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

Effects of implementing non-nutritive sucking on oral feeding progression and outcomes in preterm infants: A systematic review and meta-analysis

BACKGROUND

Preterm infants have imperfect neurological development, uncoordinated sucking-swallowing-breathing, which makes it difficult to realize effective oral feeding after birth. How to help preterm infants achieve complete oral feeding as soon as possible has become an important issue in the management of preterm infants. Non-nutritive sucking (NNS), as a useful oral stimulation, can improve the effect of oral feeding in preterm infants. This review aimed to explore the effect of NNS on oral feeding progression through a meta-analysis.

METHODS

We systematically searched PubMed, CINHAL, Web of Science, Embase, Cochrane databases, China's National Knowledge Infrastructure (CNKI), Wanfang and VIP database from inception to January 20, 2024. Search terms included 'non-nutritive sucking' 'oral feeding' and 'premature.' Eligibility criteria involved randomized controlled studies in English or Chinese. Studies were excluded if they were reviews, case reports, or observational studies from which valid data could not be extracted or outcome indicators were poorly defined. The meta-analysis will utilize Review Manager 5.3 software, employing either random-effects or fixed-effects models based on observed heterogeneity. We calculated the mean difference (MD) and 95% confidence interval (CI) for continuous data, and estimated pooled odds ratios (ORs) for dichotomous data. Sensitivity and publication bias analyses were conducted to ensure robust and reliable findings. We evaluated the methodological quality of randomized controlled trials (RCTs) utilizing the assessment tool provided by the Cochrane Collaboration.

RESULTS

A total of 23 randomized controlled trials with 1461 preterm infants were included. The results of the meta-analysis showed that NNS significantly shortened time taken to achieve exclusive oral feeding (MD = -5.37,95%CI = -7.48 to-3.26, p<0.001), length of hospital stay(MD = -4.92, 95% CI = -6.76 to -3.09, p<0.001), time to start oral feeding(MD = -1.41, 95% CI = -2.36 to -0.45, p = 0.004), time to return to birth weight(MD = -1.72, 95% CI = -2.54 to -0.91, p<0.001). Compared to the NNS group, the control group had significant weight gain in preterm infants, including weight of discharge (MD = -61.10, 95% CI = -94.97 to -27.23, p = 0.0004), weight at full oral feeding (MD = -86.21, 95% CI = -134.37 to -38.05, p = 0.0005). In addition, NNS reduced the incidence of feeding intolerance (OR = 0.22, 95% CI = 0.14 to 0.35, p<0.001) in preterm infants.

CONCLUSION

NNS improves oral feeding outcomes in preterm infants and reduces the time to reach full oral feeding and hospitalization length. However, this study was limited by the relatively small sample size of included studies and did not account for potential confounding factors. There was some heterogeneity and bias between studies. More studies are needed in the future to validate the effects on weight gain and growth in preterm infants. Nevertheless, our meta-analysis provides valuable insights, updating existing evidence on NNS for improving oral feeding in preterm infants and promoting evidence-based feeding practices in this population.

Impact of a nurse education programme on oral feeding in a neonatal unit

BACKGROUND

Premature neonates often experience feeding difficulties during their hospital stay, and evidence-based interventions have been shown to improve feeding outcomes.

AIM

This study investigated whether an infant-cue based nurse educational feeding bundle accelerates the achievement of independent oral feeding in neonates in a neonatal intensive care unit.

STUDY DESIGN

A quality improvement study with a pre, during and post intervention test design. All premature neonates admitted to the unit were eligible. The feeding programme included a four-month nurse training module and nurse coaching.

RESULTS

A hundred and twenty-five nurses or nurse assistants attended the programme and 706 neonates were included. The median time to independent oral feeding (IOF) was 40, 36 and 37 days, respectively, for pre, during and post intervention. The reduction in time to IOF observed during the post-intervention period compared with the baseline period was significant (HR = 1.32, CI 95%: 1.01-1.74). No difference was noted in the length of hospital stay between the three study periods.

CONCLUSIONS

An infant-cue based nurse educational feeding bundle can promote earlier achievement of IOF in preterm neonates.

RELEVANCE TO CLINICAL PRACTICE

This quality improvement study demonstrates the impact that a nurse-driven intervention in neonatal care can have on improving practice. Feeding interventions involve the early introduction of oral feeding, non-nutritive sucking (NNS), and oral motor stimulation, and should be individualized for each neonate. These individualized feeding interventions applied by all nurses and assistant nurses, can facilitate the achievement of earlier independent oral feeding in preterm infants and should be included in neonatal critical care nurse education programs.

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.

Effects of Infant Driven Feeding Program on Provision of Breast Milk in Very Low Birth Weight Infants

Background: The ability to complete nipple feedings is one of the discharge criteria for most premature neonates. The Infant Driven Feeding (IDF) program suggests a system of objective promotion of oral feeds in premature infants. There is a lack of studies systematically studying the effects of IDF on the provision of breast milk. Methods: This was a retrospective study of all premature infants born before 33 weeks and birth weight of <1,500 g admitted to a level IV neonatal intensive care unit. Infants on IDF were compared with those not on IDF. Results: A total of 46 infants in the IDF group and 52 in the non-IDF group met the inclusion criteria. A higher number of infants in the IDF group breastfed at first oral attempt (54% versus 12%). Forty-five percent of IDF mothers completed a full 72 hours of protected breastfeeding at the start of oral feeds, and IDF infants had earlier removal of nasogastric (NG) tube. There was no difference in the provision of breast milk and/or breastfeeding on discharge between the two groups. There was no difference in the length of stay between the two groups. Conclusion: The IDF program attempts to streamline the promotion of oral feeds in very low birth weight infants. Higher incidence of breastfeeding at the start of oral feeds and earlier removal of NG tube did not translate into higher provision of breast milk on discharge in very low birth weight infants in the IDF group. Prospective randomized trials are needed to validate cue-based infant driven feeding programs and their effects on the provision of breast milk.

