Development of infant oral feeding skills: what do we know?

Pediatric Intestinal Failure Associated Eating Disorder: An Overview of the Importance of Oral Feeding in a Population at Risk for Feeding Difficulties

Achieving feeding skills and food acceptance is a multi-layered process. In pediatric intestinal failure (PIF), oral feeding is important for feeding skills development, physiologic adaptation, quality of life and the prevention of eating disorders. In PIF, risk factors for feeding difficulties are common and early data suggests that feeding difficulties are prevalent. There is a unique paradigm for the feeding challenges in PIF. Conventional definitions of eating disorders have limited application in this context. A pediatric intestinal failure associated eating disorder (IFAED) definition that includes feeding/eating skills dysfunction, psychosocial dysfunction, and the influence on weaning nutrition support is proposed.

Pre-Operative Characteristics Helping to Avoid Gastrostomy Tube After Mandibular Distraction in Neonates With Pierre-Robin Sequence: A Institutional Case-Series and Review of the Literature

OBJECTIVE

to investigate the ability of mandibular distraction osteogenesis (MDO) to avoid gastrostomy tube (G-tube).

DATA SOURCES

PubMed, EBSCOhost, Cochrane, and Embase.

REVIEW METHODS

We retrospectively reviewed the number of MDO cases performed at our institution for patients with Robin Sequence (RS) over the past 10 years. In our institutional review, patients were excluded if they had a G-tube already placed at the time of surgery. We also performed a systematic review of the literature. Articles were excluded if they did not detail feeding outcomes after MDO, or if MDO was performed on patients that did not have RS.

RESULTS

In our systematic review, 12 articles were included that comprised a total of 209 neonates with RS that underwent MDO. A total of 174 (83.3%) patients avoided a G-tube once MDO was performed. A total of 14 patients met the inclusion criteria at our institution. Of the 14 RS patients, 9 (64%) avoided having a G-tube placed and all (14/14) avoided tracheostomy. The average birth weight of patients avoiding a G-tube was 3.11 kg compared to 2.25 kg (P = .045) in the group requiring a G-tube. In the group avoiding a G-tube, the average weight at time of operation was 3.46 kg compared to 2.83 kg (P = .037) in the group requiring a G-tube.

CONCLUSION

MDO may be considered as a surgical option to prevent G-tube placement for neonates with non-syndromic RS who have difficulty with PO feeding but whose airway obstruction is not severe enough to require respiratory support. Based on our institutional experience, a minimum weight of 3.00 kg correlated with higher success rates of PO intake and avoiding a G-tube.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN

An observational cohort pilot study was undertaken.

SETTING

A Level 2 to Level 3 neonatal intensive care unit.

PARTICIPANTS

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

OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Effects of human milk odor stimulation on feeding in premature infants: a systematic review and meta-analysis

Previous studies suggested odor stimulation may influence feeding of premature neonates. Therefore, this systematic review and meta-analysis of randomized controlled trials was conducted to assess the effect of human milk odor stimulation on feeding of premature infants. All randomized controlled trials related to human milk odor stimulation on feeding in premature infants published in PubMed, Cochrane, Library, Medline, Embase, Web of science databases and Chinese biomedical literature databases, China National Knowledge Infrastructure, China Science and Technology Journal Database (VIP) and Wanfang Chinese databases were searched, and The Cochrane Handbook 5.1.0 was used to evaluate the quality and authenticity of the literature. Relevant information of the included studies was extracted and summarized, and the evaluation indexes were analyzed using ReviewManager5.3. The retrieval time was from the establishment of the database to July 28, 2022.12 articles were assessed for eligibility, and six randomized controlled studies were eventually included in the meta-analysis (PRISMA). A total of 6 randomized controlled studies with 763 patients were finally included in the study, and the quality evaluation of literatures were all grade B. Human milk odor stimulation reduced the transition time to oral feeding in premature infants [SMD = - 0.48, 95% CI (- 0.69, - 0.27), Z = 4.54, P < 0.00001] and shortened the duration of parenteral nutrition [MD = - 1.01, 95% CI (- 1.70, - 0.32), Z = 2.88, P = 0.004]. However, it did not change the length of hospitalization for premature infants [MD = - 0.03, 95% CI (- 0.41, 0.35), Z = 0.17, P = 0.86]. The implementation of human milk odor stimulation can reduce the transition time to oral feeding and the duration of parenteral nutrition in premature infants, but further studies are needed to determine whether it can reduce the length of hospital stay in premature infants. More high-quality, large-sample studies are needed to investigate the effect of human milk odor stimulation on the feeding process and other outcomes in premature infants.

The Effect of Lullabies and Classical Music on Preterm Neonates' Cerebral Oxygenation, Vital Signs, and Comfort During Orogastric Tube Feeding: A Randomized Controlled Trial

OBJECTIVE

This study investigated the effect of lullabies and classical music on preterm neonates' cerebral oxygenation, vital signs, and comfort during orogastric (OG) tube feeding.

METHODS

This was a parallel-group pretest-posttest randomized controlled study. The research was conducted between December 2020 and May 2022. The sample consisted of 51 preterm neonates hospitalized in the neonatal intensive care unit (NICU) of Selçuk University Faculty of Medicine Hospital in Konya, Türkiye. Participants were randomized into three groups (17 preterm infants in each group). The first group listened to lullabies sung by their mothers and the second group listened to classical music during OG tube feeding. The control group received routine care with no music. Data were collected using a Neonatal Identification Information Form, Physiological Parameters and rSO2 Monitoring Form, and the Newborn Comfort Behavior Scale (Comfort-Neo). The study was registered on the ClinicalTrials database (NCT05333575).

RESULTS

The lullaby group had stable peak heart rates and oxygen saturation levels (p = .002). Both lullaby and classical music groups had significantly higher cerebral oxygenation levels than the control group. The classical music group had the highest cerebral oxygenation level (p = .001). Both lullaby and classical music groups had significantly higher mean Comfort-Neo scores than the control group. The classical music group had the highest mean Comfort-Neo score (p = .040).

