Psychometric Properties of the Early Feeding Skills Assessment Tool

Psychometric properties of the Turkish version of the neonatal eating assessment tool-breastfeeding (NeoEAT-Breastfeeding)

BACKGROUND

Literature reports indicate that breastfeeding is often ended earlier than planned, within the first 6 months. Assessment tools can help nursing professionals identify early breastfeeding problems to identify interventions to support families in meeting their breastfeeding goals. Here we present our analyses of the validity/reliability of the Neonatal Eating Assessment Tool (NeoEAT)-Breastfeeding adapted to the Turkish language for use in post-discharge infants in Türkiye.

METHODS

A Turkish version of the NeoEAT-Breastfeeding was created and applied to 310 mothers of term and preterm infants (corrected age < 7 months) between June 2023 and April 2024. Validity and reliability were assessed using Cronbach's α coefficients, exploratory/confirmatory factor analysis, and item-total correlation, test-retest, and known-groups analysis.

RESULTS

The Turkish NeoEAT-Breastfeeding includes 59 items in 6 factors with 48.047% total explained variance. Exploratory factor analysis indicated that item factor loadings ranged from 0.314 to 0.788. Known-group analysis confirmed that infants with diagnosed feeding problems had higher total and subscale scores than those without (P < 0.05). The Cronbach's α coefficient was 0.87. Item-total correlations were sufficient (0.302-0.753; P < 0.01). There was excellent agreement between test values and retest values obtained after a two-week interval (intraclass correlation coefficients = 0.904-1.000).

CONCLUSION

The Turkish NeoEAT-Breastfeeding was shown to be a reliable and valid parent-reported measure of feeding problems in breastfed infants younger than 7 months of corrected age after discharge.

Biobehavioral Efficacy of the Elevated Side-Lying Position for Feeding Preterm Infants: Study Protocol

AIM

Present a study protocol investigating the biobehavioral efficacy of side-lying vs. supine positions on physiologic and behavioural responses of preterm infants during their transition from tube to full oral feeding, and identify associated infant characteristics.

DESIGN

Within-subject cross-over design.

METHODS

Sixty preterm infants born at ≤35 weeks gestational age (GA) from a level 3 NICU are observed during their transition to full oral feeding. Each undergoes two feedings within 24 h: One in the supine position and one in the side-lying position. Continuous physiologic and video data are collected 30 min before and after feeding. Physiologic measures include heart rate, respiratory rate, oxygen saturation, and autonomic nervous system regulation (heart rate variability and splanchnic-cerebral oxygen ratio). Behavioural responses are assessed via microanalysis of the sucking and breathing waveforms and videotaped feedings (Suck-breathe coordination and Early Feeding Skills assessment tool). Data are analysed using linear mixed-effects models. IRB was obtained in September 2021, with funding awarded by the National Institute of Nursing Research in July 2021.

CONCLUSION

This study will enhance our understanding of the effects of the side-lying position on preterm infant feeding, providing guidance for its clinical use as a feeding strategy.

IMPLICATIONS

Provides vital knowledge to guide evidence-based practices in enhancing oral feeding in preterm infants and inform future pivotal efficacy trials.

IMPACT

If effective, this intervention could significantly enhance the management of feeding challenges in preterm infants across neonatal care settings.

REPORTING METHOD

Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013.

PATIENT OR PUBLIC CONTRIBUTION

While direct parent involvement was not documented in our protocol, informal feedback on data collection procedures from parents was incorporated. Additionally, extensive engagement with healthcare professionals during study design addressed patient safety, logistical challenges, and ethical standards in NICU settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04942106; registered on 28 June 2021. Available at: https://clinicaltrials.gov/ct2/show/NCT04942106.

Factors associated with feeding problems in bottle-fed preterm infants: A descriptive cross-sectional study

BACKGROUND

The feeding problems of preterm infants often persist after neonatal intensive care unit discharge. Further evidence on the feeding problems preterm infants experience after hospital discharge is needed to better serve this vulnerable population. This study aimed to identify infant-related factors associated with bottle-feeding problems in preterm infants before the age of 7 months.

MATERIALS AND METHODS

This descriptive and cross-sectional study included 338 mothers of preterm infants younger than 7 months of corrected age between April 2023 and April 2024. Mothers completed a survey that included infant and mother information form and Turkish version of the NeoEAT-Bottle-feeding assessment tool.

RESULTS

Very and moderately preterm infants exhibited more problematic feeding symptoms according to NeoEAT-Bottle-feeding total scale and all subscale scores compared with late preterm infants (P < 0.05). Gestational age at birth was negatively correlated with NeoEAT-Bottle-feeding total scores (P = 0.001). Additionally, preterm infants with a diagnosed feeding problem had higher NeoEAT-Bottle-feeding total and subscale scores than those without (P < 0.01). In the multivariate regression analysis, very preterm status and presence of gastroesophageal reflux were predictors of higher NeoEAT-Bottle-feeding total and all subscale scores (P < 0.01), and moderately preterm status was associated with higher NeoEAT-Bottle-feeding total (P = 0.036) and infant regulation subscale scores (P = 0.001).

CONCLUSION

Very preterm and moderate preterm birth, gastroesophageal reflux, and diagnosed feeding disorders were associated with problematic feeding. Identifying preterm infants who have difficulty with bottle feeding can guide primary care interventions or referral to specialists to achieve more favorable long-term outcomes.

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.