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.

Responsive Feeding for Preterm or Low Birth Weight Infants: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Responsive feeding may improve health outcomes in preterm and low birth weight (LBW) infants. Our objective was to assess effects of responsive compared with scheduled feeding in preterm and LBW infants.

METHODS

Data sources include PubMed, Scopus, Web of Science, CINAHL, LILACS, and MEDICUS. Randomized trials were screened. Primary outcomes were mortality, morbidity, growth, neurodevelopment. Secondary outcomes were feed intolerance and duration of hospitalization. Data were extracted and pooled with random-effects models.

RESULTS

Eleven eligible studies were identified, and data from 8 randomized control trials with 455 participants were pooled in the meta-analyses. At discharge, the mean difference in body weight between the intervention (responsive feeding) and comparison (scheduled feeding) was -2.80 g per day (95% CI -3.39 to -2.22, I2 = 0%, low certainty evidence, 4 trials, 213 participants); -0.99 g/kg per day (95% CI -2.45 to 0.46, I2 = 74%, very low certainty evidence, 5 trials, 372 participants); -22.21 g (95% CI -130.63 to 86.21, I2 = 41%, low certainty evidence, 3 trials, 183 participants). The mean difference in duration of hospitalization was -1.42 days (95% CI -5.43 to 2.59, I2 = 88%, very low certainty evidence, 5 trials, 342 participants). There were no trials assessing other growth outcomes (eg, length and head circumference) mortality, morbidity or neurodevelopment. Limitations include a high risk of bias, heterogeneity, and small sample size in included studies.

CONCLUSIONS

Overall, responsive feeding may decrease in-hospital weight gain. Although the evidence is very uncertain, responsive feeding may slightly decrease the duration of hospitalization. Evidence was insufficient to understand the effects of responsive compared with scheduled feeding on mortality, morbidity, linear growth, and neurodevelopmental outcomes in preterm and LBW infants.

Neonatal and Preterm Infant Growth Assessment

The needs to assess preterm infant growth clinically differ from the needs to summarize growth for research. Clinically, growth assessments are used to understand individuals' growth relative to their individual genetic potential, morbidity status and nutrition care. Growth quantification for research purposes is used to quantify growth of groups using meaningful metrics. Historically, neonatology has lacked consistency in the use of growth metrics, over-used irrelevant categories and over-diagnosed growth failure. Understanding the numerous preterm infant expected growth patterns can help identify concerning growth.

Effects of oral stimulation with breast milk in preterm infants oral feeding: a randomized clinical trial

OBJECTIVES

This study was performed to evaluate the effect of oral stimulation with breast milk for preterm infants.

METHODS

A total of 68 subjects form neonatal intensive care unit were randomly assigned into control group (n=20), premature infant oral motor intervention (PIOMI) group (n=25) and premature infant oral motor intervention with breast milk (BM-PIOMI) group (n=23).

RESULTS

BM-PIOMI group had significant shorter initiation of oral feeding (IOF) time compared to PIOMI group (2.95 days, 95% CI [0.42-5.48]) or control group (9.79 days, 95% CI [7.07-12.51]). BM-PIOMI group had significant sooner transition time from IOF to full oral feeding (FOF) compared to control group (6.68 days, 95% CI [2.2-11.16]), but not to PIOMI group (2.09 days, 95% CI [-2.07 to 6.25]). Length of hospital stay (LOS) did not show statistical different between three groups (control 38.85 ± 14.40 vs. PIOMI 38.48 ± 11.76 vs. BM-PIOMI 38.04 ± 12.2). Growth mixture model identified improvement in non-nutritive sucking (NNS) score in BM-PIOMI group compared to control and PIOMI group (0.8293, p<0.0001, and 0.8296, p<0.0001, respectively).

CONCLUSIONS

Oral stimulation with breast milk can better promotes the oral feeding process of premature infants than the simple oral stimulation, by shorten IOF time and improve early NNS score, but does not shorten transition time from IOF to FOF and LOS.

Cue-based versus scheduled feeding for preterm infants transitioning from tube to oral feeding: the Cubs mixed-methods feasibility study

BACKGROUND

There is a lack of evidence of the effect of cue-based feeding compared with scheduled feeding on important outcomes for preterm infants.

OBJECTIVES

The objectives were as follows: (1) to describe the characteristics, components, theoretical basis and outcomes of approaches to feeding preterm infants transitioning from tube to oral feeding; (2) to identify operational policies, barriers and facilitators, and staff and parents' educational needs in neonatal units implementing cue-based feeding; (3) to co-produce an intervention for feeding preterm infants in response to feeding cues; (4) to appraise the willingness of parents and staff to implement and sustain the intervention; (5) to assess associated costs of implementing cue-based feeding; (6) to determine the feasibility and acceptability of a future trial; (7) to scope existing data-recording systems and potential outcome measures; and (8) to determine stakeholders' views of whether or not a randomised controlled trial of this approach is feasible.

DESIGN

This was a mixed-methods intervention development and feasibility study comprising (1) a systematic review, case studies, qualitative research and stakeholder consensus; (2) the co-production of the intervention; (3) a mixed-methods feasibility study; and (4) an assessment of stakeholder preferences for a future evaluation.

SETTING

Three neonatal units in the UK (two level 3 units and one level 2 unit).

PARTICIPANTS

Developmentally normal, clinically stable preterm infants receiving enteral feeds (n = 50), parents (n = 15 pre intervention development; n = 14 in the feasibility study) and health-care practitioners (n = 54 pre intervention development; n = 16 in the feasibility study).