CONCLUSION

Preterm neonates who listen to lullabies and classical music are likely to have higher cerebral oxygen and comfort levels. Listening to lullabies helps stabilize vital signs. These results suggest that healthcare professionals should encourage parents to get their preterm neonates to listen to lullabies and classical music.

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.

Complementary Feeding: Tradition, Innovation and Pitfalls

According to WHO, "complementary feeding (CF) is the process starting when breast milk alone or infant formula alone is no longer sufficient to meet the nutritional requirements of infants, and therefore, other foods and liquids are needed, along with breast human milk or a breastmilk substitute". CF is one of the most important "critical and sensitive periods" in human life: indeed, timing and approaches to solid foods introduction in an infant's nutrition are of utmost importance as potential epigenetic factors from infancy to adulthood. CF is also deeply influenced by each country and single-family traditions, culture, and beliefs. The aim of our narrative review is to analyze traditional CF practices, including innovative and alternative ones that emerged in the last decades, such as baby-led weaning or plant-based weaning, and to evaluate their effects on the risk of developing non-communicable diseases. Moreover, we will discuss pitfalls and misunderstandings that pediatricians frequently have to face when dealing with complementary feeding. Health care professionals must not have prejudices against parents' wishes or traditions about CF; rather, they should support and educate them in case of any alternative CF choice, always pursuing the infant's adequate growth, neuro- and taste development, and the achievement of correct eating behavior as the primary goal.

Are sucking patterns and early spontaneous movements related to later developmental functioning outcomes? A cohort study

Sucking patterns and early spontaneous movements have an important role in the determination of later developmental problems, but the relationship of the two together with long-term outcomes has not been investigated. The objectives of this study were to (i) examine the relationship between sucking patterns using the Neonatal Oral Motor Assessment Scale (NOMAS) and fidgety movements and other movement patterns using detailed General Movements Assessment (GMA), and (ii) investigate the relationship between these early assessment methods and developmental functioning outcomes at later ages. We analyzed the NOMAS from 34 weeks' postmenstrual age up to 10 weeks post-term and GMA between 9 and 20 weeks post-term age, and the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) was applied for the developmental functioning outcomes to 62 infants (61%, 62/102) between 12 and 42 months of age. Among 102 infants at-risk, 70 (69%) showed a normal sucking pattern, and 85 (83%) had fidgety movements. The median Motor Optimality Score-Revised (MOS-R), as determined by GMA, of all infants was 24. The NOMAS was related to the MOS-R and its subcategories (p < 0.05) in all infants at-risk. The NOMAS, MOS-R and its subcategories were also related to cognitive, language, and motor development at later ages according to Bayley-III (p < 0.05).   Conclusion: This longitudinal study showed that the quality of sucking patterns, fidgety movements, and MOS-R were related to later developmental functioning, indicating that abnormal sucking patterns, aberrant fidgety movements, and lower MOS-R might predict developmental disorders. What is Known: • Sucking patterns and early spontaneous movements in which central pattern generators play an important role are related. • Sucking patterns and early spontaneous movements might be used separately to predict developmental outcomes. What is New: • Sucking patterns and early spontaneous movements, when used together, were related to later developmental functioning, including cognitive, language, and motor development in at-risk infants. • Predictive value of sucking patterns was lower for each developmental functioning outcome than early spontaneous movements.

Feeding outcomes in tracheostomy-dependent infants - can we predict future gastrostomy tube use?

OBJECTIVES

To identify characteristics of infants with tracheostomy that require gastrostomy tube insertion versus those likely to orally feed to predict which patients may benefit from insertion of gastrostomy at the time of tracheostomy placement.

METHODS

Retrospective review of infants undergoing tracheostomy from birth to 18 months of age. The primary outcome was to identify pre-operative factors predictive of future gastrostomy tube use. Univariate and multivariate analyses evaluated association between pre-operative patient characteristics and feeding outcomes.

RESULTS

Of 103 patients identified, 73 met inclusion criteria. Upper airway anomaly was the indication for tracheostomy in 70.4 %. Gastrostomy tube was required in 52 patients (75.4 %), with 7 (13.5 %) placed concurrently with tracheostomy. Infants with birth complications, a neurologic diagnosis, multiple co-morbidities, or identified with aspiration risk were more likely to require a gastrostomy tube (p < 0.05).

CONCLUSIONS

Most infants who require tracheostomy placement from birth until 18 months of age will require nutritional support. Tracheostomy and gastrostomy are uncommonly placed concurrently. Coordination of placement would theoretically minimize the risk of general anesthetic exposure while potentially reducing hospital length of stay and healthcare related costs.

Bolus Feeding Via Gastric Versus Oral Routes in Very Preterm Neonates

BACKGROUND

We intend to investigate the association of bolus orogastric tube (BOG) and nipple bottle (N) feedings with postnatal growth in very premature neonates (VPN: gestational age between 28 and 33 weeks).

MATERIAL AND METHODS

The days of life (DOL) to achieve full combined oral and gastric enteral nutrition (FEN) and attain body weight (BW) of 2200 g (Wt22) and the length of hospitalization (LOH) were retrospectively associated with clinical and BOG and N feeding-related variables via multivariate regression analyses. Correlations were performed to ascertain the strength of associations.

RESULTS

In a cohort of 127 VPN, FEN demonstrated negative associations with gestational age (GA) and LOH and Wt22 with birth weight (BW). FEN showed positive associations with nil by mouth and intravenous fluid-nutrition days and with DOL to start and achieve full nipple feeding. LOH was associated with days on antibiotics and DOL to start and achieve full nipple feeding. Wt22 was associated with DOL to achieve full nipple feeding. The start day of BOG feeding had no independent associations and weak, highly significant positive correlations with Wt22, LOH, and FEN.