Acoustic and Perceptual Profiles of Swallowing Sounds in Preterm Neonates: A Cross-Sectional Study Cohort

Cervical auscultation, commonly used by speech-language pathologists in some countries as an adjuvant to the clinical feeding evaluation, requires data on acoustic and perceptual profiles of swallowing sounds. Whilst these exists in adults and children, none currently exist for preterm neonates. Our study aims to establish the acoustic and perceptual parameters of swallowing sounds in preterm neonates. Swallowing sounds were recorded on a digital microphone during oral feeding observations. Acoustic parameters of duration, peak frequency, peak power and peak intensity were determined. Perceptual parameters heard pre, during and post-swallows were rated as 'present', 'absent', or 'cannot be determined'. Eighty preterm neonates (43 males; mean age = 33.4 weeks [SD 2.6]) from three Australian special care nurseries demonstrated mean swallow durations of < 1 s. The peak amplitude correlated with the number of medical co-morbidities (r = 0.24; 95%CI 0.03-0.45). Most preterm neonates have coordinated swallows that are loud, quick and completed in < 1 s. The perceptual parameters of a bolus transit sound was consistently present in all preterm neonates. One in five pre-term neonates have an uncoordinated swallow where wheeze, stridor or wet breath sounds were present post-swallow. Our study provides clinicians with acoustic and perceptual parameters to guide use of cervical auscultation in special care nurseries. Future studies should consider simultaneous instrumental assessment to ensure validity when using cervical auscultation to support diagnostic decision-making on swallowing coordination.

Early Life Stress, DNA Methylation of NR3C1 and HSD11B2 , and Oral Feeding Skill Development in Preterm Infants : A Pilot Study

BACKGROUND

Early life stress exposure in preterm infants may alter DNA methylation of NR3C1 and HSD11B2 , disrupting neurobehaviors needed for oral feeding (PO) skill development.

PURPOSE

To (1) examine the feasibility of the study protocol; (2) describe early life stress, DNA methylation of NR3C1 and HSD11B2 , and PO skill development; and (3) explore the association between DNA methylation of NR3C1 and HSD11B2 and infant characteristics, early life stress, and PO skill development.

METHOD

We employed a longitudinal descriptive pilot study (N = 10). Infant characteristics were collected from the infant's electronic medical record. Early life stress was assessed via the modified Neonatal Infant Stressor Scale. DNA methylation of NR3C1 exon 1F and HSD11B2 promoter regions was analyzed from the infant's buccal samples. PO skill development was evaluated using the Early Feeding Skills Assessment.

RESULTS

Infants who experienced more acute and chronic stress during their neonatal intensive care unit hospitalization demonstrated higher DNA methylation at CpG 17 and 31 of the NR3C1 exon 1F and at CpG 4 and 28 of the HSD11B2 promoter regions. Infants with higher DNA methylation at these CpG sites also exhibited less optimal PO skill development and experienced longer transition from first to full PO.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Our findings revealed relationships among early life stress, DNA methylation of NR3C1 and HSD11B2 , and PO skill development in preterm infants. Future research is warranted to examine the multiomics pathways whereby early life stress influences the phenotypes of infant outcomes.

Assessing neonatal nurses: transitioning preterm infants to oral feeding - a multicenter cross-sectional study

BACKGROUND

In Egypt, approximately 10% of preterm deliveries occur between 32 and fewer than 37 weeks, leading to high neonatal intensive care unit (NICU) admissions. Preterm infants often face oral feeding difficulties due to immature development, which can lead to extended hospital stays and increased health risks.

AIM

To assess neonatal nurses' performance in terms of the transition to oral feeding in preterm infants, focusing on knowledge, practices, and attitudes.

METHODS

A descriptive, quantitative, multicenter, cross-sectional study was conducted across 16 hospitals in five governorates in Egypt from November 2023 to March 2024 involving 553 neonatal nurses. The data were collected through a self-administered questionnaire assessing knowledge and attitudes and through an observed checklist for nurses' practices. The study used statistical methods, including binary logistic regression, to analyze the data.

RESULTS

The findings revealed significant knowledge gaps among nurses, particularly in terms of oro-motor function, suck-swallow-breathe patterns, and nonnutritive sucking. A total of 64.6% of the nurses had unsatisfactory knowledge, 58.6% had unsatisfactory practices, and 45% had a negative attitude toward the oral feeding transition. Key predictors of satisfactory practices included higher education levels, full-time employment, and positive attitudes.

CONCLUSION

This study highlights critical gaps in neonatal nurses' knowledge and practices regarding the transition to oral feeding in preterm infants. Addressing these gaps through targeted educational interventions and ongoing support is essential for improving care quality and outcomes for infants. The findings revealed that a substantial proportion of nurses lacked adequate knowledge of critical areas, such as oro-motor function, the suck-swallow-breathe pattern, and nonnutritive sucking. These knowledge deficits could hinder the ability of nurses to provide optimal care during this crucial transition.

Epigenetics Embedding of Oral Feeding Skill Development in Preterm Infants: A Study Protocol

BACKGROUND

Preterm infants face challenges to feed orally, which may lead to failure to thrive. Oral feeding skill development requires intact neurobehaviors. Early life stress results in DNA methylation of NR3C1 and HSD11B2, which may disrupt neurobehaviors. Yet, the extent to which early life stress impairs oral feeding skill development and the biomechanism whereby this occurs remains unknown. Our team is conducting an NIH funded study (K23NR019847, 2022-2024) to address this knowledge gap.

PURPOSE

To describe an ongoing study protocol to determine the extent to which early life stress, reflected by DNA methylation of NR3C1 and HSD11B2 promoter regions, compromises oral feeding skill development.

