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Njeh M, Sultana Z, Plumb T, Alshaikh E, Jadcherla SR. Comparison of direct effects of rice-thickened formula vs routine feeds on symptoms and gastroesophageal reflux indices: A crossover cohort study. JPEN J Parenter Enteral Nutr 2024; 48:64-73. [PMID: 37850573 DOI: 10.1002/jpen.2566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND We compared the direct effects of routine vs rice-thickened formula on 24-h pH-impedance and symptom characteristics and then examined if dietary effects were modified by acid reflux index severity in infants. METHODS Forty infants under consideration for gastroesophageal reflux disease and therapies were evaluated at 43 ± 1 weeks postmenstrual age. Each infant was equally fed routine diet and thickened formula during evaluations. Postprandial sessions were analyzed for acid reflux index, reflux events, clearance times, distal baseline impedance, and symptoms. RESULTS Thickened formula has no effect (P ≥ 0.05) on acid reflux events' characteristics or overall symptom frequency. However, refluxate height and frequency of weakly acidic events and cough were decreased (P < 0.05). Prolonged bolus clearance and a decrease in distal baseline impedance were noted with thickened feeds (vs routine feeds) when acid reflux index was >7 (P < 0.05). CONCLUSION Our pH-impedance testing protocol identifies direct effects of potential therapies at the point of care. Acutely, thickened formula does not impact acid-specific reflux indices but decreases full-column reflux and cough reflexes. In those with an acid reflux index of >7, thickened formula prolongs the distal esophageal bolus clearance (the mechanisms of which are uncertain). Clinical trials are needed to clarify objective indications and therapeutic use of thickened formulas for infants with gastroesophageal reflux disease, along with short- and long-term side effects.
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Affiliation(s)
- Minna Njeh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Zakia Sultana
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Toni Plumb
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Enas Alshaikh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sudarshan R Jadcherla
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio, USA
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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2
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Osborn EK, Alshaikh E, Nelin LD, Jadcherla SR. A decade of evidence: standardized feeding initiative targeting feeding milestones and predicting NICU stays in premature infants in an all-referral level IV NICU. J Perinatol 2023; 43:1105-1112. [PMID: 37117395 PMCID: PMC10147899 DOI: 10.1038/s41372-023-01675-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/10/2023] [Accepted: 04/12/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Ten-year data from the simplified, individualized, milestone-targeted, pragmatic, longitudinal and educational (SIMPLE) feeding initiative were examined by gestational age (GA) category to characterize the feeding milestones, length of hospital stays (LOHS), annual variability and predictive models for LOHS. STUDY DESIGN Preterm infants (≤32 weeks GA, N = 434) in level-IV NICU had milestone-targeted feeding plans. Continuous data were analyzed for outcomes. RESULTS Over 93% successfully attained full oral feedings. Earlier acquisition of feeding milestones correlated with earlier discharge (P < 0.05). Year-wise analysis showed sustained maintenance of milestones (P < 0.05). Milestones and outcomes (P < 0.001) were significantly correlated with different GA categories. Prediction models for LOHS were derived using GA, BPD, age at full enteral, postmenstrual age (PMA) at 1st and full oral feeds. CONCLUSIONS The SIMPLE feeding program minimized variability and promoted acquisition of feeding milestones consistently. LOHS is predictable using feeding milestones, co-morbidities, GA, and PMA at feeding milestones.
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Affiliation(s)
- Erika K Osborn
- The Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Enas Alshaikh
- The Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Leif D Nelin
- Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- The Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
- Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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3
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Miller AN, Shepherd EG, El-Ferzli G, Nelin LD. Multidisciplinary bronchopulmonary dysplasia care. Expert Rev Respir Med 2023; 17:989-1002. [PMID: 37982177 DOI: 10.1080/17476348.2023.2283120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/09/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION Bronchopulmonary dysplasia (BPD) is a chronic respiratory disease in neonates and infants, which often presents with multisystem organ involvement, co-morbidities, and prolonged hospital stays. Therefore, a multidisciplinary chronic care approach is needed in the severest forms of BPD to optimize outcomes. However, this approach can be challenging to implement. The objective of this article is to review and synthesize the available literature regarding multidisciplinary care in infants and children with established BPD, and to provide a framework that can guide clinical practice and future research. AREAS COVERED A literature search was conducted using Ovid MEDLINE, CINAHL, and Embase and several components of multidisciplinary management of BPD were identified and reviewed, including chronic care, team development, team members, discharge planning, and outpatient care. EXPERT OPINION Establishing a core multidisciplinary group familiar with the chronicity of established BPD is recommended as best practice for this population. Acknowledging this is not feasible for all individual centers, it is important for clinical practice and future research to focus on the development and incorporation of national consulting services, telemedicine, and educational resources.