CONCLUSION

Bolus orogastric tube feeding has no independent implications for postnatal growth, duration of hospitalization, or chronological age to attain full enteral nutrition in VPN unless combined with nipple feeding to provide enteral nutrition. Oral bottle feeding accelerates postnatal catch-up growth and full enteral nutrition acquisition while reducing hospitalization duration. Initiating nipple feeding at 32 weeks of postmenstrual age may be safe in stable VPN. Antibiotic therapy increases hospitalization duration.

The Effect of Breast Milk Odor on Feeding Cues, Transition Time to Oral Feeding, and Abdominal Perfusion in Premature Newborns: A Randomised Controlled Trial

PURPOSE

The present study was conducted to determine the effect of odor stimulation with breast milk (BM) applied to premature newborns before and during enteral feeding on feeding cues, transition time to oral feeding and abdominal perfusion.

DESIGN

This study was a parallel group pretest-post test randomised controlled trial (RCT).

METHODS

The study was conducted in the neonatal intensive care unit (NICU) in Türkiye. Study data were collected from 32 premature newborns between October 2020 and December 2021. Newborns were randomly assigned to either intervention (n = 16) or control (n = 16) groups. Odor stimulation with BM was applied to newborns in the intervention group (IG) before and during enteral feeding for 3 days. Data were collected with the Newborn Information Form, Abdominal Perfusion Follow-up Form, and Feeding Cues Follow-up Form. Yates corrected and Fisher chi-squared test, Mann-Whitney U test, Cohen Kappa statistics, Permanova analysis, and Wilcoxon test were used in the analysis. The study was registered in ClinicalTrials.gov (NCT04843293).

RESULTS

The frequency of feeding cues in newborns who were exposed to the odor of BM, was higher than in the control group (CG) (p < .05). The transition times to oral feeding were similar in newborns in the IG and CG (p > .05). Abdominal perfusion level of newborns in the IG was higher than the CG (p < .05), and the level of abdominal perfusion showed a significant difference in terms of group*time interaction (p < .05).

CONCLUSION

Our findings suggest that odor stimulation with BM will be beneficial in improving the digestive functions of premature newborns.

Randomised controlled trial to compare the effect of PIOMI (structured) and routine oromotor (unstructured) stimulation in improving readiness for oral feeding in preterm neonates

Background

Oral motor stimulation interventions improve oral feeding readiness and earlier full oral feeding in preterm neonates. However, using a structured method may improve the transition time to full oral feeds and feeding efficiency with respect to weight gain and exclusive breastfeeding when compared to an unstructured intervention.

Objective

To compare the effect of Premature Infant Oral Motor Intervention (PIOMI) and routine oromotor stimulation (OMS) on oral feeding readiness.

Methods

Randomised controlled trial conducted in a neonatal intensive care unit between June-December 2022. Preterm neonates, 29+0-33+6 weeks corrected gestational age, were studied. The intervention group received PIOMI and the control group received OMS. Primary outcome: time to oral feeding readiness by Premature Oral Feeding Readiness Assessment Scale (POFRAS) score ≥30. Secondary outcomes: time to full oral feeds, duration of hospitalisation, weight gain, and exclusive breastfeeding rates.

Results

A total of 84 neonates were included and were randomised 42 each in PIOMI and OMS groups. The mean chronological age and time to oral feeding readiness were lower by 4.6 and 2.7 days, respectively, for PIOMI. The transition time to full oral feeds was 2 days lower for PIOMI and the duration of hospitalisation was 8 days lower. The average weight gain was 4.9 g/kg/day more and the exclusive breastfeeding rates at 1 month and 3 months post-discharge were higher by 24.5% and 27%, respectively, for the PIOMI group. The subgroup analysis of study outcomes based on sex and weight for gestational age showed significant weight gain on oral feeds in neonates receiving PIOMI. Similarly, the subgroup analysis based on gestational age favoured the PIOMI group with significantly earlier transition time and weight gain on oral feeds for the neonates >28 weeks of gestational age. The odds of achieving oral feeding readiness by 30 days [OR 1.558 (0.548-4.426)], full oral feeds by 45 days [OR 1.275 (0.449-3.620)], and exclusive breastfeeding at 1 month [OR 6.364 (1.262-32.079)] and 3 months [3.889 (1.186-12.749)] after discharge were higher with PIOMI.

Conclusion

PIOMI is a more effective oromotor stimulation method for earlier and improved oral feeding in preterm neonates.

Clinical trial registration

https://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=70054&EncHid=34792.72281&modid=1&compid=19','70054det', identifier, CTRI/2022/06/043048.

Trends in morbidities of late preterm infants in the neonatal intensive care unit

OBJECTIVE

To characterize demographics and trends in length of stay (LOS), morbidities, and mortality in late preterm infants.

STUDY DESIGN

Cohort study of infants born between 34 0/7 and 36 6/7 weeks gestation between 1999 and 2018 without major congenital anomalies at Pediatrix Medical Group neonatal intensive care units (NICUs).

RESULTS

307,967 infants from 410 NICUs met inclusion criteria. The median (25th-75th percentile) LOS was 11 (8-16) days in the entire period. Postmenstrual age (PMA) at discharge increased during the cohort for all gestational ages (p < 0.001). There was a decrease in invasive ventilation, receipt of phototherapy, and reflux medications observed (p < 0.001).

CONCLUSION

In this large cohort, given 20 years of time for medical advancement, there was no significant improvement in the LOS of late preterm infants. All infants had an increased PMA at discharge, despite multiple practice changes that were observed.

Higher Dose Noninvasive Transcutaneous Auricular Vagus Nerve Stimulation Increases Feeding Volumes and White Matter Microstructural Complexity in Open-Label Study of Infants Slated for Gastrostomy Tube

OBJECTIVE

To determine whether transcutaneous auricular vagus nerve stimulation (taVNS) paired with twice daily bottle feeding increases the volume of oral feeds and white matter neuroplasticity in term-age-equivalent infants failing oral feeds and determined to need a gastrostomy tube.