METHODS

This protocol employs a longitudinal prospective cohort study. Preterm infants born between 26 and 34 weeks gestational age have been enrolled. We evaluate early life stress, DNA methylation, cortisol reactivity, neurobehaviors, and oral feeding skill development during neonatal intensive care unit hospitalization and at 2-week post-discharge.

RESULTS

To date, we have enrolled 70 infants. We have completed the data collection. Currently, we are in the data analysis phase of the study, and expect to disseminate the findings in 2025.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The findings from this study will serve as a foundation for future clinical and scientific inquiries that support oral feeding and nutrition, reduce post-discharge feeding difficulties and lifelong risk of maladaptive feeding behaviors and poor health outcomes. Findings from this study will also provide further support for the implementation of interventions to minimize stress in the vulnerable preterm infant population.

Effect of Nonnutritive Sucking on Oral Feeding in Neonates With Perinatal Asphyxia: A Randomized Controlled Trial

AIMS

The effect of nonnutritive sucking (NNS) stimulation is unclear in infants with perinatal asphyxia. Thus, the aim of this study was to assess the effect of NNS stimulation on oral intake, discharge time, and early feeding skills in infants with perinatal asphyxia.

DESIGN

A randomized controlled study was conducted.

METHOD

Of the 94 infants, 47 were included in the experimental group and given NNS stimulation once a day before tube feeding by a speech-language therapist (SLT) in addition to hypothermia treatment. Infants' feeding performances on the days of first oral intake and discharge were evaluated with the Early Feeding Skills Scale (EFS).

RESULTS

The time from tube feeding to oral intake was significantly lower in the experimental group compared to the control group (p < .05). EFS scores at discharge were significantly higher in the experimental group than in the control group (p < .05). There was no significant difference between the experimental and control groups in terms of discharge and weight gain (p > .05).

CONCLUSIONS

The findings indicated that the NNS stimulation positively affected oral intake and early feeding skills in infants with perinatal asphyxia, as in preterms. However, NNS stimulation had no significant effect on discharge and weight gain in infants with asphyxia. This finding may be attributed to other factors. It is recommended to use NNS by an SLT in a neonatal intensive care unit within a multidisciplinary team to accelerate the transition to oral feeding and improve feeding skills in infants with perinatal asphyxia. Further studies on the effect of NNS stimulation in infants with perinatal asphyxia are needed to corroborate its effects on discharge time and weight gain.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

Establishing Normative Values for Healthy Term Infant Feeding Performance: Neonatal Eating Assessment Tool-Mixed, Oral Feeding Scale, and Early Feeding Skills Assessment

PURPOSE

Infants with perceived feeding problems are frequently referred for assessment of their feeding abilities. However, little is known regarding how healthy nondysphagic infants perform on commonly used assessments, making determination of impairment difficult. The aim of this investigation was to elucidate the characteristics of healthy term infant feeding performance using three commonly employed clinical assessments: Neonatal Eating Assessment Tool-Mixed (NeoEat-Mixed), Oral Feeding Scale, and Early Feeding Skills (EFS).

METHOD

In this prospective case-control study, we recruited 30 infants without feeding impairments to undergo video-monitored bottle feeds under their normal feeding conditions. Caregiver perception of infant feeding was evaluated using the NeoEat-Mixed. Milk ingestion was monitored real time using the Oral Feeding Scale for rate of milk transfer and modified proficiency as characterized by the total volume consumed out of the total volume the caregiver provided. Videos were analyzed by two speech pathologists using the EFS assessment. Descriptive statistics were used to characterize performance.

RESULTS

Participants underwent feeding monitoring at an average chronological age of 4 ± 2 months. Caregivers primarily reported normal, nonconcerning feeding patterns across all of the NeoEAT-Mixed outcomes. Infants consumed milk at an average rate of transfer of 7 ± 3 ml/min, a modified proficiency of 50 ± 21%, and achieved the highest OFS score of 4 (93%, n = 28). The majority of infants scored the best EFS score (mature-3) as it related to the absence of color changes during the feed (97%, n = 29), although commonly scored in the worst EFS score (immature-1) in their presentation of one or more compelling stress cues (63%, n = 19).

CONCLUSION

Establishing healthy term infant normative values for commonly used feeding assessments is critical in accurately distinguishing infants with feeding impairments from those with normal developmental variants.

Improving feeding skills and transition to breastfeeding in early preterm infants: a randomized controlled trial of oromotor intervention

Introduction

Oromotor therapy exercises used for preterm infants in the NICU might promote oral-motor skills and shorten discharge day. This study investigates the impact of an oral-motor therapy program on the successful transition to breastfeeding (BF) and the enhancement of feeding skills in preterm infants below 30 weeks of gestational age who experience feeding intolerance.

Methods

The intervention group received oral-motor therapy programme for one month, while the control group did not. The feeding skills were evaluated by Early Feeding Skills Assessment Tool (EFS) and Preterm Oral Feeding Readiness Scales (POFRAS).

Results

There was a significant difference in EFS and POFRAS scores, transition to bottle feeding at discharge and transition to BF after discharge between babies given oral-motor therapy programme and controls (p < 0.05). While the transition time to full enteral feeds did not vary significantly between the groups, noteworthy outcomes were observed in the intervention group, including differences in feeding type at discharge, the nature of feeds at discharge, and the success of transitioning to breastfeeding after discharge.

Discussion

We conclude that the oromotor therapy exercises in NICU improves the quality of sucking, contributes to better oromotor skills and promotes transition to enteral feeding and BF in preterm babies.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT05845684).