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Affiliation(s)
- Audrey N Miller
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital and Division of Neonatology, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | - Edward G Shepherd
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital and Division of Neonatology, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | - George El-Ferzli
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital and Division of Neonatology, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | - Leif D Nelin
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital and Division of Neonatology, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
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4
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Spagnoli J, Dhanireddy R, Gannon E, Chilakala S. Effect of cue-based feeding on time to nipple feed and time to discharge in very low birth weight infants. Sci Rep 2023; 13:9509. [PMID: 37308556 DOI: 10.1038/s41598-023-36634-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 06/07/2023] [Indexed: 06/14/2023] Open
Abstract
The objective of this study is to evaluate the effectiveness of a cue-based feeding protocol in improving time to nipple feed and time to discharge in very low birth weight infants in a Level III Neonatal Intensive Care Unit. Demographic, feeding, and discharge data were recorded and compared between the two cohorts. The pre-protocol cohort included infants born from August 2013 through April 2016 and the post-protocol cohort included infants born from January 2017 through December 2019. 272 infants were included in the pre-protocol cohort and 314 infants in the post-protocol cohort. Both cohorts were statistically comparable in gestational age, gender, race, birthweight, prenatal care, antenatal steroid use, and rates of maternal diabetes. There were statistically significant differences between the pre- versus post-protocol cohorts in median post-menstrual age (PMA) in days at first nipple feed (PO) (240 vs 238, p = 0.025), PMA in days at full PO (250 vs 247, p = 0.015), and length of stay in days (55 vs 48, p = 0.0113). Comparing each year in the post-protocol cohort, for each outcome measure, a similar trend was noted in 2017 and 2018, but not in 2019. In conclusion, the cue-based feeding protocol was associated with a decrease in the time to first PO, time to full nipple feeds, and the length of stay in very-low-birthweight infants.
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Affiliation(s)
- Jonathan Spagnoli
- Department of Pediatrics, Division of Neonatology, The University of Tennessee Health Science Center, 201 Rout Center for Women and Newborns, 853 Jefferson Avenue, Memphis, TN, 38103, USA
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, Division of Neonatology, The University of Tennessee Health Science Center, 201 Rout Center for Women and Newborns, 853 Jefferson Avenue, Memphis, TN, 38103, USA
- Regional One Health Rout Center for Women and Newborns, Memphis, TN, USA
| | - Emily Gannon
- Department of Pediatrics, Division of Neonatology, The University of Tennessee Health Science Center, 201 Rout Center for Women and Newborns, 853 Jefferson Avenue, Memphis, TN, 38103, USA
| | - Sandeep Chilakala
- Department of Pediatrics, Division of Neonatology, The University of Tennessee Health Science Center, 201 Rout Center for Women and Newborns, 853 Jefferson Avenue, Memphis, TN, 38103, USA.
- Regional One Health Rout Center for Women and Newborns, Memphis, TN, USA.
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Mayerl CJ, Gould FDH, Adjerid K, Edmonds C, German RZ. The Pathway from Anatomy and Physiology to Diagnosis: A Developmental Perspective on Swallowing and Dysphagia. Dysphagia 2023; 38:33-41. [PMID: 35441265 PMCID: PMC9579268 DOI: 10.1007/s00455-022-10449-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 04/04/2022] [Indexed: 01/29/2023]
Abstract
Dysphagia results from diverse and distinct etiologies. The pathway from anatomy and physiology to clinical diagnosis is complex and hierarchical. Our approach in this paper is to show the linkages from the underlying anatomy and physiology to the clinical presentation. In particular, the terms performance, function, behavior, and physiology are often used interchangeably, which we argue is an obstacle to clear discussion of mechanism of pathophysiology. We use examples from pediatric populations to highlight the importance of understanding anatomy and physiology to inform clinical practice. We first discuss the importance of understanding anatomy in the context of physiology and performance. We then use preterm infants and swallow-breathe coordination as examples to explicate the hierarchical nature of physiology and its impact on performance. We also highlight where the holes in our knowledge lie, with the ultimate endpoint of providing a framework that could enhance our ability to design interventions to help patients. Clarifying these terms, and the roles they play in the biology of dysphagia will help both the researchers studying the problems as well as the clinicians applying the results of those studies.
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Affiliation(s)
- C J Mayerl
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH, 44272, USA
| | - F D H Gould
- Department of Cell Biology and Neuroscience, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - K Adjerid
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH, 44272, USA
| | - C Edmonds
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH, 44272, USA
| | - R Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH, 44272, USA.
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Hasenstab KA, Prabhakar V, Helmick R, Yildiz V, Jadcherla SR. Pharyngeal biorhythms during oral milk challenge in high-risk infants: Do they predict chronic tube feeding? Neurogastroenterol Motil 2023; 35:e14492. [PMID: 36371708 PMCID: PMC10078406 DOI: 10.1111/nmo.14492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Eating difficulties are common in high-risk neonatal intensive care unit (NICU) infants; mechanisms remain unclear. Crib-side pharyngo-esophageal motility testing is utilized to assess contiguous swallowing physiology, and cross-system interplay with cardio-respiratory rhythms. Aims were to: (1) identify whether distinct pharyngeal rhythms exist during oral milk challenge (OMC), and (2) develop a chronic tube feeding risk prediction model in high-risk infants. METHODS Symptomatic NICU infants (N = 56, 29.7 ± 3.7 weeks birth gestation) underwent pharyngo-esophageal manometry with OMC at 40.9 ± 2.5 weeks postmenstrual age (PMA). Exploratory cluster data analysis (partitioning around k-medoids) was performed to identify patient groups using pharyngeal contractile rhythm data (solitary swallows and swallows within bursts). Subsequently, (a) pharyngeal-esophageal, cardio-respiratory, and eating method characteristics were compared among patient groups using linear mixed models, and (b) chronic tube feeding prediction model was created using linear regression. RESULTS Three distinct patient groups were identified with validity score of 0.6, and termed sparse (high frequency of solitary swallows), intermediate, or robust (high swallow rate within bursts). Robust group infants had: lesser pharyngeal and esophageal variability, greater deglutition apnea, pharyngeal activity, and esophageal activity (all p < 0.05), but less frequent heart rate decreases (p < 0.05) with improved clinical outcomes (milk transfer rate, p < 0.001, and independent oral feeding at discharge, p < 0.03). Chronic tube feeding risk = -11.37 + (0.22 × PMA) + (-0.73 × bronchopulmonary dysplasia) + (1.46 × intermediate group) + (2.57 × sparse group). CONCLUSIONS Robust pharyngeal rhythm may be an ideal neurosensorimotor biomarker of independent oral feeding. Differential maturation of cranial nerve-mediated excitatory and inhibitory components involving foregut, airway, and cardiac rhythms distinguishes the physiologic and pathophysiologic basis of swallowing and cardio-respiratory adaptation.