STUDY DESIGN

In this prospective, open-label study, 21 infants received taVNS paired with 2 bottle feeds for 2 - 3 weeks (2x). We compared 1) increase oral feeding volumes with 2x taVNS and previously reported once daily taVNS (1x) to determine a dose response, 2) number of infants who attained full oral feeding volumes, and 3) diffusional kurtosis imaging and magnetic resonance spectroscopy before and after treatment by paired t tests.

RESULTS

All 2x taVNS treated infants significantly increased their feeding volumes compared with 10 days before treatment. Over 50% of 2x taVNS infants achieved full oral feeds but in a shorter time than 1x cohort (median 7 days [2x], 12.5 days [1x], P < .05). Infants attaining full oral feeds showed greater increase in radial kurtosis in the right corticospinal tract at the cerebellar peduncle and external capsule. Notably, 75% of infants of diabetic mothers failed full oral feeds, and their glutathione concentrations in the basal ganglia, a measure of central nervous system oxidative stress, were significantly associated with feeding outcome.

CONCLUSIONS

In infants with feeding difficulty, increasing the number of daily taVNS-paired feeding sessions to twice-daily significantly accelerates response time but not the overall response rate of treatment. taVNS was associated with white matter motor tract plasticity in infants able to attain full oral feeds.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT04643808).

Interventions to Enhance Achievement to Independent Oral Feeds in Premature Infants: A Scoping Review

AIM

To assess the effectiveness of interventions aimed at facilitating the transition from full tube to independent oral feeds in premature infants.

METHODS

Scoping review methodology using the Preferred Reporting items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA_ScR). A search of six databases (EMBASE, MEDLINE, CINAHL, Web of Science, COCHRANE, and OT Seeker), using keywords related to oral feeding and premature infants retrieved 11,870 articles. Full-text screening was completed for 36 articles, and 21 articles were included in this review.

RESULTS

Review of the 21 articles revealed five intervention types: oral stimulation (n = 14), swallow/gustatory stimulation (n = 3), olfactory stimulation (n = 2), tactile/kinesthetic stimulation (n = 1), and auditory stimulation (n = 1). Oral stimulation had the most studies with consistent evidence supporting its beneficial effect to facilitate achievement to independent oral feeds, swallow/gustatory stimulation appeared to have some benefit, but evidence for olfactory, tactile/kinesthetic, and auditory stimulation was sparse.

CONCLUSION

Oral stimulation has the most studies with consistent evidence, and thus is suggested as a suitable early intervention strategy that can be used by health providers to facilitate the achievement to independent oral feeds in premature infants. The alternate forms of stimulation have limited evidence and necessitate further studies to confirm their benefits.

Comparison of the introduction of consistencies in complementary feeding introduction between preterm and full-term newborns - Cohort from 0 to 12 months

PURPOSE

To compare the introduction of consistencies during the period of complementary feeding of preterm and full-term newborns up to 12 months of life, as well as to evaluate the presence of oral motor dysfunction and its relation to difficulty in introducing food consistencies in these groups.

METHODS

This is an observational, analytical, cohort study, with ambispective data collection, carried out at the Municipal Department of Health of Mafra, state of Santa Catarina, Brazil. The study sample consisted of 87 newborns, 41 full-term and 46 preterm. While data was collected, interviews were held with the mothers/guardians. The anthropometric assessment was carried out by a nutritionist by measuring body weight, length, and head circumference, followed by assessment of oral and functional motor skills by the adapted Clinical Evaluation Protocol of Pediatric Dysphagia (PAD-PED), assessment of breastfeeding and neuropsychomotor development, and assessment of the presence of maternal depression and psychological risk of children with up to 12 months of corrected age.

RESULTS

We verified oral motor dysfunction in 15 newborns, in both groups, in the liquid consistency in the first assessment, persisting in two cases in the full-term newborns and in three cases in the preterm infants, in the last assessment for the solid consistency.

CONCLUSION

We observed no difference in the introduction of food consistencies between groups. Breastfeeding was more frequent in newborns in the first assessment and similar in other assessments. Regarding the predictors for oral motor dysfunction, bottle feeding increased the odds by about seven times and invasive oral procedures by about six times.

The Association of Tube Weaning and Oral Skill Development in Infants With Tube Dependency: A Prospective Study

OBJECTIVE

This study was the first of its kind by assessing oral skills development during and after applying the "Graz Model" of tube weaning.

METHODS

This prospective case series study included data of 67 (35 females, 32 males, treated from March 2018 to April 2019) tube dependent children, who participated in the effective "Graz Model" of tube weaning. Parents filled out the standardized Pediatric Assessment Scale for Severe Feeding Problems (PASSFP) prior to and immediately after completion of the program. Paired sample t tests were conducted to examine pre-to-post changes in the children's oral skills.

RESULTS

The study showed that oral skills increased significantly during tube weaning PASSFP score of 24.76 (standard deviation, SD = 12.38) prior to versus 47.97 (SD = 6.98) after completion of the program. Furthermore, significant changes in their sensory and tactile perception and in their general eating behavior were observed. Children also showed reduced oral aversion symptoms and food pocketing, could enjoy their meals, and increased their food repertoire. Mealtime duration could be decreased, and parents were less anxious about their infants' intake and less frustrated because of their children's eating behavior.

CONCLUSION

The results of this study demonstrated for the first time that tube dependent children can improve their oral skills significantly during and after their participation in the child-led approach of the "Graz model" of tube weaning.