Effects of Swaddling During Bottle Feeding in Preterm Infants

BACKGROUND

Preterm infants have immature oral feeding skills, affecting length of hospital stay and long-term feeding outcomes. Swaddling has positive effects on pain and stress responses, state regulation, and physiological stability in preterm infants in the neonatal intensive care unit (NICU). Swaddling during bottle feeding may support preterm infant behavioral organization and oral feeding skills. Swaddling is used inconsistently during feeding in the NICU and has not been critically examined for effects on bottle feeding performance in preterm infants.

PURPOSE

To examine the effects of swaddling on bottle feeding quality and efficiency in preterm infants.

METHODS

A convenience sample of 30 infants born before 34 weeks of gestation was selected in an urban level IV NICU. Using an experimental, randomized crossover design, each infant was swaddled for one feeding and unswaddled for one feeding. Feeding efficiency was measured by rate and volume consumed. Feeding quality was examined by the Early Feeding Skills Assessment and frequency of physiological changes. Data were analyzed using dependent t tests and Wilcoxon signed rank test.

RESULTS

When swaddled, participants demonstrated significantly better scores on all related subtests of the Early Feeding Skills Assessment ( P ≤ .001). Infants demonstrated no difference in frequency of bradycardia or oxygen desaturations greater than 4 seconds. No significant differences were found in feeding efficiency outcomes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Swaddling can be used in the NICU to improve bottle feeding quality in preterm infants. Future investigation is needed on long-term effects of swaddling during bottle feeding on feeding performance, weight gain, and length of stay.

Clinical validation of the infant-driven feeding scales© in Turkey

BACKGROUND

Supporting the development of feeding skills among preterm infants is an important component of neonatal care. The selection of appropriate and supportive feeding interventions begins with a comprehensive assessment of the infant's skills.

PURPOSE

This study aimed to adapt the Infant-Driven Feeding Scales© (IDFS) to the Turkish language.

METHODS

This was a methodological, observational, single-center cross-sectional study. The study included 80 infants born at a gestational age ≥ 32 weeks, consecutively admitted to a tertiary Neonatal Intensive Care Unit (NICU). Research data were collected using a premature infant descriptive information form (IDIF), IDFS, and LATCH Score for Breastfeeding Assessment. For the Turkish validity-reliability of the IDF, the translate-back translate method was used with the content validity index (CVI) assessed.

RESULTS

The scale had CVI values between 0.90 and 1.00 with a mean CVI = 0.96. For measures 1 and 2, there were significant positive and high-level correlations between IFDS-R and IFDS-Q correlation values (r = 0.553-0.958; p = 0.001) and significant negative, low-level correlations between IFDS-R and IFDS-Q with the LATCH scale (r = 0.439-0.532; p = 0.001). According to inter-observer compatibility analyses, the kappa value was 0.94-1.00 for the first measure and 0.96-1.00 for the second measure (p = 0.001). There were negative significant correlations between IDFS-R points with gestational age and postmenstrual age (PMA) (p = 0.001), and gestational age and PMA were explanatory factors for 13.8% of IDFS-R points (F = 7.30, p = 0.001).

CONCLUSIONS

The IDFS is recommended for use as a valid and reliable tool to ease the safe and successful development of oral feeding skills in preterm infants and to plan evidence-based interventions.

IMPLICATIONS FOR PRACTICE

The IDFS appears to be a beneficial measurement device for use in assessing the state of readiness of preterm infants for oral feeding and for early determination of risks that may occur due to delayed feeding independence of infants.

Psychometric properties of the oral feeding assessment in premature infants scale

Professionals that work in neonatal units need to identify the strengths and weaknesses of the premature infant who is in the transition process from feeding through a gastric tube to oral feeding. The main aim of this study was to validate the Oral FEeding Assessment in premaTure INfants (OFEATINg) instrument. A psychometric validity and reliability study was conducted in Neonatal Intensive Care Units of two public, metropolitan, university hospitals. The study population were premature infants at a postconceptional age of 31-35 weeks. The study included evaluation of the reliability, convergent, discriminant and construct validity, sensitivity and specificity of the OFEATINg instrument. A total of 621 feedings of 56 preterm infants were evaluated. Confirmatory factor analysis identified 3 factors and 13 indicators with a good fit to the model. Cronbach's alpha coefficient was 0.78. The instrument showed high indices of inter-rater reliability (Pearson 0.9 and intraclass correlation coefficient 0.95). The OFEATINg scale is a valid and reliable instrument for evaluating the readiness for oral feeding of preterm infants. It may enable clinicians to evaluate the physiological and behavioral abilities involved in the oral feeding process and help them make decisions related to the transition to full oral feeding.Clinical trial registration: This study was prospectively registered at the two Institutional review boards.

Mothers' involvement in assessing feeding skills of premature infants

OBJECTIVE

Among the problems faced by premature infants after birth are weakness in oral-motor skills and an inability to achieve oral feeding independence. The Early Feeding Skills (EFS) Assessment is a tool for identifying infant's feeding ability level and determining the levels at which an infant requires support for safe and efficient feeding. Given the effective role of mothers and their involvement in taking care of premature infants and the importance of examining the psychometric properties of tools used for assessing infant's feeding, this study aimed at evaluating inter-rater reliability (between mother and rater) using the EFS Instrument.