INTERVENTION

An evidence-informed multicomponent intervention comprising training, a feeding protocol, feeding assessment tools, supplementary training materials [including posters, a film and a narrated PowerPoint (Microsoft Corporation, Redmond, WA, USA) presentation] and the 'Our Feeding Journey' document.

MAIN OUTCOME MEASURES

The main outcome measures were recruitment and screening rates, infant weight gain, duration of the intervention, feeding outcomes, implementation outcomes (contextual facilitators and barriers, acceptability, adoption, appropriateness and fidelity) and stakeholder preferences for a future evaluation.

RESULTS

The systematic review of 25 studies concluded that evidence in favour of cue-based feeding should be treated cautiously. The case studies and qualitative research highlighted contextual barriers to and facilitators of the implementation of cue-based feeding. The telephone survey found that many neonatal units are considering implementing cue-based feeding. We recruited 37% of eligible infants, and there was good retention in the study until discharge but a high loss to follow-up at 2 weeks post discharge. The mean number of days from intervention to transition to full oral feeding was 10.8, and the mean daily change in weight gain was 25 g. The intervention was acceptable to parents and staff, although there was dissatisfaction with the study documentation. Intervention training did not reach all staff. A cluster-randomised design with a composite outcome was suggested by stakeholders for a future study.

LIMITATIONS

The intervention was available only in English. Intervention training did not reach all staff. There was low recruitment to qualitative interviews and observations. Only a small number of medical staff engaged in either the training or the interviews.

CONCLUSIONS

It is feasible to implement a cue-based feeding intervention with improved training and documentation. Further work is needed to assess the feasibility of a future trial, noting evidence of existing lack of equipoise.

FUTURE WORK

The next steps are to digitalise the intervention and conduct a survey of all neonatal units in the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018097317 and ISRCTN13414304.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 74. See the NIHR Journals Library website for further project information.

A cross-sectional analysis of infant-driven and traditional feeding outcomes for neonatal intensive care unit infants

OBJECTIVE

The goal of this study was to assess the impact of infant-driven feeding (IDF) compared to traditional feeding protocols in promoting earlier successful feeding outcomes.

STUDY DESIGN

We performed a cross-sectional analysis of infants admitted to a level three neonatal intensive care unit (NICU) over a 2-year period. We compared infants fed with the traditional protocol to those under the IDF protocol.

RESULTS

Infants in the IDF group were younger at first feed (p < 0.001). There was no difference in age at nasogastric (NG) tube removal or at discharge, length of stay, or percentage breastfeeding at discharge. There were no differences in outcomes within two subgroups born at <35 and <32 weeks gestation, respectively.

CONCLUSION

The IDF program led to earlier initiation of oral feeding. However, this did not lead to earlier NG tube removal or discharge, a shorter length of stay, or increase in the rates of breastfeeding.

Cue-Based Feeding as Intervention to Achieve Full Oral Feeding in Preterm Infants Primarily Managed with Bubble CPAP

OBJECTIVE

 Cue-based feeding aims at matching introduction of per oral (PO) feeding with physiological readiness of preterm infants to facilitate PO intake and avoid oral aversion. It was claimed that cue-based feeding may lead to delay in the initiation or achieving full PO feeding in clinical setting primarily using bubble nasal continuous positive airway pressure (CPAP). The study aimed to examine the association of cue-based feeding with time of introduction and completing oral feeding in infants primarily managed with bubble CPAP.

STUDY DESIGN

 A retrospective analysis where outcomes of preterm infants ≤32 weeks' gestational age (GA) and ≤2,000 g birth weight (BW) were compared after a practice change from volume-based feeding advancement to cue-based feeding. Continuous variables were compared by using t-test and multilinear regression analysis to control for confounding variables.

RESULTS

 Of the 311 preterm infants who met inclusion and exclusion criteria, 194 were in the cue-based feeding group and 117 were in the volume-based advancement historical comparison group. There were no differences between groups regarding demographic or clinical variables. Postmenstrual age (PMA) of initial feeding assessment was less in the cue-based feeding group. Age of first PO feeding and when some PO was achieved every feed was mildly delayed in the cue-based feeding compared with comparison group, 34 (±1.3) versus 33.7 (±1.2) weeks, and 36.2 (±2.3) versus 36.0 (±2.4) weeks, (p < 0.01) respectively. However, the age of achieving full PO did not differ between groups, 36.8 (±2.2) versus 36.4 (±2.4) weeks (p = 0.13). There was no difference between groups regarding growth parameters at 36 weeks' PMA or at discharge. Similar results were obtained when examining subcategories of infants ≤1,000 g and 1,001 to 2,000 g.

CONCLUSION

 Cue-based feeding may not be associated with a delay in achieving full oral feeding or prolongation of the length of stay in preterm infants managed with CPAP.

KEY POINTS

· Cue-based feeding matches introduction of PO feeding with physiological readiness.. · Cue-based feeding may not be associated with a delay in achieving full oral feeding in preterm infants.. · Cue-based feeding is not associated with prolongation of the length of stay in preterm infants.. · Cue based feeding in preterm infants managed with noninvasive bubble CPAP is examined..

Effect of SINC Feeding Protocol on Weight Gain, Transition to Oral Feeding, and the Length of Hospitalization in Preterm Infants: A Randomized Controlled Trial

BACKGROUND

The present study aims to test the effect of the Safe Individualized Nipple-Feeding Competence (SINC) protocol on the preterm infants' weight gain, transition to oral feeding, and duration of hospitalization.