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Affiliation(s)
- Kathryn A Hasenstab
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Varsha Prabhakar
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Roseanna Helmick
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Vedat Yildiz
- Biostatistics Resource at Nationwide Children's Hospital (BRANCH), Columbus, Ohio, USA.,Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sudarshan R Jadcherla
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Division of Neonatology, Pediatric Gastroenterology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Alemdar DK, İnal S, Bulut M. Clinical validation of the infant-driven feeding scales© in Turkey. J Pediatr Nurs 2022; 67:148-154. [PMID: 36122545 DOI: 10.1016/j.pedn.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/20/2022] [Accepted: 09/07/2022] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Dilek Küçük Alemdar
- Associate Professor, Ordu University Faculty of Health Sciences, Department of Pediatric Nursing, Ordu, Turkey.
| | - Sevil İnal
- Professor, İstanbul-Cerrah Paşa University Faculty of Health Sciences, Department of Midwifery, İstanbul, Turkey
| | - Muhammet Bulut
- MD, Associate Professor, Giresun University Faculty of Medicine, Department of Pediatrics, Giresun, Turkey
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Hasenstab KA, Jadcherla SR. Evidence-Based Approaches to Successful Oral Feeding in Infants with Feeding Difficulties. Clin Perinatol 2022; 49:503-520. [PMID: 35659100 DOI: 10.1016/j.clp.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Infants in the neonatal intensive care unit (NICU) frequently have feeding difficulties with the root cause remaining elusive to identify. Evaluation of the provider/parent/infant feeding process may provide objective clues to sources of feeding difficulty. Specialized testing may be necessary to determine if the infant's swallowing skills are dysfunctional, immature, or maldeveloped, and to determine the risk of feeding failure or chronic tube feeding. Current evidence-based diagnostic and management approaches resulting in successful oral feeding in the NICU infant are discussed.
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Affiliation(s)
- Kathryn A Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA
| | - Sudarshan R Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA; Division of Neonatology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Division Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, USA.
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9
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Osborn EK, Jadcherla SR. Developing a Quality Improvement Feeding Program for NICU Patients. Neoreviews 2022; 23:e23-e35. [PMID: 34970663 DOI: 10.1542/neo.23-1-e23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Practices in NICUs vary widely, particularly when clinical decisions involve complex tasks and multiple disciplines, which occurs with feeding preterm infants. Neonatal feeding difficulties in preterm infants often lead to prolonged tube feeding and therefore lengthened hospital stays. Education and compliance with evidence-based protocols and guidelines are needed on the initiation of feedings and feeding advancement to transform enteral and oral feeding practices and thus reduce practice variation and improve clinical outcomes.
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Affiliation(s)
- Erika K Osborn
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Sudarshan R Jadcherla
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH.,Divisions of Neonatology and Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
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10
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McFadden A, Fitzpatrick B, Shinwell S, Tosh K, Donnan P, Wallace LM, Johnson E, MacGillivray S, Gavine A, Farre A, Mactier H. Cue-based versus scheduled feeding for preterm infants transitioning from tube to oral feeding: the Cubs mixed-methods feasibility study. Health Technol Assess 2021; 25:1-146. [PMID: 34878383 DOI: 10.3310/hta25740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Shona Shinwell
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Karen Tosh
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Peter Donnan
- Tayside Clinical Trials Unit, University of Dundee, Dundee, UK
| | - Louise M Wallace
- School of Health, Wellbeing and Social Care, The Open University, Milton Keynes, UK
| | | | | | - Anna Gavine
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Albert Farre
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Helen Mactier
- Princess Royal Maternity, NHS Greater Glasgow and Clyde, Glasgow, UK
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Sultana Z, Hasenstab KA, Jadcherla SR. Pharyngoesophageal motility reflex mechanisms in the human neonate: importance of integrative cross-systems physiology. Am J Physiol Gastrointest Liver Physiol 2021; 321:G139-G148. [PMID: 34105355 PMCID: PMC8410102 DOI: 10.1152/ajpgi.00480.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Swallowing is a critical function for survival and development in human neonates and requires cross-system coordination between neurological, airway, and digestive motility systems. Development of pharyngoesophageal motility is influenced by intra- and extrauterine development, pregnancy complications, and neonatal comorbidities. The primary role of these motility reflex mechanisms is to maintain aerodigestive homeostasis under basal and adaptive biological conditions including oral feeding, gastroesophageal reflux, and sleep. Failure may result in feeding difficulties, airway compromise, dysphagia, aspiration syndromes, and chronic eating difficulties requiring prolonged tube feeding. We review the integration of cross-systems physiology to describe the basis for physiological and pathophysiological neonatal aerodigestive functions.
