Neonatal Eating Outcome Assessment: tool development and inter-rater reliability

A qualitative inquiry of speech-language therapists' views about breastfeeding management

BACKGROUND

 Management of oropharyngeal dysphagia within the first few days of an infant's life results in favourable breastfeeding outcomes, indicating the importance of investigating the breastfeeding management practices of speech-language therapists (SLTs) working within this field.

OBJECTIVES

 Little has been published about SLTs' management of breastfeeding in low- and middle-income settings. This study explores the perspectives of a group of experienced South African SLTs on their approach to breastfeeding management.

METHOD

 Qualitative data were gathered through semi-structured online interviews with 12 experienced SLTs and were subjected to thematic analysis.

RESULTS

 Three main themes emerged: (1) Approach to breastfeeding management; (2) Exposure, skills and knowledge related to breastfeeding management and (3) Perspectives and attitudes towards breastfeeding management. Participants demonstrated a clear understanding of their roles within the scope of breastfeeding management, which aligns with established literature. Their approaches appeared to be influenced by their perspectives and attitudes towards breastfeeding, as well as their exposure, skills and knowledge in this area. The study underscores the need for breastfeeding training in undergraduate programmes and highlights the demand for continuous professional development opportunities.

CONCLUSION

 While the findings are drawn from a small sample of experienced clinicians, they offer valuable insights for speech-language pathology clinical educators and professional organisations.Contribution: This study suggests a re-evaluation of university curricula to enhance exposure to breastfeeding management.

Association between combined use of epidural analgesia and oxytocin administration during labor and offspring outcomes: a narrative review and proposal

Studies have suggested that the administration of epidural analgesia (Epi) and oxytocin (OT) during labor affects offspring outcomes. However, the effects of their combined use remain unclear. This article aimed to review the outcomes of offspring exposed to Epi and OT, identify research gaps, and discuss future research directions. We searched the MEDLINE/PubMed, Web of Science, and Cochrane Library databases to identify studies describing offspring outcomes in the Epi, OT, Epi-OT, and control groups. We included one systematic review, six cohort studies, and one case-control study. The offspring outcomes at birth did not differ between the Epi-OT and Epi groups. In the first hour of life, the pre-feeding and sucking behaviors of the Epi-OT group showed an inverse correlation. At 2 days of age, the breastfeeding behavior and skin temperature patterns differed significantly between the Epi-OT and other groups. At 4 days of age, hyperbilirubinemia was more prevalent in the Epi-OT versus control group. Behavioral scores at 1 month differed little among the Epi-OT, Epi, and control groups. No eligible studies examined 1 month to 1 year of life. From 1 to >13 years of age, the risk of autism spectrum disorder was higher in the Epi and Epi-OT groups versus the control group. Most eligible studies were small and observational without randomization, and the results were inconsistent. Additional large cohort studies of various aspects of offspring development are required to assess the long-term effects of Epi-OT administration.

Item-Level Psychometrics of the Neonatal Eating Outcome Assessment in Orally Feeding Infants

BACKGROUND

The Neonatal Eating Outcome Assessment determines feeding performance based on the infant's postmenstrual age (PMA).

OBJECTIVE

To examine item-level measurement properties of this assessment's rating scale.

METHODOLOGY

In this retrospective study, Rasch analysis was completed on clinical data from the Neonatal Eating Outcome Assessment for 100 infants (52 preterm and 48 full-term) using Winsteps version 3.93.1. Instead of PMA-based scores, ordered letters converted to numerical scores were analyzed.

RESULTS

Analysis demonstrated that Section I (Pre-Feeding Skills) represents a separate construct from Sections II and III (Oral Feeding and End of Feeding, respectively). Sections II and III were adequately unidimensional to complete Rasch analysis. These sections fit the Rasch model overall, but rating scale category underuse was common, which may be attributed to sample characteristics.

IMPLICATIONS

This analysis supports using validated ordered letter scoring of Sections II and III to measure oral feeding performance in preterm and full-term newborns.

Relationships between preterm medical factors and feeding behaviors at term-equivalent age

AIM

To identify relationships between early medical factors and preterm infant feeding behaviors at term-equivalent age.

