randomisation, concealment of treatment allocation and blinding of the intervention and outcome assessors are needed. In order to facilitate meta-analysis of these data, future research should involve outcome measures consistent with those used in previous studies.

Oral stimulation for promoting oral feeding in preterm infants

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.

Non-nutritive sucking for gastro-oesophageal reflux disease in preterm and low birth weight infants

BACKGROUND

Gastro-oesophageal reflux (GOR) is commonly diagnosed in the neonatal population (DiPietro 1994), and generally causes few or no symptoms (Vandenplas 2009). Conversely, gastro-oesophageal reflux disease (GORD) refers to GOR that causes troublesome symptoms with or without complications such as damage to the oesophagus (Vandenplas 2009). Currently there is no evidence to support the range of measures recommended to help alleviate acid reflux experienced by infants. Non-nutritive sucking (NNS) has been used as an intervention to modulate neonatal state behaviours through its pacifying effects such as decrease infant fussiness and crying during feeds (Boiron 2007; Pickler 2004).

OBJECTIVES

To determine if NNS reduces GORD in preterm infants (less than 37 weeks' gestation) and low birth weight (less than 2500 g) infants, three months of age and less, with signs or symptoms suggestive of GORD, or infants with a diagnosis of GORD.

SEARCH METHODS

We performed computerised searches of the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2013), MEDLINE (1966 to September 2013), CINAHL (1982 to September 2013), and EMBASE (1988 to September 2013). We applied no language restrictions.

SELECTION CRITERIA

Controlled trials using random or quasi-random allocation of preterm infants (less than 37 weeks' gestation) and low birth weight (less than 2500 g) infants three months of age and less with signs or symptoms suggestive of GORD, or infants with a diagnosis of GORD. We included studies reported only by abstracts, and cluster and cross-over randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed and selected trials from searches, assessed and rated study quality and extracted relevant data. We identified two studies from the initial search. After further review, we excluded both studies.

MAIN RESULTS

We identified no studies examining the effects of NNS for GORD in preterm and low birth weight infants

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine the effectiveness of NNS for GORD. Adequately powered RCTs on the effect of NNS in preterm and low birth weight infants diagnosed with GORD are required.

Comparison of tongue muscle characteristics of preterm and full term infants during nutritive and nonnutritive sucking

BACKGROUND

Independent oral feeding requires coordination of suck, swallow and breathe and the lingual musculature plays a significant 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 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 tongue force between NS and NNS and FT infants did not. FT 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 feasibility 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.

Non-nutritive sucking for preterm infants in Egypt

OBJECTIVE

To assess how non-nutritive sucking (NNS) using a pacifier affected physiological and behavioral outcomes of preterm infants.

DESIGN

Short-term longitudinal, experimental design.

SETTING

The study took place at the neonatal intensive care unit at Al-Mansoura, Egypt.

METHODS

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.

RESULTS

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.

CONCLUSION

Non-nutritive sucking was found to improve physiological and behavioral responses of preterm infants.

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.

Frequency-modulated orocutaneous stimulation promotes non-nutritive suck development in preterm infants with respiratory distress syndrome or chronic lung disease

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.

Technological solutions and main indices for the assessment of newborns' nutritive sucking: a review

Nutritive Sucking (NS) is a highly organized process that is essential for infants' feeding during the first six months of their life. It requires the complex coordination of sucking, swallowing and breathing. The infant's inability to perform a safe and successful oral feeding can be an early detector of immaturity of the Central Nervous System (CNS). Even though the importance of early sucking measures has been confirmed over the years, the need for standardized instrumental assessment tools still exists. Clinicians would benefit from specifically designed devices to assess oral feeding ability in their routine clinical monitoring and decision-making process. This work is a review of the main instrumental solutions developed to assess an infant's NS behavior, with a detailed survey of the main quantities and indices measured and/or estimated to characterize sucking behavior skills and their development. The adopted sensing measuring systems will be described, and their main advantages and weaknesses will be discussed, taking into account their application to clinical practice, or to at-home monitoring as post-discharge assessment tools. Finally, the study will highlight the most suitable sensing solutions and give some prompts for further research.

State of the science: a contemporary review of feeding readiness in the preterm infant

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.

Effects of the neonatal intensive care unit environment on preterm infant oral feeding

OBJECTIVE

To examine the effect of neonatal intensive care unit environmental characteristics (perceived levels of light and sound, and time of day) in open unit wards and single-family rooms (SFRs) on oral feeding outcomes in preterm infants.