A Unique Clinical Tool for the Evaluation of Oral Feeding Skills in Infants

Background. Occupational therapy practice for oral feeding assessment is based on clinical observation of infants' sucking, swallowing, and breathing ability, which is influenced by clinical experience and provides poor evidence on explanatory factors. Purpose. To test the clinical utility and safety of a nipple monitoring device for the quantitative evaluation of oral feeding skills. Method. Sixteen infants, with no severe medical complications, participated in a pre-experimental pilot study. Oral feeding performances (duration, intake volume, and rate of transfer), and occurrence of adverse events (apnea, bradycardia, and oxygen desaturations) were recorded to ensure the tool does not interfere with infant's feeding ability or does not create any adverse effects. Findings. There was no significant difference in duration, intake volume, rate of transfer between the two monitored sessions, and no occurrence in adverse events. Implications. The findings suggest that the nipple monitoring device may be used for quantitative assessment and intervention planning of oral feeding difficulties in infants.

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

Background and purpose

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

Methods

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

Results

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

Conclusions

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

Effects of Kangaroo Care on the development of oral skills and achievement of exclusive oral feeding in preterm infants

PURPOSE

analyze the effects of hospitalization in the Kangaroo Neonatal Intermediate Care Unit (UCINCa), the second stage of the Kangaroo Care (KC), on the development of oral feeding skills in preterm neonates.

METHODS

an analytical observational study of the prospective longitudinal type, carried out in a public hospital in Southern Brazil, where infants were accompanied until hospital discharge. The sample consisted of 20 preterm neonates hospitalized at the UCINCa and 26 preterm neonates at the Conventional Neonatal Intermediate Care Unit (UCINCo), that were periodically evaluated through the levels of oral skill, in a bottle, according to the criteria of proficiency and milk transfer rate. The outcomes considered were a progression of the oral skill level, days of transition to obtain the full oral route, and days of hospital stay.

RESULTS

the duration of transition to exclusive oral feeding was shorter for preterm neonates at the UCINCa (4.5 vs. 10 days) relative to those at the UCINCo (p = 0.041). By the third assessment, all preterm neonates at the UCINCa had reached level 4, while participants at the UCINCo only achieved this level of performance on the fifth assessment. The average number of days of hospitalization was four days shorter in UCINCa participants (p=0.098).

CONCLUSION

the admission to the UCINCa had been a further acceleration in the maturation of oral skills, which allowed for a faster transition to exclusive oral feeding as compared to neonates admitted in UCINCo.

International Guidelines for the Diagnosis and Management of Hyperinsulinism

Hyperinsulinism (HI) due to dysregulation of pancreatic beta-cell insulin secretion is the most common and most severe cause of persistent hypoglycemia in infants and children. In the 65 years since HI in children was first described, there has been a dramatic advancement in the diagnostic tools available, including new genetic techniques and novel radiologic imaging for focal HI, however; there have been almost no new therapeutic modalities since the development of diazoxide. Recent advances in neonatal research and genetics have improved our understanding of the pathophysiology of both transient and persistent forms of neonatal hyperinsulinism. Rapid turnaround of genetic test results combined with advanced radiologic imaging can permit identification and localization of surgically-curable focal lesions in a large proportion of children with congenital forms of HI, but are only available in certain centers in 'developed' countries. Diazoxide, the only drug currently approved for treating HI, was recently designated as an "essential medicine" by the World Health Organization but has been approved in only 16% of Latin American countries and remains unavailable in many under-developed areas of the world. Novel treatments for HI are emerging, but they await completion of safety and efficacy trials before being considered for clinical use. This international consensus statement on diagnosis and management of HI was developed in order to assist specialists, general pediatricians, and neonatologists in early recognition and treatment of HI with the ultimate aim of reducing the prevalence of brain injury caused by hypoglycemia. A previous statement on diagnosis and management of HI in Japan was published in 2017. The current document provides an updated guideline for management of infants and children with HI and includes potential accommodations for less-developed regions of the world where resources may be limited.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' post-menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review.

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

Following the updated search, two review authors screened the titles and abstracts of studies and full-text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effects of an Oral Stimulation Program on Feeding Outcomes in Preterm Infants: A Systematic Review and Meta-Analysis

AIMS

To review the literature on the effects of unimodal sensorimotor stimulation protocols on feeding outcomes in very preterm and moderate to late preterm infants (PIs).

METHODS

Five databases were searched up to April 2022. Studies comparing unimodal sensorimotor stimulation protocols based on the combination of manual oral stimulation with NNS against usual care in PIs, on-time transition to full oral feeding (FOF), feeding efficacy, length of hospital stay, and/or body weight gain.

RESULTS

Eleven studies were included. Compared to usual care, unimodal sensorimotor stimulation protocols based on manual oral stimulation combined with NNS demonstrated to be more effective in decreasing time transition to FOF (standardized mean difference [95%CI] - 1.08 [-1.74, -0.41]), improving feeding efficacy (2.15 [1.18, 3.13]) and shortening length of hospital stay (-0.35 [-0.68, -0.03]). However, the proposed intervention was not effective in improving weight gain (0.27 [-0.40, 0.95]). There were no significant differences according to gestational age (p > .05).

CONCLUSIONS

Based on fair-to-high quality evidence, unimodal sensorimotor stimulation protocols combined with NNS reduce time transition to FOF, improve feeding efficacy, and shorten the length of hospital stay; yet the proposed intervention yielded no significant effects on body weight gain when compared to usual care in PIs.

Oral characteristics and dietary habits of preterm children: A retrospective study using National Health Screening Program for Infants and Children

The rate of preterm birth is increasing worldwide and preterm infants are susceptible to oral health problems. Hence, this study aimed to investigate the effect of premature birth on dietary and oral characteristics as well as dental treatment experiences of preterm infants using a nationwide cohort study. Data was retrospectively analyzed from National Health Screening Program for Infants and Children (NHSIC) of the National Health Insurance Service of Korea. 5% sample of children born between 2008 and 2012 who completed first or second infant health screening were included and divided into full-term and preterm-birth groups. Clinical data variables such as dietary habits, oral characteristics, and dental treatment experiences were investigated and comparatively analyzed. Preterm infants showed significantly lower rates of breastfeeding at 4-6 months (p<0.001), delayed start of weaning food at 9-12 months (p<0.001), higher rates of bottle feeding at 18-24 months (p<0.001), poor appetite at 30-36 months (p<0.001) and higher rates of improper swallowing and chewing function at 42-53 months (p = 0.023) than full-term infants. Preterm infants also had eating habits leading to poor oral conditions and higher percentage of absence of dental visit compared to full-term infants (p = 0.036). However, dental treatments including 1-visit pulpectomy (p = 0.007) and 2-visit pulpectomy (p = 0.042) significantly decreased when oral health screening was completed at least once. The NHSIC can be an effective policy for oral health management in preterm infants.