METHODS

Forty-three very preterm infants born ≤32 weeks gestation had standardized feeding assessments using the Neonatal Eating Outcome Assessment at term-equivalent age (36-42 weeks postmenstrual age). Medical factors were collected and analyses were run to determine if associations between different medical factors and feeding performance exist.

RESULTS

Lower Neonatal Eating Outcome Assessment scores at term-equivalent age were associated with lower estimated gestational age (p < .01), lower birthweight (p < .01), older postmenstrual age at discharge (p < .01), longer length of stay in the neonatal intensive care unit (p < .01), chronic lung disease (p = .03), as well as more days on total parenteral nutrition (p = .03), endotracheal intubation (p < .01), and noninvasive mechanical ventilation (p < .01).

CONCLUSION

More feeding problems are observed in infants born earlier, with longer hospital stays, and with complex medical courses. Knowledge of the association between these medical factors and feeding difficulties allows for identification of infants who may benefit from early, targeted interventions to optimize the feeding process.

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.

Associations between feeding and development in preterm infants in the NICU and throughout the first year of life

BACKGROUND

There is little published evidence regarding associations between feeding and development in preterm infants which could help identify infants most needing follow-up services.

AIMS

To determine if preterm infant feeding and development were predictable throughout the first year of life and identify associations with maternal factors, neonatal factors, and socioeconomic measures.

STUDY DESIGN

Prospective single-site study of the feeding and development of extremely and very preterm infants at three time points throughout the first year of life.

SUBJECTS

Infants <32 weeks gestational age were followed from neonatal intensive care unit (NICU) discharge (DC) until 12 months corrected gestational age (CGA).

OUTCOME MEASURES

Feeding and development were evaluated at NICU DC, 3 months and 12 months CGA. Maternal health, infant health, and socioeconomic measures were also recorded.

RESULTS

Significant differences were found between assessments for feeding and development at each of the three time points: NICU DC (p = 0.026), 3 months CGA (p = 0.001), and 12 months CGA (p = 0.000); however, no associations were found between feeding and development at NICU DC and 12 months CGA (p = 0.137). Of the maternal factors determined to be significant, none were consistent enough as to be considered relevant.

CONCLUSIONS

This study demonstrated that preterm infants with typical feeding and development at DC may go on to develop concerns in these areas, and those who scored abnormally at DC may perform typically during the first year of life. This study affirms the importance of NICU follow-up services to support feeding and development for all infants born <32 weeks gestation.

Maternal Perceptions About Sensory Interventions in the Neonatal Intensive Care Unit: An Exploratory Qualitative Study

BACKGROUND

Mothers play an important role in providing positive sensory experiences to their infants during NICU hospitalization. However, little is known regarding maternal perceptions about sensory-based interventions in the NICU. Further, understanding maternal perceptions was an important part of the process during development of the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

METHODS

Twenty mothers of very preterm infants were interviewed after NICU discharge and asked open-ended questions about sensory-based interventions they performed in the NICU and probed about their perceptions related to the development of a sensory-based guideline and the use of volunteers to provide sensory-based interventions when unable to be present in the NICU. Interviews were transcribed and uploaded into NVivoV.12 for content analysis.

RESULTS

Mothers reported that kangaroo care was a common sensory intervention they performed in the NICU. Of the 18 mothers who commented on the development of a sensory-based guideline, 17 (94%) said they would be accepting of one. Among 19 mothers, 18 (95%) supported volunteers conducting sensory-based interventions in their absence. Identified themes included: 1) Perceptions about development of a sensory-based guideline, 2) Perceptions of interactions with healthcare providers, 3) Maternal participation in sensory interventions, 4) Maternal experience, and 5) Emotions from mothers.

CONCLUSION

Maternal perceptions regarding the development of a sensory-based guideline were favorable, and the SENSE program has since been finalized after incorporating important insights learned from stakeholders in this study. Mothers' perceptions were tied to their NICU experiences, which elicited strong emotions. These findings highlight important considerations when developing family-centered interventions.

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.