METHODS

This is a cross-sectional study. Participants in this study included 30 mothers with premature infants admitted to the NICU ward of Imam Khomeini Hospital in Ahvaz, Iran. To evaluate the inter-rater reliability of the "Early Feeding Skills (EFS) Assessment Instrument", feeding skills of the infants were evaluated by the mother and a rater. Statistical analysis was carried out using Intraclass Correlation Coefficients (ICC) in SPSS software (Ver. 22).

RESULTS

The inter-rater reliability of the total score for each section of the EFS Instrument was good (ICC >0.75). ICC values for inter-rater agreement in assessing Oral Feeding Readiness, Ability to Maintain Engagement in Feeding, Ability to Organize Oral-Motor Functioning, Ability to Coordinate Swallowing, Ability to Maintain Physiologic Stability, and Oral Feeding Recovery were 0.87, 0.94, 0.91, 0.85, 0.95 and, 0.80, respectively.

CONCLUSION

If mothers are appropriately trained on the EFS assessment, they can actively participate with the health care professionals providing care to their children. Furthermore, remote participation is possible. The findings of this study revealed significant inter-rater reliability.

The Effect of Training on Neonatal Nurses' Knowledge about Transitioning Preterm Infants to Oral Feeding

BACKGROUND

Neonatal nurses require knowledge of evidence-based interventions that can be utilized for supporting oral feeding skills in preterm infants. Little is known about the impact of education/training programs on neonatal nurses' knowledge of this topic.

PURPOSE

This study was conducted to determine the effect of a training program about evidence-based interventions for the transition to and support of oral feeding in preterm infants on the knowledge levels of neonatal nurses.

METHODS

We conducted a pretest-posttest studywith 73 neonatal nurses in a research and training hospital. Participants completed a demographic information form and their knowledge about oral feeding in preterm infants was assessed before and after a 240-min training about the transition to oral feeding and evidence-based therapeutic interventions to promote preterm infants' oral feeding skills.

RESULTS

Posttest scores evaluated at 1 week (81.6 ± 6.8) and 1 month (79.5 ± 6.5) after the training were significantly higher than pre-test scores (66.8 ± 6.9) (p < 0.001).

CONCLUSION

Neonatal nurses showed higher levels of knowledge about evidence-based interventions for supporting oral feeding skills in preterm infants at 1 week and 1 month after the training program compared to their knowledge before training.

IMPLICATIONS FOR PRACTICE

Providing training to neonatal intensive care nurses on the transition to oral feeding in preterm infants will increase their level of knowledge and ensure that oral feeding interventions for preterm infants can be implemented using evidence-based therapeutic methods.

Improve the clinical effective decision of the oral feeding readiness in preterm infants: Revise and validate the TC-POFRAS

BACKGROUND

Currently there is limited information to guide health professionals regarding the optimal time frame to initiate safe and effective oral feedings to preterm infants. The study aims to revise and validate a streamlined version of the Traditional Chinese-Preterm Oral Feeding Readiness Assessment Scale, the TC-POFRAS®, and evaluate its construct validity in the clinical decisions regarding feeding readiness of preterm infants.

METHODS

Eighty-one clinically stable preterm infants were assessed using the TC-POFRAS for oral feeding readiness. Item-total correlation analysis was used to check if any item was inconsistent with the averaged TC-POFRAS scores. Cronbach's α coefficient was used to evaluate the inter-item consistency. Exploratory factor analysis was used to determine the coherence of variables to reorganize assessment domains. The revised version of TC-POFRAS (TC-POFRAS®) was developed and a new cut-off score based on discriminant accuracy was established.

RESULTS

Based on the results from statistical analysis, five items ("lips posture," "tongue posture," "biting reflex," "gag reflex," and "tongue cupping") were deleted from the original TC-POFRAS to form the TC-POFRAS®. The TC-POFRAS®'s global accuracy was 92.1%. The cut-off value of 19 was the one that presented the most optimization of sensitivity based on specificity. The TC-POFRAS® was reconstructed into corrected gestational age and five behavioral domains.

CONCLUSIONS

The TC-POFRAS® is considered a valid, safe, and accurate objective instrument to assist health professionals to initiate oral feeding of preterm infants.

Effect of Left and Right Semi-elevated Side-Lying Positions on Feeding Performance of Preterm Infants

OBJECTIVE

To determine the effect of right and left semi-elevated side-lying positions on the feeding performance and skills of bottle-fed preterm infants.

DESIGN

A single-group, crossover experimental study.

SETTINGS

Level 3 NICU of a training and research hospital in Istanbul.

PARTICIPANTS

A total of 60 preterm infants born at 24 to 36 6/7 weeks gestation.

METHODS

We collected data using an infant information form, feeding observation form, and the Turkish version of the Early Feeding Skills Assessment (EFS-Turkish). For each infant, we collected data for two feeds: one in the right and one in the left semi-elevated side-lying position.

RESULTS

We found no difference between the right and left semi-elevated side-lying positions in the volume or percentage of food taken (p = .582 and p = .625, respectively), feeding duration (p = .901), or feeding efficiency (p = .423). We observed no significant differences between feedings in the left and right semi-elevated side-lying positions in mean EFS-Turkish total score (p = .251) or subscale scores (p > .05).

CONCLUSION

Neonatal nurses can feed preterm infants in both directions of the semi-elevated side-lying position when following evidence-based feeding guidelines.

Tools available to screen for child feeding dysfunction: A systematic review

INTRODUCTION

The aim of this systematic review is to identify existing pediatric feeding screening tools that have been shown to be valid and reliable in identifying feeding dysfunction in children.

METHOD

A database search produced 5862 relevant articles to be screened based on pre-determined inclusion/exclusion criteria. After full text review of 183 articles, 64 articles were included in the review.