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Affiliation(s)
- Zakia Sultana
- 1Innovative Infant Feeding Disorders Research Program, Center for
Perinatal Research, Nationwide Children’s Hospital Research Institute, Columbus, Ohio
| | - Kathryn A. Hasenstab
- 1Innovative Infant Feeding Disorders Research Program, Center for
Perinatal Research, Nationwide Children’s Hospital Research Institute, Columbus, Ohio
| | - Sudarshan R. Jadcherla
- 1Innovative Infant Feeding Disorders Research Program, Center for
Perinatal Research, Nationwide Children’s Hospital Research Institute, Columbus, Ohio,2Divisions of Neonatology, Pediatric Gastroenterology, and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio,3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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12
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Lane A, Pacella J, Beal JR, Sahmoun AE, Fedo-Rosvold S, Bellas WM, Brower-Breitwieser C. A cross-sectional analysis of infant-driven and traditional feeding outcomes for neonatal intensive care unit infants. J Perinatol 2021; 41:1865-1872. [PMID: 34012051 DOI: 10.1038/s41372-021-01084-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/31/2021] [Accepted: 04/29/2021] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Audrey Lane
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Jonathan Pacella
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA.
| | - James R Beal
- Department of Family Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Abe E Sahmoun
- Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Susan Fedo-Rosvold
- Neonatal Intensive Care Unit, Sanford Children's Hospital Fargo, Fargo, ND, USA
| | - William M Bellas
- Neonatal Intensive Care Unit, Sanford Children's Hospital Fargo, Fargo, ND, USA
| | - Carrie Brower-Breitwieser
- Sanford Health Eating Disorders and Weight Management Center, Fargo, ND, USA. .,Department of Psychiatry and Behavioral Sciences, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA.
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Alain C, Samson N, Nadeau C, Beaudoin JF, Lienhart C, Counil C, Praud JP. Nasal respiratory support and tachypnea and oral feeding in full-term newborn lambs. J Appl Physiol (1985) 2021; 130:1436-1447. [PMID: 33661723 DOI: 10.1152/japplphysiol.00567.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Newborn infants with respiratory difficulties frequently require nasal respiratory support such as nasal continuous positive airway pressure (nCPAP) or high-flow nasal cannulae (HFNC). Oral feeding of these infants under nasal respiratory support remains controversial out of fear of aspiration and cardiorespiratory events. The main objective of this study was to evaluate the safety of oral feeding under different types of nasal respiratory support in newborn lambs without or with tachypnea. Eight lambs aged 4-5 days were instrumented to record sucking, swallowing, respiration, ECG, oxygen saturation, and arterial blood gases. Each lamb was given two bottles of 30 mL of milk with a pause of 30 s under videofluoroscopy in four conditions [no respiratory support, nCPAP 6 cmH2O, HFNC 7 L/min, HFNCCPAP (= HFNC 7 L/min + CPAP 6 cmH2O)] administered in random order. The study was conducted in random order over 2 days, with or without standardized tachypnea induced by thoracic compression with a blood pressure cuff. Generalized linear mixed models were used to compare the four nasal respiratory supports in terms of safety (cardiorespiratory events and aspiration), sucking-swallowing-breathing coordination, and efficacy of oral feeding. Results reveal that no nasal respiratory support impaired the safety of oral feeding. Most of the few laryngeal penetrations we observed occurred with HFNCCPAP. Nasal CPAP modified sucking-swallowing-breathing coordination, whereas the efficiency of oral feeding decreased under HFNCCPAP. Results were similar with or without tachypnea. In conclusion, oral feeding under nasal respiratory support is generally safe in a term lamb, even with tachypnea.NEW & NOTEWORTHY The practice of orally feeding newborns suffering from respiratory problems while on nCPAP or HFNC remains controversial for fear of triggering cardiorespiratory events or aspiration pneumonia, or aggravating chronic lung disease. The present results show that bottle-feeding is generally safe in full-term lambs under nasal respiratory support, both without and with tachypnea.
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Affiliation(s)
- Charles Alain
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Nathalie Samson
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Charlène Nadeau
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-François Beaudoin
- Centre d'imagerie moléculaire de Sherbrooke (CIMS), Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Camille Lienhart
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Clément Counil
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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NICU infants who require a feeding gastrostomy for discharge. J Pediatr Surg 2021; 56:449-453. [PMID: 32828544 DOI: 10.1016/j.jpedsurg.2020.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/05/2020] [Accepted: 07/18/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine population data for infants receiving a gastrostomy tube (GT) in our Neonatal Intensive Care Unit (NICU) to better understand the premature infant population at risk for GT prior to discharge. STUDY DESIGN We identified all NICU infants born 2015-2016 who received a GT and determined the birth gestational age below which GTs were placed due to oral feeding failure secondary to prematurity-related comorbidities, rather than anomalies or other reasons. Aggregate data were used to compare infants born <30 weeks (w) gestation who received a GT with those who did not. RESULTS GTs were placed in 117 infants. More than half of the NICU patients who receive GTs were actually >32 weeks gestation; a cut-off of <30w was a good identifier for those who failed achieving full oral feeds due to prematurity-related problems. Infants born <30w (n = 282) not receiving GTs were discharged at a significantly lower postmenstrual age (36w) and lower weight (2.3 kg) compared with infants who received a GT (49w, 5 kg). CONCLUSIONS The population of premature infants born <30w gestation constitute the population of infants at risk for a GT based solely on prematurity. LEVELS OF EVIDENCE III.