NURSES' PERCEPTIONS ABOUT THE FEEDING OF PRETERM NEWBORNS

ABSTRACT Objective: to analyze nurses' perceptions about the feeding of preterm newborns and their motivations in using feeding methods during hospitalization in the neonatology unit. Method: descriptive study with a qualitative approach. Data collection was carried out between July 2019 and January 2020, using semi-structured interviews with 30 nurses from a neonatology unit. The analysis of interview data was carried out using lexicographical textual analysis, the descending hierarchical classification, and similarity analysis through IRaMuTeQ - R Interface software. Results: 876 text segments were analyzed in the descending hierarchical classification, retaining 86.3% of the total for the creation of five classes that resulted from content participation. The similarity analysis of the words representing the nurses' perception about oral feeding and the choice of feeding method led to three central cores, represented by the words: think, give, bottle. Conclusion: Nurses recognize the importance of continuing education and training in the assessment of oral skills. The reason for choosing the feeding method is often based on criteria such as preference, speed, and ease.

Neonatal feeding performance is related to feeding outcomes in childhood

AIM

Define relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment.

STUDY DESIGN

Ninety-one infants (44 preterm infants born ≤32 weeks at term-equivalent age and 47 full-term infants within 4 days of life) had feeding evaluated using the Neonatal Eating Outcome Assessment and the Neonatal Oral Motor Assessment Scale (NOMAS). At 4 years of age, 39 of these infants (22 preterm infants and 17 full-term infants; 43% follow-up rate) had parent-report measures of feeding conducted using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Pediatric Eating Assessment Tool (PediEAT).

RESULTS

Lower Neonatal Eating Outcome Assessment scores were related to higher PediEAT scores (p = 0.01; r = -0.44), but were not related to BPFAS scores (p = 0.17; r = -0.23). Relationships were not detected between the NOMAS and BPFAS (p = 0.35; r = 0.17), and relationships between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34). There was a relationship between the BPFAS and PediEAT scores at 4 years (p < 0.001; r = 0.66). Preterm infants performed poorer than full-term infants on the Neonatal Eating Outcome Assessment (p < 0.001) and NOMAS (p < 0.001), but no differences were detected in preterm compared to full-term performance on the BPFAS (p = 0.87) and PediEAT scores (p = 0.27).

DISCUSSION

Neonatal feeding performance is an important predictor of feeding outcomes at 4 years of age. The Neonatal Eating Outcome Assessment has predictive validity, and the Pediatric Eating Assessment Tool has concurrent validity with relationships to another childhood feeding tool.

A pilot study demonstrating the impact of the supporting and enhancing NICU sensory experiences (SENSE) program on the mother and infant

AIM

To explore differences in maternal mental health and infant neurobehavioral outcome among infants who received and did not receive the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

STUDY DESIGN

Eighty preterm infants (50 receiving standard-of-care and 30 receiving the SENSE program) born ≤32 weeks gestation were enrolled within the first week of life in a prospective quasi-experimental design, using a historical control group for comparison. Standard-of-care consisted of tactile (skin-to-skin, touch, holding) and olfactory (scent cloth, close maternal contact) interventions as determined to be appropriate by health care professionals and parents. The SENSE group received specific doses of tactile (skin-to-skin care, holding, massage, touch), auditory (human speech, music), olfactory (scent cloth, close maternal contact), kinesthetic/vestibular (movement, rocking/transfers), and visual (dim or cycled light) exposures, based on the infant's postmenstrual age and tailored to medical status and infant cues according to the SENSE program. The SENSE program includes the intentional delivery of positive, age-appropriate sensory exposures by parents (or a sensory support team, when parents are unavailable) each day of NICU hospitalization. Infant neurobehavioral outcome, as well as maternal mental health and confidence, were assessed prior to NICU discharge, using standardized measures.

RESULTS

Seventy-three infants were included in the final analysis. Mothers whose infants received the SENSE program demonstrated higher scores on the Maternal Confidence Questionnaire (p = 0.01). Infants who received the SENSE program demonstrated less asymmetry on the NICU Network Neurobehavioral Scale (p = 0.02; mean difference 0.9) and higher scores on the Hammersmith Neonatal Neurological Evaluation (p < 0.001; mean difference 4.8).

DISCUSSION

Preliminary evidence demonstrates improvements in maternal confidence and infant neurobehavioral performance following SENSE implementation.