DESIGN

Data were collected at each scheduled oral feeding for 87 preterm infants from the first oral feeding until discharge. Data included the prescribed volume of feeding and the volume consumed, the infant's level of wakefulness before feeding, and the nurse's perception of light and sound.

RESULTS

Data were collected on 5111 feedings in the ward unit and 5802 in the SFR unit from feedings involving 87 preterm infants. Light and sound were rated significantly lower in the SFR (χ² = 139 and 1654.8, respectively). Feeding times of 9 am, 12 noon, and 3 pm were associated with the highest perceived levels of light and sound, regardless of unit design (P < 0.0001). Moderate light levels and feeding times of 12, 3, and 6 am were associated with improved feeding outcomes. Infants consumed a greater proportion of their prescribed feeding volume when fed in the open ward and when awake before feeding.

CONCLUSION

Further study on the clinical effects of unit design is needed, as is study on the effects of environmental stimuli, so that interventions can be appropriately developed and tailored for infants needing the most support for optimal development.

Oral-motor function and feeding intervention

This article presents the elements of the Oral Motor Intervention section of the Infant Care Path for Physical Therapy in the Neonatal Intensive Care Unit (NICU). The types of physical therapy interventions presented in this path are evidence based as well as infant driven and family focused. In the context of anticipated maturation of suck-swallow-breathe coordination, the timing and methods for initiation of oral feedings and transition from gavage to full breast or bottle-feedings are presented with supporting evidence.

Transition from gavage to nipple feeding for preterm infants with bronchopulmonary dysplasia

BACKGROUND

The transition from gavage to nipple feeding is difficult for preterm infants with bronchopulmonary dysplasia because of tachypnea and hypoxemia from chronic respiratory distress.

OBJECTIVE

The aim of this study was to test the hypothesis that preterm infants with bronchopulmonary dysplasia who transitioned from gavage to nipple feeding with the semidemand method would achieve nipple feeding sooner and be discharged from hospital sooner than control infants who received standard care.

METHODS

Forty-two infants were randomized to the control condition and 44 to the experimental protocol. Mean gestational ages and birth weights were 25 ± 1.5 weeks and 784 g for controls and 25 ± 1.4 weeks and 787 g for experimental infants. Control infants received standard care that included gradual increases in the number of nipple to gavage feedings per day. Experimental infants received the semidemand method that used infant behavioral and cardiorespiratory signs to regulate frequency, length, and volume of nipple feedings. General linear model procedures were used to compare study groups.

RESULTS

Experimental infants achieved nipple feeding at M = 5.9 ± 0.7 days compared with control infants, M = 12.3 ± 0.8 (p < .0001). Length of hospitalization was not significantly different between groups.

DISCUSSION

The semidemand method significantly shortened the time for infants to attain nipple feeding in a manner taking their respiratory distress into consideration.

The use of nonnutritive sucking to facilitate oral feeding in a term infant: a single case study

This individual case study presents an evaluation of and reflection on the use of nonnutritive sucking as a technique to facilitate nutritive sucking with an infant with feeding difficulties. Nonnutritive sucking is used in a variable way with mainly premature or sick infants. However, the rationale underpinning use of such an approach is not clear. The infant participant in this study, Baby H, was born at 37 weeks. This case illustrates the use of nonnutritive sucking as an approach with supported rationales for promoting transition toward oral feeding with infants who have complex needs and who are term infants. The literature focuses on using nonnutritive sucking with premature infants who have no additional difficulties such as hypoxic neonatal encephalopathy, meconium aspiration, sepsis, or severe perinatal asphyxia. The intervention carried out with Baby H demonstrates that nonnutritive sucking can contribute toward the management of an infant's feeding development. Baby H took 23 days to develop a sequential nonnutritive sucking pattern, but her ability to transfer this to nutritive sucking and safe feeding took the first 17 months of this infant's life. This study is unique in that it explored the issues involved with a term infant who had complex needs that impacted on feeding development. It is important because many practitioners use nonnutritive sucking with infants who have complex needs.

Evolution and development of dual ingestion systems in mammals: notes on a new thesis and its clinical implications

Traditionally, the development of oral feeding is viewed as a continuous, unitary process in which reflex-dominated sucking behavior gives rise to a more varied and volitional feeding behavior. In contrast, we consider the thesis that the infant develops two separable ingestive systems, one for suckling and one for feeding. First, we apply an evolutionary perspective, recognizing that suckling-feeding is a universal, mammalian developmental sequence. We find that in mammalian evolution, feeding systems in offspring were established prior to the evolution of lactation, and therefore suckling is a separable feature that was added to feeding. We next review an experimental literature that characterizes suckling and feeding as separable in terms of their topography, sensory controls, physiological controls, neural substrates, and experience-based development. Together, these considerations constitute a view of “dual ingestive systems.” The thesis, then, is that suckling is not a simple precursor of feeding but is a complete behavior that emerges, forms, and then undergoes a dissolution that overlaps with the emergence of independent feeding. This thesis guides us to focus differently on the challenges of properly managing and facilitating oral ingestion in infants, especially those born preterm, prior to the developmental onset of suckling.