METHODS

The procedure was designed as a single-blind, parallel-group randomized controlled trial. The trial was conducted in a neonatal intensive care unit (NICU) in Konya, Turkey. Data were collected from 80 preterm infants between February 2018 and March 2019. Infants (gestational weeks 28-33) were randomly assigned to the intervention (n = 39) and control groups (n = 41). The intervention group received the SINC feeding protocol, whereas the control group received the standard feeding. Data were collected using the Family Information Form, the Preterm Infant Follow-Up Form, and the SINC Protocol Evaluation Checklist. Infants were followed from hospitalization to discharge. The outcomes were weight gain, transition to oral feeding, and the length of hospitalization from birth to discharge. Pearson χ² test, Fisher exact test, independent t-test, Mann-Whitney U test, and general linear model test were used in analyzing the data.

RESULTS

The main effects of groups on weight measurements were found to be statistically significant (P < .001). There were no significant differences in terms of the transition from gavage to full oral feeding and the length of hospitalization (P > .05).

CONCLUSIONS

SINC protocol positively influences weight gain in preterm infants. It is important to evaluate different evidence-based feeding methods both as they apply to the NICU stay and how they may affect long-term outcomes of preterm infant.

Stopping enteral feeds for prevention of transfusion-associated necrotising enterocolitis in preterm infants

BACKGROUND

Feeding practices around the time of packed red blood cell transfusion have been implicated in the subsequent development of necrotising enterocolitis (NEC) in preterm infants. Specifically, it has been suggested that withholding feeds around the time of transfusion may reduce the risk of subsequent NEC. It is important to determine if withholding feeds around transfusion reduces the risk of subsequent NEC and associated mortality.

OBJECTIVES

• To assess the benefits and risks of stopping compared to continuing feed management before, during, and after blood transfusion in preterm infants • To assess the effects of stopping versus continuing feeds in the following subgroups of infants: infants of different gestations; infants with symptomatic and asymptomatic anaemia; infants who received different feeding schedules, types of feed, and methods of feed delivery; infants who were transfused with different blood products, at different blood volumes, via different routes of delivery; and those who received blood transfusion with and without co-interventions such as use of diuretics • To determine the effectiveness and safety of stopping feeds around the time of a blood transfusion in reducing the risk of subsequent necrotising enterocolitis (NEC) in preterm infants SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11), in the Cochrane Library; MEDLINE (1966 to 14 November 2018); Embase (1980 to 14 November 2018); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 14 November 2018). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared stopping feeds versus continuing feeds around the time of blood transfusion in preterm infants.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality, and extracted data from the included studies.

MAIN RESULTS

The search revealed seven studies that assessed effects of stopping feeds during blood transfusion. However, only one RCT involving 22 preterm infants was eligible for inclusion in the review. This RCT had low risk of selection bias but high risk of performance bias, as care personnel were not blinded to the study allocation. The primary objective of this trial was to investigate changes in mesenteric blood flow, and no cases of NEC were reported in any of the infants included in the trial. We were unable to draw any conclusions from this single study. The overall GRADE rating for quality of evidence was very low.

AUTHORS' CONCLUSIONS

Randomised controlled trial evidence is insufficient to show whether stopping feeds has an effect on the incidence of subsequent NEC or death. Large, adequately powered RCTs are needed to address this issue.

Oral Feeding Success: A Concept Analysis

BACKGROUND

The term "oral feeding success" (OFS) is frequently used in clinical practice and research. However, OFS is inconsistently defined, which impacts the ability to adequately evaluate OFS, identify risk factors, and implement interventions in clinical practice and research.

PURPOSE

To develop the defining attributes, antecedents, and consequences for the concept of OFS in preterm infants during their initial hospitalization.

METHODS

PubMed, CINAHL, and PsycINFO databases were searched for English articles containing the key words "oral feeding success" and "preterm infants." The Walker and Avant method for concept analysis was employed.

RESULTS

Sixteen articles revealed the defining attributes, antecedents, and consequences. Defining attributes included (1) physiologic stability; (2) full oral feeding; and (3) combined criteria of feeding proficiency (≥30% of the prescribed volume during the first 5 minutes), feeding efficiency (≥1.5 mL/min over the entire feeding), and intake quantity (≥80% of the prescribed volume).

IMPLICATIONS FOR PRACTICE

The 3 defining attributes may be used in clinical practice to consistently evaluate OFS. The antecedents of OFS provide clinicians with a frame of reference to assess oral feeding readiness, identify risk factors, and implement effective interventions. The consequences of OFS allow clinicians to anticipate challenges when OFS is not achieved and create a care plan to support the infants.

IMPLICATIONS FOR RESEARCH

The empirical referents of OFS provide consistent and clear operational definitions of OFS for use in research. The antecedents and consequences may guide researchers to select specific measures or covariates to evaluate valid measures of OFS.

Impact of Feeding Interval on Time to Achieve Full Oral Feeding in Preterm Infants: A Randomized Trial

BACKGROUND

Preterm infants are scheduled to receive total feeding amount in either 3-hour or 2-hour intervals. A gavage feeding may be required if the scheduled amount is not completed orally. Feedings every 2 hours are one-third smaller than feedings every 3 hours. Thus, if the volume of each feed is reduced by decreasing the feeding interval from 3 to 2 hours, the likelihood that the infant completes each volume orally increases, and the probability of requiring gavage feeding decreases. The impact of feeding with 2-hour or 3-hour intervals on time to achieve full oral feeding in preterm infants was investigated.

METHODS

Infants on full enteral gavage feedings were randomized into 2 groups to receive feedings in either 3-hour or 2-hour intervals. The time to achieve full oral feeding and the duration of feeding transition from gavage to oral feedings were investigated. Data were presented as median (interquartile range).

RESULTS

The study included 100 infants (gestational age: 29 [28-31] weeks, birth weight: 1205 [1040-1380] g) with 50 in each group. The postmenstrual age to achieve full oral feeding was 35 (35-37) weeks in the 3-hour-interval group and 35 (34-36) weeks in the 2-hour-interval group; P = 0.131. The duration of feeding transition was similar between groups.