Interrater Reliability and Concurrent Validity of the Neonatal Eating Outcome Assessment

IMPORTANCE

Few neonatal feeding assessments are currently available, and the Neonatal Eating Outcome Assessment is the only one that identifies feeding impairment while considering the developmental changes that occur from preterm birth to term-equivalent age.

OBJECTIVE

To determine the interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment.

DESIGN

Prospective, observational study.

SETTING

Level 4 neonatal intensive care unit.

PARTICIPANTS

A convenience sample of 7 neonatal therapists participated in reliability testing. For concurrent validity, a prospective cohort of 52 preterm infants born ≤32 wk gestation had feeding assessed at term-equivalent age.

OUTCOMES AND MEASURES

Intraclass correlations (ICCs) and Fleiss's κ statistics were used to define reliability across therapists, who independently scored five videos of preterm infants orally feeding using the Neonatal Eating Outcome Assessment. Concurrent validity was determined by evaluating relationships between the Neonatal Oral Motor Assessment Scale (NOMAS) and the Neonatal Eating Outcome Assessment using an independent-samples t test and χ² analysis.

RESULTS

The ICC for the Neonatal Eating Outcome Assessment total score was 0.90 (confidence interval [CI] [0.70, 0.99]). Fleiss's κ scores for the 19 scorable items on the Neonatal Eating Outcome Assessment had predominately moderate, fair, and slight agreement, with 3 items having poor agreement. Dysfunctional NOMAS scores were related to lower Neonatal Eating Outcome Assessment scores (t[49.4] = 3.72, mean difference = 12.2, 95% CI [5.60, 18.75], p = .001).

CONCLUSIONS AND RELEVANCE

The Neonatal Eating Outcome Assessment has excellent reliability. Concurrent validity was established.

WHAT THIS ARTICLE ADDS

This article reports that the final version of the Neonatal Eating Outcome Assessment (Version 5.7) has excellent interrater and concurrent validity and is an important tool to assess the occupation of infant feeding in clinical practice.

Preterm infant feeding performance at term equivalent age differs from that of full-term infants

OBJECTIVE

To identify differences in feeding skill performance among preterm infants at term equivalent age compared with full-term infants.

STUDY DESIGN

Ninety-two infants (44 preterm infants born ≤32 weeks gestation at term equivalent age and 48 full-term infants within 4 days of birth) had a standardized oral feeding assessment.

RESULT

Preterm infants at term equivalent age had lower Neonatal Eating Outcome Assessment scores (67.8 ± 13.6 compared with 82.2 ± 8.1; p < 0.001) and were more likely to have poor arousal (p = 0.04), poor tongue positioning (p = 0.04), suck-swallow-breathe discoordination (p < 0.001), inadequate sucking bursts (p = 0.01), tonal abnormalities (p < 0.001), discoordination of the jaw and tongue during sucking (p < 0.001), lack of positive engagement with the feeder and/or discomfort (p < 0.001), signs of aspiration (p < 0.001), difficulty regulating breathing (p < 0.001), and have an inability to maintain an appropriate state (p < 0.001), and complete the feeding (<0.001).

CONCLUSION

A broad range of feeding-related difficulties appear to remain evident in preterm infants at term equivalent age.

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.

Pacifier use in newborns: related to socioeconomic status but not to early feeding performance

AIM

Mothers are often advised not to use pacifiers until breastfeeding has been well-established. This study determined the infant and social factors that were related to pacifier use during the first few days of life and whether it led to alterations in feeding performance.

METHODS

We enroled 51 full-term infants and their mothers at Barnes-Jewish Hospital in urban St. Louis, USA, in 2015. Before they were discharged the mothers completed a questionnaire, and infant feeding was assessed using a standardised assessment.

RESULTS

There were 24 (47%) infants who used a pacifier during the first few days of life and seven (29%) of these were exclusively breastfed. Pacifier use was less common among mothers who exclusively breastfed (p = 0.04). Pacifier use was more common among mothers whose income was less than 25 000 US dollars (p = 0.02), who were single (p = 0.002) and who did not have a college education (p = 0.03). No associations between pacifier use and feeding performance were observed.

CONCLUSION

While lower socioeconomic status was related to pacifier use, feeding performance in the first few days of life was no different between those infants who did and did not use pacifiers after a full-term birth.