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

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

Feeding Difficulties in Preterm Infants

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.

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

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

Nutritive sucking pattern--from very low birth weight preterm to term newborn

The contribution of maturation and stimulation to the development of oral feeding was investigated, with two main objectives: (1) to analyze the nutritive sucking pattern of very-low-birth-weight newborns from their first oral feeding to the acquisition of independent oral feeding, and (2) to compare the nutritive sucking patterns of these babies, after feeding autonomy, with healthy term newborns.

METHODS

Two groups were considered for analysis. Group 1: N=15 Very-Low-Birth-Weight (VLBW), gestacional age (GA)=28.15+/-1.5, birth weight (BW)=1178.3+/-174.4. The intervention program began at 30.19+/-1.52 weeks GA. Group 2: N=25 term newborns, healthy, GA=39.04+/-1.2, BW=3370.42+/-310.76. Repeated measures of the following variables were taken (weekly for group 1): suction efficacy (SEF), rhythm of milk transfer (RMT), suctions, bursts and pauses. Group 2 was analysed only once between the 2nd and 5th day of life.

RESULTS

Group 1 has revealed a minimal suction number at 32 GA weeks (82+/-77.6) and maximal suction number at 36-37 GA weeks (162.7+/-60.7). The number of sucks seemed to be dependent of weight (p=0.005), duration of intervention (p=0.001) and chronological age (p=0.000). Significant statistical effects of gestational age were not observed (p=0.904). Sucks in bursts represented 77% at the beginning of oral feeding (32 weeks GA), and 96% at 33 weeks GA, remaining constant thereafter. The number of sucks and bursts increased with GA and weeks of feeding. The mean duration of the pauses decreased from first to fourth week of feeding (week1=14.1+/-9.1 and week4=6.4+/-1.4 s). The sucking efficacy (SEF) was better explained by weight (p=0.000), number of sucks in 5 min (p=0.025) and chronological age (p=0.044). Gestational age (p=0.051) and nutritive intervention duration (NDI) (p=0.110) did not contribute to explain SEF. Despite the observation of significant statistical differences between groups regarding GA (35.9/39.08; p=0.00), chronological age (53.3/2.5; p=0.00) and weight (1875/3360; p=0.00), the nutritive suction pattern was not statistically different between groups after feeding autonomy.

CONCLUSION

in VLBW oral feeding before 32 weeks GA allows the attainment of a mature nutritive suction pattern before term (37-40 weeks). Experience seems to be one of the influencing factors in the change of the nutritive suction pattern.

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.

Pacifier Stiffness Alters the Dynamics of the Suck Central Pattern Generator

Variation in pacifier stiffness on non-nutritive suck (NNS) dynamics was examined among infants born prematurely with a history of respiratory distress syndrome. Three types of silicone pacifiers used in the NICU were tested for stiffness, revealing the Super Soothie™ nipple is 7 times stiffer than the Wee™ or Soothie™ pacifiers even though shape and displaced volume are identical. Suck dynamics among 20 preterm infants were subsequently sampled using the Soothie™ and Super Soothie™ pacifiers during follow-up at approximately 3 months of age. ANOVA revealed significant differences in NNS cycles/min, NNS amplitude, NNS cycles/burst, and NNS cycle periods as a function of pacifier stiffness. Infants modify the spatiotemporal output of their suck central pattern generator when presented with pacifiers with significantly different mechanical properties. Infants show a non-preference to suck due to high stiffness in the selected pacifier. Therefore, excessive pacifier stiffness may decrease ororhythmic patterning and impact feeding outcomes.

[Development of sucking rhythm and the influence of stimulation in premature infants]

BACKGROUND

The sucking development pattern of the preterm newborn (PTNB) in the neonatal period is important for an effective sucking and oral motor development. The establishment of a safe and efficient feeding in pre-term newborns is related to a rhythmic and coordinated sucking. Nonnutritive sucking stimulation can have an influence on the development of sucking and the development of sucking rhythm of pre-term newborns.

AIM

To analyze the development of the sucking rhythm, in non-nutritive and nutritive sucking in preterm newborns, as a consequence of non-nutritive sucking stimulation and in terms of corrected gestational age.