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Differentiating esophageal sensitivity phenotypes using pH-impedance in intensive care unit infants referred for gastroesophageal reflux symptoms. Pediatr Res 2021; 89:636-644. [PMID: 32375162 PMCID: PMC7644596 DOI: 10.1038/s41390-020-0930-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 03/24/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND To identify esophageal sensitivity phenotypes relative to acid (SAcid), bolus (SBolus), acid and bolus (SAcid+Bolus), and none (SNone) exposures in infants suspected with gastroesophageal reflux disease (GERD). METHODS Symptomatic infants (N = 279) were evaluated for GERD at 42 (40-45) weeks postmenstrual age using 24-h pH-impedance. Symptom-associated probability (SAP) for acid and bolus components defined esophageal sensitivity: (1) SAcid as SAP ≥ 95% for acid (pH < 4), (2) SBolus as SAP ≥ 95% for bolus, (3) SAcid+Bolus as SAP ≥ 95% for acid and bolus, or (4) SNone as SAP < 95% for acid and bolus. RESULTS Esophageal sensitivity prevalence (SAcid, SBolus, SAcid+Bolus, SNone) was 28 (10%), 94 (34%), 65 (23%), and 92 (33%), respectively. Emesis occurred more in SBolus and SAcid+Bolus vs SNone (p < 0.05). Magnitude (#/day) of cough and emesis events increased with SBolus and SAcid+Bolus vs SNone (p < 0.05). SAcid+Bolus had increased acid exposure vs SNone (p < 0.05). Distributions of feeding and breathing methods were distinct in infants with SBolus vs SNone (both, p < 0.05). Multivariate analysis revealed that arching and irritability events/day were lesser at higher PMAs (p < 0.001) and greater for infants on NCPAP (p < 0.01) with SBolus and SAcid+Bolus (p < 0.05). Coughs/day was greater at higher PMAs (p < 0.001) for infants with gavage and transitional feeding methods (p < 0.02) with SBolus and SAcid+Bolus (p < 0.05) but lesser with Trach (p < 0.001). Number of emesis events/day were greater with SBolus and SAcid+Bolus (p < 0.001). Sneezes/day decreased for infants on Trach (p = 0.02). CONCLUSIONS Feeding and breathing methods can influence the frequency and type of aerodigestive symptoms. We differentiated esophageal sensitivity phenotypes in NICU infants referred for GERD symptoms using pH-impedance. Acid sensitivity alone was rare, which may explain poor response to acid suppressives; aerodigestive symptoms were predominantly linked with bolus spread. Magnitude of esophageal acid exposure and esophageal sensitivity to bolus spread may explain the pathophysiological basis for symptoms. IMPACT Objective GERD diagnosis and reasons for symptoms in NICU infants remains unclear. Differentiation of esophageal sensitivities by acid and bolus components of GER reveal distinct symptom profiles, specifically the bolus component of GER significantly contributes to symptom occurrence. Acid only sensitivity to GER is rare, and acid-suppressive therapy alone may not improve symptoms in a majority of NICU infants. Magnitude of esophageal acid exposure and esophageal sensitivity to any bolus spread may explain the pathophysiological basis for symptoms. Feeding and breathing methods can influence the frequency and type of aerodigestive symptoms. GERD treatments should be individualized to the patient's GERD phenotype and likely also target the bolus component of GER.
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Abstract
BACKGROUND There has been an increase in infants with neonatal abstinence syndrome (NAS) in neonatal intensive care units (NICUs) over the past several decades. Infants with NAS experience withdrawal as a result of the sudden termination at birth of substance exposure during pregnancy. A serious sign related to infants diagnosed with NAS is poor feeding. The prevalence of NAS urges researchers and clinicians to develop effective strategies and techniques to treat and manage the poor feeding of infants exposed to substances in utero. PURPOSE To synthesize current feeding methods and practices used for infants diagnosed with NAS. METHODS/SEARCH STRATEGY PubMed, CINAHL, and Scopus were searched for articles published within the last 20 years that focused on feeding practices or feeding schedules, were written in English, were peer-reviewed, and described human studies. The search terms utilized were "neonatal abstinence syndrome" OR "neonatal opioid withdrawal syndrome" AND "feeding." FINDINGS/RESULTS Three findings emerged regarding techniques and management of poor feeding in the NAS population. The findings included infants who received mother's own milk had decreased severity and later onset of clinical signs of withdrawal, demand feeding is recommended, and the infant's cues may be helpful to follow when feeding. IMPLICATIONS FOR PRACTICE Clinicians should encourage mother's own milk in this population unless contraindications are present. Caregivers and clinicians must be receptive to cues when feeding infants with NAS. IMPLICATIONS FOR RESEARCH Even with the clinical knowledge and experience that infants with NAS are difficult to feed, there is limited research assessing techniques and schedules that are effective in managing successful feeding. Future research should compare feeding schedules such as on-demand feeding versus regimented feeding schedules, as well as investigate techniques that mothers and nurses can utilize to encourage oral intake in this population.Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=37.
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Celen R, Tas Arslan F, Soylu H. Effect of SINC Feeding Protocol on Weight Gain, Transition to Oral Feeding, and the Length of Hospitalization in Preterm Infants: A Randomized Controlled Trial. JPEN J Parenter Enteral Nutr 2020; 45:567-577. [PMID: 33236355 DOI: 10.1002/jpen.2049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 11/17/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Raziye Celen
- Department of Pediatric Nursing, Faculty of Nursing, Selçuk University, Konya, Turkey
| | - Fatma Tas Arslan
- Department of Pediatric Nursing, Faculty of Nursing, Selçuk University, Konya, Turkey
| | - Hanifi Soylu
- Department of Pediatrics, Faculty of Medicine, Selçuk University, Konya, Turkey
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Abstract
In the United States, preterm birth rates have steadily increased since 2014. Despite the recent advances in neonatal-perinatal care, more than 40% of very low-birth-weight infants develop chronic lung disease (CLD) and almost 25% have feeding difficulties resulting in delayed achievement of full oral feeds and longer hospital stay. Establishment of full oral feeds, a major challenge for preterm infants, becomes magnified among those on respiratory support and/or with CLD. The strategies to minimize aerodigestive disorders include supporting nonnutritive sucking, developing infant-directed feeding protocols, sensory oromotor stimulation, and early introduction of oral feeds.