A Comparison of the Clinical Presentation of Preterm Birth and Autism Spectrum Disorder: Commonalities and Distinctions in Children Under 3

Premature infants and infants later diagnosed with autism spectrum disorder (ASD) share many commonalities in clinical presentations. However, prematurity and ASD also have differences in clinical presentation. These overlapping phenotypes can lead to misdiagnoses of ASD or missing a diagnosis of ASD in preterm infants. We document these commonalities and differences in various developmental domains with the hope of aiding in the accurate early detection of ASD and timely intervention implementation in children born premature. Given the degree of similarities in presentation, evidence-based interventions designed specifically for preterm toddlers or toddlers with ASD may ultimately aid both populations.

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

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

Clinical challenges to the concept of ectogestation

Since the publication of the successful animal trials of the Biobag, a prototypical extrauterine support for extremely premature neonates, numerous ethicists have debated the potential implications of such a device. Some have argued that the Biobag represents a natural evolution of traditional newborn intensive care, while others believe that the Biobag would create a new class of being for the patients housed within. Kingma and Finn argued in Bioethics for making a categorical distinction between fetuses, newborns and 'gestatelings' in a Biobag on the basis of a conceptual distinction between ectogenesis versus ectogestation. Applying their arguments to the clinical realities of newborn intensive care, however, demonstrates the inapplicability of their ideas to the practice of medicine. Here, I present three clinical examples of the difficulty and confusion their argument would create for clinicians and offer a possible remedy: namely, discarding the term 'artificial womb' in favour of 'Biobag'.

A thickened formula reduces feeding-associated oxygen desaturation and bradycardia in preterm infants

BACKGROUND

Although preterm infants often experience desaturation or bradycardia during oral feeding, specific guidelines for its management are lacking.

PURPOSE

This study aimed to investigate the effects of a commercial thickened formula (TF) on oxygen saturation and heart rate stabilization during oral feeding in preterm infants.

METHODS

This retrospective study included 122 infants born at a median (interquartile range [IQR]) 31+6 weeks (29+4 -34+6 weeks) of gestation weighing 1,725 g (1,353-2,620 g) and fed commercial cornstarch-containing TF due to feeding-associated desaturation or bradycardia. We excluded infants fed TF to treat symptomatic regurgitation. Desaturation and bradycardia events were compared between 3 days prior to the change and 3 days after the change to TF. Desaturation and bradycardia were defined as SpO2 <85% and heart rate <100 beats/min during or immediately after oral bottle feeding, respectively.

RESULTS

The median (IQR) postmenstrual age and weight were 36+1 weeks (34+6-38+0 weeks) and 2,395 g (2,160-2,780 g), respectively, at the time of change to TF. The frequency of desaturation significantly decreased after TF feeding (median [IQR]: 2.3 [1.3-3.3] events/day vs. 0.3 [0-1.7] events/day, P< 0.001). Bradycardia also decreased after TF feeding (0.3 [0-1] events/day vs. 0 [0-0.7] events/day, P=0.006). There were no cases of diarrhea or electrolyte abnormalities after TF feeding. Defecation frequency decreased (P=0.037), and polyethylene glycol was prescribed to 27% of the TF-fed infants. In a subgroup analysis of 16 infants with bronchopulmonary dysplasia, the frequency of desaturation was reduced (2.3 [1.8-3.8] events/day vs. 0.5 [0-1.5] events/day, P=0.042), and weight gain improved (22.5 [3.1-36.3] g/day vs. 41.3 [28.1-55.1] g/day, P=0.019), after TF feeding.

CONCLUSION

TF feeding significantly reduces oral feeding-associated oxygen desaturation and bradycardia in preterm infants. TF may be useful for stabilizing oxygen saturation and heart rate among preterm infants with difficulties in oral feeding.

Pre-feeding premature infant oral motor intervention (PIOMI) for transition from gavage to oral feeding: A randomised controlled trial

PURPOSE

To assess the performance of premature infant oral motor intervention for transition from gavage to full spoon feeding in preterm infants.

METHODS

Preterm neonates born between 28 + 0-32 + 6 weeks gestation (n = 32) were randomised into an intervention group (premature infant oral motor intervention) for five minutes twice a day along with routine care (n = 16) and a control group (routine care, n = 16) once they reached a feed volume of at least 150 ml/kg/day administered by gavage method. The primary outcome measure was time (in days) to transition from gavage to full spoon feeds.

RESULTS

The mean (SD) time to transition from gavage to full spoon feeds was attained significantly earlier in the intervention group than the control group (9.93 [5.83] vs 16.43 [10.46] days; mean difference, -6.5 days; 95% CI, -12.58 to -0.41). There was no significant difference between the two groups in terms of the duration of hospital stay, rates of physiological stability, and culture positive sepsis.

CONCLUSION

Premature infant oral motor intervention, as used in this specific population, significantly reduces the time to transition to full spoon feeds without increasing culture positive sepsis and physiological instability.