METHOD

95 preterm newborns randomly divided in three groups: Group 1, control group (35 PTNB), did not receive non-nutritive sucking stimulation; Group 2 (30 PTNB), received non-nutritive sucking stimulation using an orthodontic pacifier for premature infants (Nuk); and Group 3 (30 PTNB), received non-nutritive sucking stimulation using a gloved finger.

RESULTS

The mean gestational age was of 30.5 weeks (+/- 1.57), the mean corrected gestational age at the moment of enrollment in the study was of 31.6 weeks (+/- 1.31), and the mean birth weight was of 1.390 grams, with no statistical differences between the groups. The number of sucking bursts and pauses per minute increased by 0.16 per week and the duration of the bursts by 0.81 seconds; the duration of pauses decreased by 3.8 seconds per week while the number of sucks/second was constant, 1.15 and 0.95 for non-nutritive and nutritive sucking, respectively. No statistically significant differences were found between the groups for any of the studied variables.

CONCLUSION

The stimulation of non-nutritive suction in preterm newborns did not modify the post-natal development of sucking rhythm. The process of maturation, represented by the corrected gestational age, was considered the most responsible factor for this process.

Transitioning premature infants from gavage to breast

Breast milk provides physiologic and neurodevelopmental protection for premature infants. Most hospitals are breast-milk friendly, but the number of premature infants breastfeeding successfully at discharge is relatively small. There are evidence-based techniques to improve the odds of premature infants breastfeeding at discharge and into the first year of life. Measures that help the infant make the transition to the breast include kangaroo care, nonnutritive sucking, avoidance of bottles, and consistent and supportive staff. A guide to management of the transition process is provided in this article.

The development of potentially better practices to support the neurodevelopment of infants in the NICU

OBJECTIVE

To review the existing evidence used to identify potentially better care practices that support newborn brain development.

STUDY DESIGN

Literature review.

RESULT

Sixteen potentially better practices are identified and grouped into two operational clinical bundles based upon timing for recommended implementation.

CONCLUSION

Existing evidence supports the implementation of selected care practices that potentially may support newborn brain development.

Preliminary Ultrasound Observation of Lingual Movement Patterns During Nutritive versus Non-nutritive Sucking in a Premature Infant

Term neonates must suck, swallow, and respire in a coordinated manner during successful oral feeding. When infants are born prematurely, these skills may not be fully mature. To stimulate sucking responses, premature infants are offered pacifiers under the premise that non-nutritive sucking experiences facilitate oral feeding readiness. This case reported examined the lingual-hyoid mechanics of non-nutritive suck (NNS) patterns with a pacifier versus nutritive suck (NS) during a bottle feed in a premature infant using a noninvasive ultrasound imaging technique as a pilot to discern aspects of oral feeding candidacy. Lingual patterns during NS resulted in significantly greater displacements and excursions than NNS (p < 0.0001) in both anterior and posterior regions of the tongue (p < 0.0001). In addition, the angle of hyoid movement during NNS was significantly smaller (p < 0.05) than the angle recorded during NS tasks. Unlike an expected neonatal sucking pattern of horizontal anterior-posterior movements of the tongue body, vertical tongue body excursions occurred as described in the literature of representing a 6-9-month developmental skill level. Through the integration of semiautomatic computerized analyses of tongue surface configurations and hyoid activity, these data may enhance knowledge of oral swallowing function in developing preterm neonates.

Predictors of nutritive sucking in preterm infants

OBJECTIVE

The purposes of this analysis were to determine how select characteristics of nutritive sucking (number of sucks, sucks/burst, and sucks/minute) change over time and to examine the effect of select factors (morbidity, maturity, prefeeding behavior state, and feeding experience) on those changes.

STUDY DESIGN

A longitudinal, non-experimental study was conducted in a Level 3 neonatal intensive care unit using a convenience sample of 88 preterm infants. Statistical analyses were performed using a repeated-measures mixed-model in SAS.

RESULTS

Sucking activity (number of sucks, sucks/burst, and sucks/minute) was predicted by morbidity, maturity, feeding experience and prefeeding behavior state. Experience at oral feeding had the greatest effect on changes in the number of sucks, suck/burst and sucks/minute.

CONCLUSION

Experience at feeding may result in more rapid maturation of sucking characteristics.