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Bapat R, Gulati IK, Jadcherla S. Impact of SIMPLE Feeding Quality Improvement Strategies on Aerodigestive Milestones and Feeding Outcomes in BPD Infants. Hosp Pediatr 2019; 9:859-866. [PMID: 31658999 DOI: 10.1542/hpeds.2018-0243] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Delays with enteral and oral feeding milestones among premature infants with bronchopulmonary dysplasia (BPD) can be due to provider variation or infant-dependent factors. Our objectives with this study were to compare aerodigestive milestones and length of stay in BPD infants after implementing a quality improvement program to improve feeding outcomes. METHODS Using the Institute for Healthcare Improvement model for quality improvement, we implemented the simplified, individualized, milestone-targeted, pragmatic, longitudinal, and educational (SIMPLE) feeding strategy to enhance feeding and aerodigestive milestones among BPD infants. The key interventions addressed were as follows: (1) enteral feed initiation and advancement protocol; (2) oral feeding progression guidelines, optimization of respiratory support, feeding readiness scores, nonnutritive breastfeeding, and cue-based feeding; (3) active multidisciplinary collaboration; and (4) family-centered care. Comparisons were made between baseline (January 2009 to March 2010) and SIMPLE feeding strategy (May 2010 to December 2013) groups. Both groups included infants between 23 0/7 and 32 6/7 weeks' birth gestation, and ≤34 weeks' postmenstrual age at admission and discharge. RESULTS The baseline group and SIMPLE feeding group included 92 patients and 187 patients, respectively. Full enteral feeding, first oral feeding, full oral feeding, and length of stay milestones were (all P < .05) achieved sooner in the SIMPLE feeding group. Although the overall prevalence of BPD in the 2 groups is similar, the incidence of moderate BPD has decreased (P < .05) and severe BPD has increased (P < .05) in the SIMPLE feeding group. CONCLUSIONS SIMPLE feeding strategy advances postnatal maturation and acquisition of feeding milestones irrespective of the severity of BPD and impacts the length of stay, thereby lowering resource use.
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Affiliation(s)
- Roopali Bapat
- Nationwide Children's Hospital, Columbus, Ohio; and
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Ish K Gulati
- Nationwide Children's Hospital, Columbus, Ohio; and
- Innovative Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Sudarshan Jadcherla
- Nationwide Children's Hospital, Columbus, Ohio; and
- Innovative Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
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Viswanathan S, Jadcherla S. Transitioning from gavage to full oral feeds in premature infants: When should we discontinue the nasogastric tube? J Perinatol 2019; 39:1257-1262. [PMID: 31366911 DOI: 10.1038/s41372-019-0446-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND The optimal timing for discontinuation of nasogastric (NG) tube in premature infants transitioning to oral feeding is not known. OBJECTIVE To determine whether early removal of NG-tube is appropriate in low-risk premature infants. METHODS Prospectively collected data of premature infants started on oral feeds at ≤34 weeks gestation were reviewed. Infants were categorized into 'early' or 'late' NG-removal groups based on the proportion of oral intake in the preceding 2-days, i.e., 60-79% or 80-100% of the total volume, respectively. RESULTS In total 50 infants in early group vs. 43 in late group. Both groups had similar oral intake and weight change in the subsequent 2-days post-NG removal. The days from NG-removal to target oral volume, and to hospital discharge trended shorter in early vs. late group. CONCLUSIONS Discontinuing NG-tube when the oral feeding competency reaches ~75% of prescribed feeding volume is safe and appropriate in low-risk premature infants.
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Affiliation(s)
- Sreekanth Viswanathan
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA. .,Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
| | - Sudarshan Jadcherla
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.,Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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Canning A, Fairhurst R, Chauhan M, Weir KA. Oral Feeding for Infants and Children Receiving Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula Respiratory Supports: A Survey of Practice. Dysphagia 2019; 35:443-454. [DOI: 10.1007/s00455-019-10047-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/09/2019] [Accepted: 08/05/2019] [Indexed: 12/19/2022]
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Collins CR, Hasenstab KA, Nawaz S, Jadcherla SR. Mechanisms of Aerodigestive Symptoms in Infants with Varying Acid Reflux Index Determined by Esophageal Manometry. J Pediatr 2019; 206:240-247. [PMID: 30466790 PMCID: PMC6389384 DOI: 10.1016/j.jpeds.2018.10.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To test whether symptom generation in infants is related to the severity of gastroesophageal reflux disease (GERD) symptoms as determined by the Acid Reflux Index (ARI), stimulus media, and stimulus volume during provocative esophageal manometry. STUDY DESIGN Symptomatic neonates (n = 74) born at a median of 28.9 weeks gestation (range, 23.4-39.4 weeks) were studied at a median of 41.0 weeks (range, 34.6-48.0 weeks) postmenstrual age using 24-hour pH-impedance methods to determine ARI severity, followed by provocative esophageal manometry with graded mid-esophageal infusions (0.1-5.0 mL) of air, water, and apple juice. Peristaltic reflexes and symptom characteristics were compared among ARI severity categories using linear mixed models and generalized estimating equations. RESULTS The effects of 2635 separate esophageal stimuli on reflexes and symptoms were analyzed. Peristaltic reflexes occurred in 1880 infusions (71%), and physical, cardiorespiratory, sensory symptoms were seen in 439 infusions (17%). Symptom prevalence did not differ across the ARI severity categories (ARI <3, 18%; ARI 3-7, 17%; ARI >7, 16%; P = 1.0). Symptom and peristaltic responses increased with incremental stimulus volumes (all media, P < .001). CONCLUSIONS Symptoms and peristaltic reflexes are manifestations of the recruitment of several neurosensory and neuromotor pathways evoked by mid-esophageal infusions. ARI severity grade plays no role in symptom generation, indicating that GERD should not be diagnosed and severity should not be assigned based on symptoms alone. An increase in symptom occurrence was noted with increasing stimulus volumes, which provided increased activation of receptors, afferents, and efferents in evoking peristaltic clearance reflexes.