Initiating and Supporting Breastfeeding: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Exclusive breastfeeding is recommended for children for the first 4 to 6 months of life, with complementary foods added thereafter. It is the most ecological way of protecting the child's and mother's health. Training of health professionals is required to avoid transmitting inconsistent information in 3 areas: 1) implementing these 3 predictors: safe skin-to-skin, first breastfeed, and rooming-in 24/7; 2) teaching and monitoring: i) early signs of waking and feeding rhythms, ii) positioning and latching, and iii) signs of effective transfer; and 3) referring women to specialized support services if difficulties arise (eg, inadequate milk production, pain, cracked nipples, engorgement). Breastfeeding should continue during mastitis or an abscess. Ultrasound-guided needle aspiration is beneficial in treating an abscess. Précis: Information is provided to enable health professionals to better support breastfeeding and help women with the most common difficulties, thus promoting breastfeeding initiation and duration.

The Galactagogue Effect of Maternal Ingestion of Corn-Based Preparations: A Preliminary Study

Background: Low human milk production frequently occurs in mothers of premature children with low birth weights who require intensive care. Research Aims: To investigate whether corn-based preparations increase human milk production in women with insufficient milk volumes. Method: This was an intervention study evaluated whether there was an increase in human milk production after a mother's consumption of corn-based preparations. The participants included women with hypogalactia and mothers of infants in neonatal and pediatric intensive care units. The corn-based preparations included green corn cakes and sweet hominies. A total of 35 mother-infant pairs participated in this study. Each mother served as their own control. The study took place over 2 weeks, and data were collected at baseline and after the intervention. At baseline, a socioeconomic questionnaire was used to collect information regarding maternal food consumption, volume of milk expressed, and infant weight and length. All evaluations, except for questionnaire administration, were performed during the intervention phase, when the lactating women ingested the corn-based preparations. Results: A significantly higher average volume of milk was expressed in the intervention period (397.6 ± 182.6 mL/day) compared to baseline (343.6 ± 155.8 mL/day) on the paired t-test (p < 0.001) analysis. Neither energy nor macronutrients consumed correlated with milk volume. Conclusion: The tested corn-based preparations acted as galactagogues and could be used to stimulate milk production in lactating women.

Impact of an Infant-Driven Feeding Initiative on Feeding Outcomes in the Preterm Neonate

BACKGROUND

Poor feeding techniques result in adverse outcomes for preterm infants. Infant-driven feeding (IDF) is a structured feeding method that standardizes neonatal cue-based feedings, and matches the neurodevelopmental stage of the preterm infant. The purpose of this quality improvement project is to assess whether initiation of an IDF initiative impacts time from first nipple feed (NF) to full NF and to discharge in infants born before 35 weeks' gestational age. Secondary aims include assessment of the impact of IDF on neonatal growth and feasibility of following an IDF protocol in a level III neonatal intensive care unit (NICU).

METHODS

This quality improvement project assesses differences in time to first NF, length of hospital stay, and neonatal growth before and after usage of an IDF protocol. Eighty infants were included, 40 prior to and 40 after IDF intervention. Nurses were trained on IDF philosophy and methods prior to initiation.

RESULTS

IDF was associated with discharge at a younger corrected gestational age (CGA), attainment of ad lib feeds at a younger CGA, and shorter amount of days between first NF and discharge. Infants utilizing IDF had slower weight gain, demonstrated by a larger drop in z score in the IDF group. The medical team and bedside nurses were able to follow the IDF protocol with few exceptions.

IMPLICATIONS FOR PRACTICE/RESEARCH

IDF allows for optimization of a preterm infant's NICU stay and prepares infants for a safe discharge sooner. This could lead to increased parental satisfaction and decreased hospital cost. Further studies are indicated to ensure these benefits remain and focus on impact direct breastfeeding plays in the IDF model.

Complementary feeding in preterm infants: a position paper by Italian neonatal, paediatric and paediatric gastroenterology joint societies

Nutrition in the first 1000 days of life is essential to ensure appropriate growth rates, prevent adverse short- and long-term outcomes, and allow physiologic neurocognitive development. Appropriate management of early nutritional needs is particularly crucial for preterm infants. Although the impact of early nutrition on health outcomes in preterm infants is well established, evidence-based recommendations on complementary feeding for preterm neonates and especially extremely low birth weight and extremely low gestational age neonates are still lacking. In the present position paper we performed a narrative review to summarize current evidence regarding complementary feeding in preterm neonates and draw recommendation shared by joint societies (SIP, SIN and SIGENP) for paediatricians, healthcare providers and families with the final aim to reduce the variability of attitude and timing among professionals.

Advantages of side-lying position. A comparative study of positioning during bottle-feeding in preterm infants (≤34 weeks GA)

BACKGROUND

The quality and safety of bottle-feeding in premature infants can be improved by optimal positioning. This study analysed the advantages of side-lying position (SLP) and semielevated position (SEP) during bottle-feeding in premature infants.

MATERIAL AND METHODS

A total of 42 neonates (n=42) born ≤34 weeks of gestational age were included in the study. Four feeding sessions-two in SLP and two in SEP- were analysed for each newborn. The level of saturation (SpO₂) and heart rate, which are the parameters assessing the physiological stability, were measured in the studied newborns. The other factors that were examined to determine the quality of feeding included the total time of decline of SpO₂ to ≤85%, level of the newborn's alertness measured using the Neonatal Behavioral Assessment Scale, and the frequency of choking episodes. The proportion of milk consumed (volume of milk consumed relative to the volume expected) and the feeding duration as well as the total time of feeding session were recorded.

RESULTS

SLP was safer in terms of the frequency of choking episodes. Choking episodes were more frequently observed with feeding in SEP (p<0.001). Moreover, the proportion of milk consumed by infants was statistically significantly higher in SLP (p<0.046) compared to SEP. No significant differences in the other tested parameters were noted in infants fed in SLP and infants fed in SEP.

CONCLUSIONS

This study demonstrated that SLP is effective in reducing the number of choking episodes during feeding. The proportion of milk consumed was better when the neonates were fed in SLP.

Pilot Study of Sham Feeding in Postoperative Neonates

OBJECTIVE

Sham feeding may enhance development of oral skills in neonates after bowel surgery and decrease stress levels in mothers. In this pilot study, we test the feasibility of sham feeding, identify safety hazards, and assess maternal satisfaction.