Changes in sucking performance from nonnutritive sucking to nutritive sucking during breast- and bottle-feeding

Our aim was to obtain a better understanding of the differences between breast-feeding and bottle-feeding, particularly with regard to how sucking performance changes from nonnutritive sucking (NNS) to nutritive sucking (NS). Twenty-two normal term infants were studied while breast-feeding at 4 and 5 d postpartum. Five of the 22 infants were exclusively breast-fed, but we tested the other 17 infants while breast-feeding and while bottle-feeding. Before the milk ejection reflex (MER) occurs, little milk is available. As such, infants perform NNS before MER. For bottle-feeding, a one-way valve was affixed between the teat and the bottle so that the infants needed to perform NNS until milk flowed into the teat chamber. At the breast, the sucking pressure (-93.1 +/- 28.3 mm Hg) was higher during NNS compared with NS (-77.3 +/- 27.0 mm Hg). With a bottle, the sucking pressure was lower during NNS (-27.5 +/- 11.2 mm Hg) compared with NS (-87.5 +/- 28.5 mm Hg). Sucking frequency was higher and sucking duration was shorter during NNS compared with that during NS both at the breast and with a bottle. There were significant differences in the changes of sucking pressure and duration from NNS to NS between breast- and bottle-feeding. The change in sucking pressure and duration from NNS to NS differed between breast-feeding and bottle-feeding. Even with a modified bottle and teats, bottle-feeding differs from breast-feeding.

Relationship of the first suck burst to feeding outcomes in preterm infants

OBJECTIVE

This study examined the relationship between the number of sucks in the first nutritive suck burst and feeding outcomes in preterm infants. The relationships of morbidity, maturity, and feeding experience to the number of sucks in the first suck burst were also examined.

METHODS

A non-experimental study of 95 preterm infants was used. Feeding outcomes included proficiency (percent consumed in first 5 min of feeding), efficiency (volume consumed over total feeding time), consumed (percent consumed over total feeding), and feeding success (proficiency >or=0.3, efficiency >or=1.5 mL/min, and consumed >or=0.8). Data were analyzed using correlation and regression analysis.

RESULTS AND CONCLUSIONS

There were statistically significant positive relationships between number of sucks in the first burst and all feeding outcomes-proficiency, efficiency, consumed, and success (r=0.303, 0.365, 0.259, and tau=0.229, P<.01, respectively). The number of sucks in the first burst was also positively correlated to behavior state and feeding experience (tau=0.104 and r=0.220, P<.01, respectively). Feeding experience was the best predictor of feeding outcomes; the number of sucks in the first suck burst also contributed significantly to all feeding outcomes. The findings suggest that as infants gain experience at feeding, the first suck burst could be a useful indicator for how successful a particular feeding might be.

Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants

BACKGROUND

Non-nutritive sucking is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behaviour and improves digestion of enteral feedings. Non-nutritive sucking has been considered to be a benign intervention, although it has the potential to have a negative effect on breastfeeding or on the incidence of later oral aversion.

OBJECTIVES

To determine whether non-nutritive sucking (NNS) in preterm infants influences: a) weight gain, b) energy intake, c) heart rate, d) oxygen saturation, e) length of hospital stay, f) intestinal transit time, g) age at full oral feeds, or h) any other clinically relevant outcomes.

SEARCH STRATEGY

MEDLINE and CINAHL databases back to 1976 and The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005) were searched. The EMBASE database was added to the search strategy for 2005. Reference lists/bibliographies of relevant articles and reviews were also searched. A comprehensive list of relevant articles was sent to two major authors in this area. They were asked if they knew of any other published or unpublished studies relevant to the area that had not been included in the original list.

SELECTION CRITERIA

All trials utilizing experimental or quasi-experimental designs in which non-nutritive sucking in preterm infants was compared to no provision of non-nutritive sucking. Measured clinically relevant outcomes. Reports were in English or a language for which a translator was available.Computerized searches were conducted by both reviewers. All potentially relevant titles and abstracts identified by either reviewer were extracted. All retrieved articles were assessed for relevance independently by each reviewer, based on a pre-determined set of criteria. The reference lists/bibliographies of each article were reviewed independently for additional relevant titles and were also retrieved and assessed for relevance. Articles that met all relevance criteria were then assessed for methodologic quality based on a predetermined set of criteria. Those articles judged to have the appropriate quality by both reviewers were included in the analysis.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the two authors. No subgroup analyses were performed because of the small number of studies related to the relevant outcomes.

MAIN RESULTS

This review consisted of 21 studies, 15 of which were randomized controlled trials. NNS was found to decrease significantly the length of hospital stay in preterm infants. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance. No negative outcomes were reported in any of the studies.

AUTHORS' CONCLUSIONS

This review found a significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects. In view of the fact that there are no long-term data, further investigations are recommended. In order to facilitate meta-analysis of these data, future research in this area should involve outcome measures consistent with those used in previous studies. In addition, published reports should include all relevant data.