CONCLUSIONS

Feeding every 2 hours caused no improvement in the time to achieve full oral feeding. The 3-hour-interval feeding is appropriate for the neonatal units, where less handling of preterms and decreased workload of nurses are valuable.

Transition From Nasogastric Tube to Oral Feeding: The Role of Parental Guided Responsive Feeding

Background and Objective: Strategies to transition preterm infants from tube to oral feeding vary greatly and the transition may take days to weeks. The study objective was to evaluate the effect of parental guided responsive feeding (PGRF) on this transition. Methods: We conducted a randomized controlled trial on infants born at <32 weeks gestation. The PGRF intervention was performed by parents, and included feeding intervals and volumes which were guided by the infants' behavioral cues of hunger and satiety. If a minimum volume was not taken orally, an intermediate volume was supplemented via nasogastric tube. The control group was traditionally fed (TF), with pre-planned volumes of intake and at given scheduled intervals. Results: The study comprised 67 infants (PGRF 32, TF 35). PGRF infants reached full oral feeding within less days (median 2 vs. 8 days, p = 0.001), at an earlier age (median 34.28 vs. 35.14 weeks, p < 0.001), returned to baseline weight gain at 35 weeks (1.77 ± 0.70 vs. 1.25 ± 0.63 g/kg/day, p = 0.002), were discharged earlier (36.34 ± 0.6 vs. 36.86 ± 0.9 weeks, p = 0.001), were more likely to be fed by their parents (p < 0.001), and experienced less apnea/bradycardia events at 34 weeks (median 3.5 vs. 9 per week p = 0.047) compared to the TF infants. The regression model demonstrated that independent variables predicted 43.7% of the variance of time to full oral feeding [F _{(9, 65)} = 4.84 p < 0.001]. The only significant variable was feeding group (B = -6.43 p < 0.001); The PGRF infants were more likely to reach full oral feeding earlier. Conclusion: PGRF is safe, and associated with short-term advantages, higher parental engagement, and earlier discharge. Clinical Trial Registration: Identifier: SHEBA-12-9574-IM-CTIL; "Adjusted Individual Oral Feeding for Improving Short and Long Term Outcomes of Preterm Infants."

Intervention time until discharge for newborns on transition from gavage to exclusive oral feeding

Purpose Measure the intervention time required for transition from gavage to exclusive oral feeding, comparing newborns exposed exclusively to the mother's breast with those who, in addition to breastfeeding, received supplementation using a cup or baby bottle. Methods Analytical, longitudinal, cohort study conducted with 165 newborns (NB) divided into groups according to severity of medical complications (G1-with no complications; G2-with significant complications), and into subgroups according to feeding mechanism (A and B). All NBs were low birth weight, on Kangaroo Mother Care, and breast stimulated according to medical prescription and hospital routine. Regarding feeding pattern, subgroup A comprised NBs exclusively breastfed at hospital discharge, whereas subgroup B was composed of NBs fed through cup/bottle at some time during hospitalization. The number of days spent in each stage of transition was recorded for each NB. Results History of clinical complications significantly influenced total intervention time. Study participants in subgroups G1-A (10 days), G1-B (9 days), and G2-A (12 days) displayed greater chances of early discharge compared with those in subgroup G2-B (16 days). Conclusion NBs with no important history of clinical complications displayed greater chances of early hospital discharge. NBs with significant history of clinical complications that underwent gavage to exclusive breastfeeding transition presented smaller intervention time than those that required supplementation using cup/bottle. Feeding transition using the gavage-to-exclusive oral feeding technique is recommended for Speech-language Pathology practice in Neonatology.

Clinicians guide for cue-based transition to oral feeding in preterm infants: An easy-to-use clinical guide

RATIONALE, AIMS AND OBJECTIVES

This article aims to provide evidence to guide multidisciplinary clinical practitioners towards successful initiation and long-term maintenance of oral feeding in preterm infants, directed by the individual infant maturity.

METHOD

A comprehensive review of primary research, explorative work, existing guidelines, and evidence-based opinions regarding the transition to oral feeding in preterm infants was studied to compile this document.

RESULTS

Current clinical hospital practices are described and challenged and the principles of cue-based feeding are explored. "Traditional" feeding regimes use criteria, such as the infant's weight, gestational age and being free of illness, and even caregiver intuition to initiate or delay oral feeding. However, these criteria could compromise the infant and increase anxiety levels and frustration for parents and caregivers. Cue-based feeding, opposed to volume-driven feeding, lead to improved feeding success, including increased weight gain, shorter hospital stay, fewer adverse events, without increasing staff workload while simultaneously improving parents' skills regarding infant feeding. Although research is available on cue-based feeding, an easy-to-use clinical guide for practitioners could not be found. A cue-based infant feeding regime, for clinical decision making on providing opportunities to support feeding success in preterm infants, is provided in this article as a framework for clinical reasoning.

CONCLUSIONS

Cue-based feeding of preterm infants requires care providers who are trained in and sensitive to infant cues, to ensure optimal feeding success. An easy-to-use clinical guideline is presented for implementation by multidisciplinary team members. This evidence-based guideline aims to improve feeding outcomes for the newborn infant and to facilitate the tasks of nurses and caregivers.

Somatosensory Modulation of Salivary Gene Expression and Oral Feeding in Preterm Infants: Randomized Controlled Trial

Background

Despite numerous medical advances in the care of at-risk preterm neonates, oral feeding still represents one of the first and most advanced neurological challenges facing this delicate population. Objective, quantitative, and noninvasive assessment tools, as well as neurotherapeutic strategies, are greatly needed in order to improve feeding and developmental outcomes. Pulsed pneumatic orocutaneous stimulation has been shown to improve nonnutritive sucking (NNS) skills in preterm infants who exhibit delayed or disordered nipple feeding behaviors. Separately, the study of the salivary transcriptome in neonates has helped identify biomarkers directly linked to successful neonatal oral feeding behavior. The combination of noninvasive treatment strategies and transcriptomic analysis represents an integrative approach to oral feeding in which rapid technological advances and personalized transcriptomics can safely and noninvasively be brought to the bedside to inform medical care decisions and improve care and outcomes.