RESULTS

Forty-four studies detailed development and validation of unique feeding screening tools for the pediatric population. The remaining twenty studies were validations studies of already developed screening tools.

DISCUSSION

Multiple screening tools identified were effective in determining feeding dysfunction in children. Several tools employed excellent techniques to measure reliability and validity for diverse pediatric populations. Careful consideration of the tools listed in this review will help practitioners determine the best method for feeding screening in their facility.

Translation and study of the measurement properties of the Early Feeding Skills Assessment tool in premature newborn

INTRODUCTION

With the aim of improving the care of the premature newborn during their hospital stay, and their well-being in the transition from enteral to independent feeding, it is proposed to incorporate an assessment system within a Spanish Neonatal Unit. The translation of the Early Feeding Skills Assessment (EFSA) tool is presented, along with a study of its measurement properties.

PATIENTS AND METHOD

A total of 104 assessments were made on premature babies of less than 34 + 6 weeks of gestational age, admitted to the neonatal unit with total or partial feeding, including a normal neurological examination for their age and with physiological stability.

RESULTS

The EFSA 2010 tool achieved an acceptable value (0.76) as regards its internal consistency. The EFSA 2018 tool maintained an acceptable internal consistency value (0.751). As regards the reliability between two observers, the results showed a satisfactory and excellent reliability in 57.69% of the items in the EFSA 2010 tool, a property that improved in the EFSA 2018 tool (73.68%).

CONCLUSIONS

The Spanish version of the EFSA tool is consistent and reliable for use as a tool for the assessment of oral abilities for feeding premature babies admitted into a Spanish Neonatal Unit.

Clinical Validation of the Preterm Oral Feeding Readiness Assessment Scale in Taiwan

PURPOSE

A successful transition from gavage to full oral feeding is a decisive indicator for discharging premature infants from the neonatal intensive care unit. A clinically useful measure of oral feeding readiness would help nurses initiate implementation of the cue-based feeding model in Taiwan. The study aimed to assess the validity and reliability of the Traditional Chinese Preterm Oral Feeding Readiness Assessment Scale (TC-POFRAS).

DESIGN AND METHODS

81 preterm infants were enrolled and assessed by TC-POFRAS regarding their oral feeding readiness. This study included two phases. Phase 1 conducted a cross language validation procedure and item-level content validity indices (I-CVIs) for content validity were estimated. In phase 2, Cronbach's alpha for internal consistency at each category and total scale levels were estimated. A receiver operating characteristic (ROC) curve was estimated to explore the scale's performance. The optimal cut-off value of TC-POFRAS was identified by the best Youden's Index [maximum (sensitivity + specificity - 1)].

RESULTS

All of the I-CVIs were 1.00. The whole Cronbach's alpha for internal consistency was 0.804 (95% CI = 0.736-0.862), and Cronbach's alpha values were between 0.538 (95% = 0.332-0.689) and 0.687 (95%CI = 0.572-0.781) for categories. The area under ROC was 92.2%, and an optimal cut-off value of TC-POFRAS was 29 (sensitivity: 0.938, specificity: 0.941).

CONCLUSIONS

The TC-POFRAS has been verified to be an effective and accurate instrument to determine the initiation of oral feeding in preterm infants.

PRACTICE IMPLICATIONS

The TC-POFRAS is an appropriate and complementary assessment instrument for professionals to conveniently use in clinical practice.

Measuring Responsive Feeding in Sri Lanka: Development of the Responsive Feeding Practices Assessment Tool

OBJECTIVE

To develop and validate a tool focusing on responsive feeding (RF) practices among mothers and infants aged between 6 and 12 months in Sri Lanka.

DESIGN

A comprehensive review, an in-depth qualitative study, and a cross-sectional study were carried out.

SETTING

Anuradhapura District, Sri Lanka.

PARTICIPANTS

Sample of mother-infant pairs (n = 170).

VARIABLES MEASURED

Items were developed by extracting data from a previous in-depth qualitative study on RF, informed by currently available RF items.

ANALYSIS

Content validation was performed among experts using standard techniques, followed by cognitive interviews among mothers. Structural validity was assessed using principal component analysis. Test-retest reliability was done with a sample of 50 mothers.

RESULTS

Cognitive validation with mothers confirmed the applicability and comprehensiveness of the tool. The tool possessed good reliability with an intraclass correlation of 0.80 and internal consistency of 0.79. The principal component analysis showed a clear 3 factor solution. The 3 factors were interpreted as responsive communication during feeding, appropriate feeding, attentive to child's signals, and proactive preparation of the feeding environment. The final version of the tool consisted of 15 items.

CONCLUSIONS AND IMPLICATIONS

The 15-item Responsive Feeding Practices Assessment Tool is a valid tool to assess RF.

[Research advances in assessment tools for feeding problems in children]

As one of the most important non-nutritional factors associated with children's growth and development, feeding problems in children are getting more and more attention from medical professionals and guardians. The evaluation of feeding problems has developed from the single-factor and descriptive research in the past to the multi-factor and analytical research at present, and thus a good quantitative analysis system is increasingly important for researchers. However, the development of localized quantitative analysis tools remains a weak link in this field. Therefore, it is a research hotspot to develop child feeding assessment scales and questionnaires with high reliability, validity, and operability in combination with China's cultural background and eating habits and provide effective assessment tools for feeding problems in Chinese children. Through classification based on research mode and screening, this article reviews the research findings in the field of child feeding, so as to provide a basis for future research.

Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review

Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding 'domains' (baby's behaviour; mother's behaviour; position; latching; effective feeding; breast health; baby's health; mother's view of  feed; number, timing and length of feeds). Results: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form. Conclusions: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.

Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review

Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding 'domains' (baby's behaviour; mother's behaviour; position; latching; effective feeding; breast health; baby's health; mother's view of  feed; number, timing and length of feeds). Results: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form. Conclusions: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.

A Behavioral Epigenetics Model to Predict Oral Feeding Skills in Preterm Infants

BACKGROUND

Preterm infants experience a multitude of prenatal and postnatal stressors, resulting in cumulative stress exposure, which may jeopardize the timely attainment of developmental milestones, such as achieving oral feeding. Up to 70% of preterm infants admitted to the neonatal intensive care unit experience challenges while initiating oral feeding. Oral feeding skills require intact neurobehavioral development. Evolving evidence demonstrates that cumulative stress exposure results in epigenetic modification of glucocorticoid-related genes. Epigenetics is a field of study that focuses on phenotypic changes that do not involve alterations in the DNA sequence. Epigenetic modification of glucocorticoid-related genes alters cortisol reactivity to environmental stimuli, which may influence neurobehavioral development, and is the essence of the evolving field of Preterm Behavioral Epigenetics. It is plausible that early-life cumulative stress exposure and the ensuing epigenetic modification of glucocorticoid-related genes impair neurobehavioral development required for achievement of oral feeding skills in preterm infants.

PURPOSE

The purpose of this article is to build upon the evolving science of Preterm Behavioral Epigenetics and present a conceptual model that explicates how cumulative stress exposure affects neurobehavioral development and achievement of oral feeding skills through epigenetic modification of glucocorticoid-related genes.

METHODS/RESULTS

Using the Preterm Behavioral Epigenetics framework and supporting literature, we present a conceptual model in which early-life cumulative stress exposure, reflected by DNA methylation of glucocorticoid-related genes and altered cortisol reactivity, disrupts neurobehavioral development critical for achievement of oral feeding skills.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Future investigations guided by the proposed conceptual model will benefit preterm infant outcomes by introducing epigenetic-based approaches to assess and monitor preterm infant oral feeding skills. Furthermore, the proposed model can guide future investigations that develop and test epigenetic protective interventions to improve clinical outcomes, representing an innovation in neonatal care.

Assessment Across the Life Span: The Clinical Swallow Evaluation

Purpose This clinical focus article considers the roles of the clinical swallow examination (CSE) as a clinically meaningful assessment method used in both adult and pediatric populations. Method This clinical focus article explores the utility of the CSE across the life span. Specifically, components, reliability, standardized assessments, and limitations of the CSE within the adult and pediatric populations are highlighted. Conclusions The CSE remains a crucial assessment tool for the speech-language pathologist. The experienced clinician can make important judgments regarding patient safety and function. If the CSE is conducted mindfully and methodically, findings can help chart the course of care for individuals needing additional assessment and possibly intervention.

Quantitative assessment of nutritive sucking patterns in preterm infants

OBJECTIVE

To assess patterns of nutritive sucking in very preterm infants ≤32 weeks of gestation.

STUDY DESIGN

Very preterm infants who attained independent oral feeding were prospectively assessed with an instrumented feeding bottle that measures nutritive sucking. The primary outcome measure was nutritive sucking performance at independent oral feeding.

RESULT

We assessed nutritive sucking patterns in 33 very preterm infants. We recorded 63 feeding sessions. The median number of sucks was 784 (IQR: 550-1053), the median sucking rate was 36/min (IQR: 27-55), and the median number of sucking bursts during the first 5 min of oral feeding was 14 (IQR: 12-16). Maximum sucking strength correlated with the number of sucks (r = 0.62; p < 0.01). No safety concerns were identified during the study.

CONCLUSION

The quantitative analysis of nutritive sucking patterns with a newly developed instrumented bottle in stable, very preterm infants is safe and feasible. More research is needed to develop and refine the instrument further.

Turkish Neonatal Nurses' Knowledge and Practices Regarding the Transition to Oral Feeding in Preterm Infants: A Descriptive, Cross-sectional Study

PURPOSE

Neonatal nurses play an important role in preterm infants' safe and successful transition to oral feeding. Little is known about neonatal nurses' knowledge and practices regarding the transition to oral feeding in preterm infants. The aim of this study was to determine neonatal nurses' knowledge levels and clinical practices related to the process of transitioning preterm infants to oral feeding.

DESIGN AND METHOD

This descriptive cross-sectional study was conducted with 275 neonatal nurses working in the neonatal intensive care units of 9 different hospitals in Istanbul, Turkey. Data were collected using a participant demographic form and a questionnaire about the neonatal nurses' knowledge and practices regarding oral feeding.

RESULTS

The mean knowledge score of the nurses in this study was 64.7 out of 100 (SD = ±8.7; range = 40-87.5). Rates of correct responses were particularly low for items related to cue-based feeding, interventions to promote oral-motor development, non-nutritive sucking, and infant positioning for oral feeding. All of the NICU nurses participating in the study did not use the protocols developed for transitioning preterm infants to oral feeding.

CONCLUSIONS

Nurses need knowledge and practical training on evidence-based therapeutic interventions that promote oral feeding skills in preterm infants during the transition to oral feeding. The use of protocols developed for transitioning preterm infants to oral feeding is limited in NICUs.

PRACTICE IMPLICATIONS

In order to facilitate safe and successful feeding, nurses should improve their knowledge and practical skills regarding the transition to oral feeding and evidence-based therapeutic interventions for preterm infants.