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Affiliation(s)
- Carissa R. Collins
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Saira Nawaz
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Center for Perinatal Research, Division of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Settle M, Francis K. Does the Infant-Driven Feeding Method Positively Impact Preterm Infant Feeding Outcomes? Adv Neonatal Care 2019; 19:51-55. [PMID: 30672812 DOI: 10.1097/anc.0000000000000577] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Achievement of independent oral feeding is a major determinant of discharge and contributes to long lengths of stay. Accumulating evidence suggests that there is great variation between and within newborn intensive care units in the initiation and advancement of oral feeding. The Infant-Driven Feeding (IDF) method is composed of 3 behavioral assessments including feeding readiness, quality of feeding, and caregiver support. Each assessment includes 5 categories and is intended as a method of communication among caregivers regarding the infant's readiness and progression toward independent oral feeding. PURPOSE To identify and summarize the available evidence on the use of the IDF method at initiation of oral feeds, time to independent oral feedings, and length of stay in the newborn intensive care unit or level II nursery for preterm infants. METHODS/SEARCH STRATEGY Four databases including CINAHL, Medline/PubMed, Ovid Nursing, and Embase were searched for "infant guided feedings," "infant driven feeding," "cue-based feeding," and "co regulated feeding." The full text of 32 articles was reviewed to identify experimental, quasiexperimental, or retrospective design to assess the evidence related to cue-based feeding. FINDINGS There were no randomized control, quasi-experimental, or retrospective studies utilizing the IDF method. There were 3 quality improvement projects utilizing the IDF method. The findings were conflicting: 1 project found the IDF method favorable in the achievement of full oral feedings, 2 projects found the IDF method favorable for reducing length of stay, and 1 project did not find differences in initiation, achievement of oral feedings, or length of stay. IMPLICATIONS FOR PRACTICE There is scant evidence limited to quality improvement projects to support the use of the IDF method. IMPLICATIONS FOR RESEARCH Research is needed to empirically validate the IDF method and to inform practice related to the initiation and advancement of oral feeding for preterm infants.
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Fry TJ, Marfurt S, Wengier S. Systematic Review of Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants. Nurs Womens Health 2018; 22:401-410. [PMID: 30138603 DOI: 10.1016/j.nwh.2018.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 07/08/2018] [Accepted: 07/01/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To examine and synthesize the outcomes of quality improvement (QI) initiatives related to cue-based feeding of preterm infants to facilitate implementation of findings to improve nursing practice. DATA SOURCES Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete and PubMed were searched for full-text articles published from 2000 through 2017 included under the medical subject heading quality improvement and whose titles included any form of the term feeding combined with any of the following: bottle, breast, cue-based, demand, infant, neonate, newborn, oral, or responsive. STUDY SELECTION Articles were considered for inclusion if they were published in English-language journals and focused on QI initiatives concerning cue-based feeding of preterm infants in NICU settings. DATA EXTRACTION After initial article review, we examined clinical outcomes and assessed study methodology using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS) framework. DATA SYNTHESIS Our review yielded seven studies related to cue-based feeding of preterm infants. Five studies included multidisciplinary stakeholder teams to assess their respective NICU environments and facilitate project completion. In two studies, feeding "champions" were designated as facilitators. In one study, researchers used a Plan-Do-Study-Act approach and emphasized process over outcome. In six studies, researchers measured hospital length of stay, which decreased in five intervention groups. In three studies, researchers measured infant weight gain, which increased in two intervention groups. In two studies, researchers monitored weight gain velocity, and in five studies, researchers reported earlier gestational attainment of full oral feedings. CONCLUSION Weight gain, time to full oral feedings, and hospital length of stay may be improved with the use of cue-based feeding. QI initiatives are a practical means to bring best evidence and multidisciplinary collaboration to the NICU.
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Jadcherla SR, Bhandari V. "Pressure" to feed the preterm newborn: associated with "positive" outcomes? Pediatr Res 2017; 82:899-900. [PMID: 28902187 PMCID: PMC5774015 DOI: 10.1038/pr.2017.198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/01/2017] [Indexed: 12/03/2022]
Affiliation(s)
- Sudarshan R. Jadcherla
- Divisions of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Vineet Bhandari
- Section of Neonatology, Department of Pediatrics, St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, PA,Address for correspondence: Vineet Bhandari, MD, DM, Drexel University College of Medicine, St. Christopher’s Hospital for Children, 160 Erie Avenue, Philadelphia, PA 19134, Phone: 215-427-5202, Fax: 215-427-8192,
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Abstract
In NICU settings, caring for neonates born as early as 23 weeks gestation presents unique challenges for caregivers. Traditionally, preterm infants who are learning to orally feed take a predetermined volume of breast milk or formula at scheduled intervals, regardless of their individual ability to coordinate each feeding. Evidence suggests that this volume-driven feeding model should be replaced with a more individualized, developmentally appropriate practice. Evidence from the literature suggests that preterm infants fed via cue-based feeding reach full oral feeding status faster than their volume-feeding counterparts and have shorter lengths of stay in the hospital. Changing practice to infant-driven or cue-based feedings in the hospital setting requires staff education, documentation, and team-based communication.