Objective

The study aimed to conduct a multicenter randomized control trial (RCT) to combine molecular and behavioral methods in an experimental conceptualization approach to map the effects of PULSED somatosensory stimulation on salivary gene expression in the context of the acquisition of oral feeding habits in high-risk human neonates. The aims of this study represent the first attempt to combine noninvasive treatment strategies and transcriptomic assessments of high-risk extremely preterm infants (EPI) to (1) improve oral feeding behavior and skills, (2) further our understanding of the gene ontology of biologically diverse pathways related to oral feeding, (3) use gene expression data to personalize neonatal care and individualize treatment strategies and timing interventions, and (4) improve long-term developmental outcomes.

Methods

A total of 180 extremely preterm infants from three neonatal intensive care units (NICUs) will be randomized to receive either PULSED or SHAM (non-pulsing) orocutaneous intervention simultaneous with tube feedings 3 times per day for 4 weeks, beginning at 30 weeks postconceptional age. Infants will also be assessed 3 times per week for NNS performance, and multiple saliva samples will be obtained each week for transcriptomic analysis, until infants have achieved full oral feeding status. At 18 months corrected age (CA), infants will undergo neurodevelopmental follow-up testing, the results of which will be correlated with feeding outcomes in the neo-and post-natal period and with gene expression data and intervention status.

Results

The ongoing National Institutes of Health funded randomized controlled trial R01HD086088 is actively recruiting participants. The expected completion date of the study is 2021.

Conclusions

Differential salivary gene expression profiles in response to orosensory entrainment intervention are expected to lead to the development of individualized interventions for the diagnosis and management of oral feeding in preterm infants.

Trial Registration

ClinicalTrials.gov NCT02696343; https://clinicaltrials.gov/ct2/show/NCT02696343 (Archived by WebCite at http://www.webcitation.org/6r5NbJ9Ym)

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.

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.

Responsive versus scheduled feeding for preterm infants

BACKGROUND

Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of a policy of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth rates, levels of parent satisfaction, and time to hospital discharge.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 17 February 2016), Embase (1980 to 17 February 2016), and CINAHL (1982 to 17 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses. We assessed the quality of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.36, 95% CI -2.44 to -0.29 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.53, 95% CI -6.80 to -4.25 days). GRADE assessments indicated low quality of evidence. The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views.

AUTHORS' CONCLUSIONS

Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some (low quality) evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. This finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.

Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation

BACKGROUND

One of the most challenging milestones for preterm infants is the acquisition of safe and efficient feeding skills. The majority of healthy full term infants are born with skills to coordinate their suck, swallow and respiration. However, this is not the case for preterm infants who develop these skills gradually as they transition from tube feeding to suck feeds. For preterm infants the ability to engage in oral feeding behaviour is dependent on many factors. The complexity of factors influencing feeding readiness has led some researchers to investigate the use of an individualised assessment of an infant's abilities. A limited number of instruments that aim to indicate an individual infant's readiness to commence either breast or bottle feeding have been developed.

OBJECTIVES

To determine the effects of using a feeding readiness instrument when compared to no instrument or another instrument on the outcomes of time to establish full oral feeding and duration of hospitalisations.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 22 February 2016), EMBASE (1980 to 22 February 2016), and CINAHL (1982 to 22 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing a formal instrument to assess a preterm infant's readiness to commence suck feeds with either no instrument (usual practice) or another feeding readiness instrument.

DATA COLLECTION AND ANALYSIS

The standard methods of Cochrane Neonatal were used. Two authors independently screened potential studies for inclusion. No studies were found that met our inclusion criteria.

MAIN RESULTS

No studies met the inclusion criteria.

AUTHORS' CONCLUSIONS

There is currently no evidence to inform clinical practice, with no studies meeting the inclusion criteria for this review. Research is needed in this area to establish an evidence base for the clinical utility of implementing the use of an instrument to assess feeding readiness in the preterm infant population.

ABM Clinical Protocol #16: Breastfeeding the Hypotonic Infant, Revision 2016

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Predictors of the time to attain full oral feeding in late preterm infants

AIM

The aim of this study was to determine the factors that predict the timing and age at which preterm infants (born 32-36 weeks gestation) commenced and attained full oral feeding.

METHODS

We conducted a retrospective review of medical records of 647 preterm infants born 2005-2011. Infants were from six neonatal intensive care units in New Zealand, all World Health Organisation Baby-friendly Hospital Initiative accredited.

RESULTS

Median time to the first oral feed offered was one day, and median time to the time of full oral feeding was 12 days. No infants attained full oral feeding before 33(+3) weeks postmenstrual age. Gestational age, birthweight, medical conditions and location of the neonatal unit were significantly associated with the time taken to commence and attain full oral feeding.

CONCLUSION

This study highlights the factors that are associated with the rate at which late preterm infants commence oral feeding and progress to full oral feeding. These findings offer important considerations not only for clinical practice but also discharge planning given the preference for preterm infants reaching full oral feeds before discharge from hospital. Prospective experimental research is required to confirm infant, maternal and environmental factors that influence feeding milestones in late preterm infants.

Responsive versus scheduled feeding for preterm infants

BACKGROUND

Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth, duration of hospital stay, and parental satisfaction.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2015), MEDLINE (1966 to September 2015), EMBASE (1980 to September 2015), and CINAHL (1982 to September 2015), conference proceedings, previous reviews, and trial registries.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses.