Patterns of Growth and Nutrition From Birth to 6 Months in Infants With Complex Congenital Cardiac Defects

BACKGROUND

Infants with complex congenital heart defects (CCHDs) experience alterations in growth that develop following surgical intervention and persist throughout early infancy, but the roles of nutritional intake and method of feeding require further exploration as their roles are not fully explained.

OBJECTIVES

The purpose of this study was to characterize trends in growth and nutritional intake during the first 6 months of life in infants with CCHD.

METHODS

We conducted a secondary analysis of growth and nutritional data from a pilot study designed to test the feasibility of nurse-guided participatory intervention with parents of infants with CCHD. Measures included demographic data, anthropometric data at birth, hospital discharge, and 6 months of age, nutritional intake at 2 and 6 months of age from parent-completed 24-hour nutrition diaries, and assessment of oral-motor skills between 1 and 2 months of age. Descriptive statistics and correlation and group differences were examined.

RESULTS

Data for 28 infants were analyzed. Infants demonstrated a decrease in weight-for-age z score (WAZ) and length-for-age z score (LAZ) from birth to hospital discharge and an increase in WAZ and LAZ by 6 months of age. Many of the infants developed failure to thrive. Across the study period, one third of the infants were receiving enteral nutrition. Infants who were orally fed had better growth WAZ and LAZ at 6 months of age when compared to infants who were enterally fed.

DISCUSSION

Infants with CCHD exhibit growth faltering throughout early infancy. Reliance on enteral nutrition did not improve growth outcomes in these infants. Findings suggest nutritional intake may not be enough to meet the nutrient requirements to stimulate catch-up growth.

Management of Oral Feeding Challenges in Neonatal Intensive Care Units (NICUs): A National Survey in China

Objectives: To investigate the current practices of oral feeding difficulties facing high-risk infants in Chinese NICUs. Methods: A questionnaire to survey infant oral feeding practices was distributed to 100 level II and III Chinese neonatal intensive care units (NICUs). Results: Responses were obtained from 88 NICUs. No Units had any structured guidelines regarding the management of infant oral feeding as they transitioned from tube to independent oral feeding. In 54 (61.4%) NICUs, nurses and physicians made shared decisions on when oral feeding were to be initiated. Fifty-four (61.4%) and 22 (25.0%) NICUs used postmenstrual age (PMA) or weight at PMA as a criterion for initiating oral feedings, respectively. The top three criteria to determine introduction of oral feeding were severity of disease, presence of sucking reflex, and trial feeding success. Adverse events were used by 78 Units as indices of oral feeding difficulty. Twenty (22.7%) and 25 (28.4%) Units had access to occupational therapists or nurses who provided oral motor interventions during feeding, i.e., oral support (chin and cheek support, aid to deglutition), non-nutritive sucking with pacifier, and oral stimulation. Conclusions: The management of oral feeding issues in NICUs vary widely in China in relation to the assessment of readiness to oral feeding, daily oral feeding practices and interventions used by staff. It is proposed that an educational program focused on the physiology of infant oral feeding, available evidence-based tools and interventions would assist NICU caregivers develop structured guidelines to improve infants' safe and efficient attainment of independent oral feeding.

Neonatal Eating Assessment Tool - Mixed Breastfeeding and Bottle-Feeding (NeoEAT - Mixed Feeding): factor analysis and psychometric properties

BACKGROUND

Early identification of feeding difficulty in infancy is critical to supporting breastfeeding and ensuring optimal nutrition for brain development. The Neonatal Eating Assessment Tool (NeoEAT) is a parent-report assessment that currently has two versions: NeoEAT - Breastfeeding and NeoEAT - Bottle-feeding for use in breast and bottle-fed infants, respectively. There are currently no valid and reliable parent-report measures to assess feeding through a combination of both breast and bottle delivery. The purpose of this study was to conduct a factor analysis and test the psychometric properties of a new measure, the NeoEAT - Mixed Breastfeeding and Bottle-Feeding (NeoEAT - Mixed Feeding), including internal consistency reliability, test-retest reliability, construct validity and known-groups validity.

METHODS

Parents of infants younger than 7 months who had fed by both bottle and breast in the previous 7 days were invited to participate. Internal consistency reliability was tested using Cronbach's α. Test-retest reliability was tested between scores on the NeoEAT - Mixed Feeding completed 2 weeks apart. Construct validity was tested using correlations between the NeoEAT - Mixed-Feeding, the Infant Gastroesophageal Reflux Questionnaire - Revised (I-GERQ-R), and the Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Known-groups validation was tested between healthy infants and infants with feeding problems.

RESULTS

A total of 608 parents participated. Exploratory factor analysis revealed a 68-item scale with 5 sub-scales. Internal consistency reliability (Cronbach's α = .88) and test-retest reliability (r = 0.91; p < .001) were both acceptable. Construct validity was demonstrated through correlations with the I-GERQ-R (r = 0.57; p < .001) and IGSQ (r = 0.5; p < .001). Infants with feeding problems scored significantly higher on the NeoEAT - Mixed Feeding, indicating more problematic feeding symptoms, than infants without feeding problems (p < .001), supporting known-groups validity.

CONCLUSIONS

The NeoEAT - Mixed Feeding is a 68-item parent-reported measure of breast- and bottle-feeding behavior for infants less than 7 months old that now has evidence of validity and reliability for use in clinical practice and research. The NeoEAT - Mixed Feeding can be used to identify infants with problematic feeding, guide referral decisions, and evaluate response to interventions.