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Jadcherla SR, Shubert TR, Malkar MB, Sitaram S, Moore RK, Wei L, Fernandez S, Castile RG. Gestational and postnatal modulation of esophageal sphincter reflexes in human premature neonates. Pediatr Res 2015; 78:540-6. [PMID: 26270576 PMCID: PMC4628557 DOI: 10.1038/pr.2015.149] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/14/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Effects of gestational age (GA) and postnatal maturation on upper and lower esophageal sphincter (UES and LES) reflex development remain unclear. We hypothesized very-preterm (VPT) born neonates (< 32 wk GA) have delayed maturation of UES contractile reflex (UESCR) and LES relaxation reflex (LESRR) vs. preterm (PT) born (32-37 wk GA) neonates. METHODS Using provocative manometry, effects of 1,263 graded mid-esophageal stimuli (air, liquid) on sensory-motor characteristics of UESCR and LESRR were investigated in 24 VPT-born and 12 PT-born neonates (37.8 ± 0.6 vs. 38.9 ± 0.4 wk postmenstrual age respectively, P = 0.14). RESULTS In response to liquid stimuli (vs. air), VPT-born neonates displayed prolonged UESCR and LESRR response latencies (P < 0.001) and prolonged UESCR and LESRR durations (P < 0.01); unlike PT-born neonates, who exhibit prolonged LESRR response latency (P < 0.01), but similar UESCR and LESRR durations (P = 0.2). Differences were noted in LESRR duration in VPT vs. PT neonates for air stimuli (P = 0.04). With liquid stimuli, increasing GA was associated with decreasing response onset latencies to UESCR and LESRR (P < 0.05), and increasing LESRR duration (P = 0.02). CONCLUSION Using GA as categorical or continuous variable, vagus-mediated mechano-sensitive and liquid-sensitive reflex characteristics of UESCR and LESRR are distinct; LESRR differs with varying intrauterine maturation suggesting inhibitory modulation progresses with advancing maturation.
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Affiliation(s)
- Sudarshan R. Jadcherla
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Neonatal Aerodigestive & Pulmonary Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Divisions of Neonatology, Pediatric Gastroenterology and Nutrition; Department of Pediatrics; The Ohio State University College of Medicine, Columbus, OH, USA,ADDRESS FOR CORRESPONDENCE: Sudarshan R. Jadcherla, MD, Professor of Pediatrics & Associate Division Chief, Academics, Division of Neonatology, Director, The Neonatal and Infant Feeding Disorders Program, Director, Neonatal Aerodigestive Pulmonary Program, Principal Investigator, Innovative Feeding Disorders Research Program, Center for Perinatal Research, WB 5211, The Research Institute at Nationwide Children’s Hospital, Nationwide Children’s Hospital, 575 Children’s Crossroads, Columbus, Ohio 43215, Phone: 614- 355-6643, Facsimile: 614-355-5899,
| | - Theresa R. Shubert
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Manish B. Malkar
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Neonatal Aerodigestive & Pulmonary Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Divisions of Neonatology, Pediatric Gastroenterology and Nutrition; Department of Pediatrics; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Swetha Sitaram
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Rebecca K. Moore
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Neonatal Aerodigestive & Pulmonary Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Lai Wei
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Soledad Fernandez
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Robert G. Castile
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Neonatal Aerodigestive & Pulmonary Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Division of Respiratory Medicine, Department of Pediatrics; The Ohio State University College of Medicine, Columbus, OH, USA
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Hanin M, Nuthakki S, Malkar MB, Jadcherla SR. Safety and Efficacy of Oral Feeding in Infants with BPD on Nasal CPAP. Dysphagia 2014; 30:121-7. [PMID: 25380678 DOI: 10.1007/s00455-014-9586-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 10/22/2014] [Indexed: 10/24/2022]
Abstract
Safety and efficacy of oral feeding was examined in infants with bronchopulmonary dysplasia (BPD) on nasal continuous positive airway pressure (NCPAP). We hypothesized that repetitive oral feeding enhances aero-digestive outcomes and reduces resource utilization. Data from infants with BPD (37-42 weeks post menstrual age) that were orally fed while on NCPAP (n = 26) were compared with those that were exclusively gavage fed on NCPAP (n = 27). Subject assignment was random and physician practice based. Specifically, we compared the differences in aero-digestive milestones, resource utilization, and safety metrics. Demographic characteristics such as gender distribution, gestational age, and birth weight, clinical characteristics such as frequency of intraventricular hemorrhage and patent ductus arteriosus needing surgical ligation were similar in both groups (p > 0.05). Characteristics of respiratory support and airway milestones were similar in both groups (p > 0.05). However, infants in NCPAP-oral fed group had earlier acquisition of full oral feeding milestone by 17 days (median) versus infants who were not orally fed during NCPAP (p < 0.05). Discharge weights and the frequency of gastrostomy tube placement were also similar in both groups (p > 0.05). There were no tracheostomies in either group. There was no incidence of clinically significant aspiration pneumonia in infants during the period of the oral feeding while on NCPAP. Controlled introduction of oral feedings in infants with BPD during NCPAP is safe and may accelerate the acquisition of oral feeding milestones.
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Affiliation(s)
- Melissa Hanin
- Department of Neonatal Occupational Therapy, Nationwide Children's Hospital, Columbus, OH, 43205, USA
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Waitzman KA, Ludwig SM, Nelson CL. Contributing to Content Validity of the Infant-Driven Feeding Scales© through Delphi surveys. ACTA ACUST UNITED AC 2014. [DOI: 10.1053/j.nainr.2014.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Erratum. J Obstet Gynecol Neonatal Nurs 2014. [DOI: 10.1111/1552-6909.12497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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