MAIN RESULTS

We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.4, 95% CI -2.4 to -0.3 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.5, 95% CI -6.8 to -4.2 days). The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views.

AUTHORS' CONCLUSIONS

Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. However, this finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.

Preterm newborn readiness for oral feeding: systematic review and meta-analysis

PURPOSE: To identify and systematize the main studies on the transition from enteral to oral feeding in preterm infants. RESEARCH STRATEGY: Articles that describe the transition from oral to enteral feeding in preterm infants were located in MEDLINE, LILACS, and SciELO databases. SELECTION CRITERIA: Original studies, with available abstract, published in the last 10 years were included. DATA ANALYSIS: Analysis of the methodology and the main results of the studies, and meta-analysis of the effects of sensory-motor-oral stimulation at the time of transition to full oral feeding and duration of hospitalization were conducted. RESULTS: Twenty-nine national and international publications were considered. Most studies were clinical trials (44.8%) and did not use rating scales to start the transition process (82.7%). In the meta-analysis, positive effect of stimulation of the sensory-motor-oral system was observed with respect to the transition time to oral diet (p=0.0000), but not in relation to the length of hospital stay (p=0.09). However, heterogeneity between studies was found both in the analysis of the transition time to full oral feeding (I2=93.98) and in the length of hospital stay (I2=82.30). CONCLUSION: The transition to oral feeding is an important moment, and various physical and clinical characteristics of preterm infants have been used to describe this process. Despite the impossibility of generalizing the results due to the heterogeneity of the studies, we have noted the importance of strategies for stimulation of sensory-motor-oral system to decrease the period of transition to full oral feeding system.

The Effect of Breast Milk Odor on Transition Time From Gavage to Oral Feeding and Hospital Stay in Premature Infants

We examined the effects of breast milk smell on transition time from gavage to oral feeding and hospital stay in premature infants. There were 92 premature infants younger than 33 weeks who were randomly selected and sequentially allocated to the following groups: control (n = 46) and intervention (n = 46). This experimental study was undertaken in 2 neonatal intensive care units located in Vali Asr and Jamee Zanan educational hospitals in Tehran, Iran. We collected data from April 6 until September 6, 2013, over 4.5 months. Participants’ demographic data were extracted from their medical records. The findings of the study indicated that the use of an impregnated pad with breast milk, which was used for olfactory stimulation, reduced premature infants’ transition feeding time by 10 days in the intervention group compared with the control group. The length of hospitalization was also reduced by 12 days in the intervention group compared with the control group. The study results suggested that neonatal intensive care unit nurses should train mothers in the performance of this simple, inexpensive method to improve the quality of care provided to premature infants and reduce feeding transition time from gavage to oral feeding.

Missed oral feeding opportunities and preterm infants' time to achieve full oral feedings and neonatal intensive care unit discharge

OBJECTIVE

To examine the association of missed oral feeding opportunities among preterm infants with achievement of full oral feedings and length of hospitalization.

STUDY DESIGN

A secondary analysis of clinical trial data was conducted. Study infants included in the analysis (N = 89) were randomized to one of four standardized feeding progression approaches; detailed records on all feedings were maintained. The proportion of oral feeding opportunities reported as missed due to factors unrelated to the infant's clinical condition was calculated for each infant.

RESULTS

The proportion of missed oral feeding opportunities per infant ranged from 0 to 0.12; 30 infants experienced one or more missed oral feeding opportunity. Each 1% increase in the proportion of missed oral feeding opportunities extended the time to achieve full oral feeding by 1.45 days (p = 0.007) and time to discharge by 1.36 days (p = 0.047).

CONCLUSION

Preterm infants' missed oral feeding opportunities may adversely affect feeding outcomes and extend hospitalization.

From tube to breast: the bridging role of semi-demand breastfeeding

Determination of the optimal timing of breastfeeding initiation for preterm infants is still a challenge for health professionals. Often unjustified delays and restrictions of breastfeeding occur due to non-evidence-based current opinions about preterm infants' feeding capacity. Semi-demand feeding has been proposed for preterm infants during the transition from scheduled to full demand feeding, to promote the establishment of self-regulated oral feeding. Although semi-demand feeding has been shown to be safe and effective in reducing time to reaching oral feeding, the implementation of this feeding pattern for preterm infants in the neonatal intensive care unit (NICU) is still limited. We developed a protocol for the application of semi-demand feeding in preterm infants based on the existing knowledge of preterm infant neurodevelopment and NICU organization and staff experience. The protocol's aim is to attain successful transition from tube feeding to breastfeeding. In this article, we describe the protocol used in the neonatal unit of the Maternal and Child Health Institute of Trieste, a third level care center in northeastern Italy.

Eating problems in very low birthweight children are highest during the first year and independent risk factors include duration of invasive ventilation

AIM

This study aimed to investigate the incidence and time course of eating problems in children born with a very low birthweight (VLBW) and to identify the perinatal risk factors.

METHODS

We used a standard eating questionnaire to study 178 VLBW children, born between 1999 and 2005 at a median of 28.6 weeks' gestation and median birthweight of 1058 g, for the first 6 years of life. The control group comprised 74 children born full term.

RESULTS

Just under a quarter of the VLBW children (24.7%) had eating problems before the age of one, and by the age of two, the cumulative incidence had increased to 28.6%. The 69 children born between 1999 and 2001 had eating problems up to the age of six, but 76.5% were resolved by the age of four. Independent risk factors were gestational age at birth, and duration of invasive ventilation and eating problems were associated with significantly poor growth.

CONCLUSION

The incidence of eating problems in VLBW children was highest during the first year of life. Gestational age and the duration of invasive ventilation were independent risk factors, and eating problems contributed to continued growth failure. Eating problems require early recognition and intervention.

Efeitos da estimulação da sucção não nutritiva com dedo enluvado na transição alimentar em recém-nascido prematuro de muito baixo peso

Objetivos analisar os efeitos da estimulação da sucção não nutritiva com a técnica do dedo enluvado, sobre o início e a transição alimentar da via gástrica para a via oral em prematuros de muito baixo peso. Métodos estudo aleatório, prospectivo, longitudinal, experimental e controlado, que incluiu 40 prematuros internados na UTI Neonatal do Hospital de Clínicas, com idade gestacional £ 32 semanas e peso de nascimento £ 1500g, clinicamente estáveis. Os prematuros foram distribuídos aleatoriamente, por meio de sorteio, em 2 grupos: grupo controle, sem SNN e grupo experimental, com SNN com dedo enluvado, 3 vezes ao dia, 3 dias na semana. Foram avaliados critérios quanto ao escore da avaliação da prontidão para início da alimentação oral, intercorrências durante a sucção nutritiva (SN) e o tempo de transição alimentar. Resultados quando comparado o grupo experimental em relação ao grupo controle observou-se um escore significantemente maior na avaliação da prontidão para início da alimentação via oral, uma menor frequência de sinais de estresse durante a sucção nutritiva e um menor tempo de transição alimentar da via gástrica para via oral. Conclusão a estimulação da sucção não nutritiva com a técnica do dedo enluvado melhorou a prontidão do prematuro para início da alimentação via oral, diminuiu a frequência dos sinais de estresse durante a alimentação via oral e reduziu o tempo de transição alimentar no grupo experimental quando comparado ao grupo controle.

Non-nutritive sucking evaluation in preterm newborns and the start of oral feeding: a multicenter study

OBJECTIVES

The assessment of early sucking by preterm infants provides information on the ability of these infants to efficiently and safely receive nutrients via an oral route (oral feeding). To analyze the application and reliability of an instrument in assessing non-nutritive sucking that indicates a capacity for oral feeding in the routine care of different neonatal units.

METHODS

A multicenter, prospective cohort study was conducted in seven neonatal units. A non-nutritive sucking assessment with a formulary validated by Neiva et al (2008) (variables evaluated: rooting reaction; easy initiation of sucking; labial sealing; tongue central groove; peristaltic tongue movements; jaw raising and lowering movements; labial, tongue and jaw coordination; sucking strength; sucking rhythm; bites; excessive jaw excursion; stress signals) was applied to 199 pre-term newborns, who had a chronological age ≥ 2 days and were clinically stable. These infants were divided into two groups based on their corrected gestational age at the first assessment, as follows: Group I-infants with a gestational age ≤ 33 weeks and Group II-infants with a gestational age between 34 and 36 6/7 weeks.

RESULTS

The mean gestational age was 31.66±2 weeks, and the mean birth weight was 1494 ± 373 g. The mean scores on the non-nutritive sucking assessment were 46 ± 25 in Group I and 49 ± 24 in Group II. The beginning of oral feeding was successful in 43 (67.2%) infants in Group I and 64 (81%) infants in Group II (p = 0.089).

CONCLUSION

The method identified preterm infants who were able to feed orally based on 33 points in the non-nutritive sucking assessment and a corrected gestational age of 32 weeks or more. The corrected gestational age was the most important factor in predicting the success of 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.

Cue-based feeding in the NICU: using the infant's communication as a guide

Although studies have shown cue-based feeding can lead to earlier achievement of full oral feeding, the successful implementation of cue-based feeding has been constrained by the volume-driven culture, which has existed for many years in the NIC U. This culture was built on the notion that a "better" nurse is one who could "get more in," and infants who are "poor feeders" are ones who "can't take enough." The infant who feeds faster is often viewed as more skilled in this task-oriented approach. The feeding relationship and the infant's communication about the experience of feeding may not be nurtured. This article will explain the central role of the preterm infant's communication in successful cue-based feeding. When the infant is perceived as having meaningful behavior (i.e., communicative intent), the focus changes from a volume-driven to a co-regulated approach, through which the infant guides the caregiver. This is cue-based feeding.

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.

Feeding behaviour and performance of preterm neonates on Paladai feeding

AIM

To evaluate the feeding behaviour and performance of preterm neonates receiving feeds by paladai (a small beaked receptacle).

METHODS

We enrolled stable neonates - 10 each in 28-30 weeks [group I] and 31-32 weeks gestation [group II], and offered them paladai feeds. We recorded the feeding sessions on alternate days until they were on full enteral feeds. The outcome variables were (1) feeding behaviour, as assessed by changes in states of wakefulness, oromotor functions and coordination between breathing and swallowing; (2) feeding performance, as assessed by proficiency and efficiency.

RESULTS

A total of 47 and 27 sessions were studied in groups I and II, respectively. The median postconceptional age (PCA) at start of paladai feeding was 30 (range, 29-32) and 32 (31-32) weeks in the two groups. The infants accepted paladai feedings in all behavioural states. Incoordination between feeding and breathing was observed in about 25% of the sessions in both the groups. We observed a rapid improvement in feeding performance with experience - the median proficiency improved from 5.5 to 10.1 mL/min and 6.2-11.5 mL/min in groups I and II, respectively. The proficiency of group I infants at a median PCA of 30.9 weeks was higher than that of group II infants at median PCA 31.7 weeks.

CONCLUSION

Stable preterm neonates can be fed with paladai from 30 weeks PCA. The oropharyngeal ability is possibly influenced more by the postnatal experience than by maturity at birth.

Reading the Feeding

The amount of milk a preemie drinks largely determines readiness for discharge from the neonatal intensive care unit. But just because an infant feeds well today doesn't mean it will last. In the long term, fostering a child's consistent, positive response to feeding may be more important.

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.