STUDY DESIGN

A convenience sample of 15 postoperative neonates was enrolled. Sham feeding with unfortified human milk was offered following a strict advancement protocol beginning with 5 mL once daily and increasing up to 30 mL, three times daily. Continuous gastric suction was used during sham feeding. Each mother completed a satisfaction survey. Sham-fed gastroschisis patients were compared with a historic cohort.

RESULTS

All 15 patients were able to sham feed. A total of 312 sham feeds were offered with a median of 23 sham events per patient. Four minor complications occurred during sham feeding. No differences were noted between 11 sham-fed gastroschisis patients and 81 historic controls. The mothers reported a decrease in stress after sham feeding using a 5-point score (3.8 ± 1.4 vs. 1.5 ± 0.7, p < 0.005) and 100% satisfaction with sham feeding.

CONCLUSION

Sham feeding is feasible for neonates after bowel surgery and is highly rated by mothers.

KEY POINTS

· Sham-feeding human milk to neonates after bowel surgery is feasible and safe.. · A novel postoperative sham feeding protocol is described.. · Mothers of sham-fed infants report it reduces stress compared with not feeding..

Preterm oral feeding scale to assist in deciding initial oral feeding of preterm infants in neonatal intensive care units

BACKGROUND

The inconsistency in decisions to commence oral feeding indicates that health professionals require clearer guidelines to determine when to initiate oral feeding in preterm infants. This study applied the Taiwan version of Preterm Oral Feeding Readiness Assessment Scale (TW-POFRAS) to clinical decision-making, especially for preterm infants with a birth weight less than 1,500 g or gestational age (GA) less than 32 weeks.

METHODS

This was a single-center observational cross-sectional study and 81 preterm infants were recruited. Lengths of stay from admission to initial one-meal oral feeding, to one-day all-meal oral feeding, and to discharge were analyzed. Scale scores, physician orders, and smooth oral intake of 5 mL of milk were analyzed. Kappa coefficients were examined to determine concordances within the results.

RESULTS

At least moderate concordance was evident (k = 0.492). Most preterm infants can begin to consume one meal of the least 5 mL of milk smoothly and proceed to consume a full day of meals with a week; they are typically discharged from the hospital within a month, except for those with a birth weight less than 1,500 g or a GA less than 32 weeks. For 17 of 81 participants, assessment results for physician orders, 5-mL milk consumption, and scale scores were inconsistent. Participants with a birth weight less than 1,500 g or GA less than 32 weeks were able to meet the 5-mL standard by the postmenstrual age of 35 weeks, at latest.

CONCLUSION

We recommend that TW-POFRAS should be used in conjunction with physicians' clinical decision-making for oral feeding readiness for preterm infants in the NICU.

Risk Factors Associated With Long-term Feeding Problems in Preterm Infants: A Scoping Review

BACKGROUND

Infants who are born preterm are at a high risk of encountering feeding problems.

PURPOSE

The aim of this scoping review is to identify risk factors associated with feeding problems that persist beyond infancy in children (aged 1-6 years) who were born preterm (<37 weeks' gestation).

METHODS

To perform this scoping review, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework was applied. To be included in this study, articles had to be published in peer-reviewed journals, had an empirical study design, examined feeding problems relating to the child's feeding ability or refusal to eat certain texture of foods, and assessed risk factors (age, weight, and medical conditions) associated with long-term feeding problems in children who were born preterm.

RESULTS

After abstract and full-text screening, a total of 9 articles meeting the inclusion criteria were included in this study. Findings from this study identified that gestational age and birth weight are significant risk factors and that sex, duration of mechanical ventilation, and length of tube feedings are potential risk factors.

IMPLICATIONS FOR PRACTICE

This study confirms that younger and smaller infants are at a high risk of encountering oral feeding difficulties and early interventions services should be focused on these preterm infants.

IMPLICATIONS FOR RESEARCH

Evaluation of timing and intensity (dose) of early interventions strategies should be investigated to provide more targeted and effective interventions for younger and smaller preterm infants.

Direct swallowing training and oral sensorimotor stimulation in preterm infants: a randomised controlled trial

OBJECTIVE

To evaluate the effects of direct swallowing training (DST) alone and combined with oral sensorimotor stimulation (OSMS) on oral feeding ability in very preterm infants.

DESIGN

Blinded, parallel group, randomised controlled trial (1:1:1).

SETTING

Neonatal intensive care unit of a South Korean tertiary hospital.

PARTICIPANTS

Preterm infants born at <32 weeks of gestation who achieved full tube feeding.

INTERVENTIONS

Two sessions per day were provided according to the randomly assigned groups (control: two times per day sham intervention; DST: DST and sham interventions, each once a day; DST+OSMS: DST and OSMS interventions, each once a day).

PRIMARY OUTCOME

Time from start to independent oral feeding (IOF).

RESULTS

Analyses were conducted in 186 participants based on modified intention-to-treat (63 control; 63 DST; 60 DST+OSMS). The mean time from start to IOF differed significantly between the control, DST and DST+OSMS groups (21.1, 17.2 and 14.8 days, respectively, p=0.02). Compared with non-intervention, DST+OSMS significantly shortened the time from start to IOF (effect size: -0.49; 95% CI: -0.86 to -0.14; p=0.02), whereas DST did not. The proportion of feeding volume taken during the initial 5 min, an index of infants' actual feeding ability when fatigue is minimal, increased earlier in the DST+OSMS than in the DST.

CONCLUSIONS

In very preterm infants, DST+OSMS led to the accelerated attainment of IOF compared with non-intervention, whereas DST alone did not. The effect of DST+OSMS on oral feeding ability appeared earlier than that of DST alone.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02508571).

Predicting Feeding Conditions of Premature InfantsThrough Non-Nutritive Sucking Skills Using a Sensitized Pacifier

Due to the lack of enough physical or suck central pattern generator (SCPG) development, premature infants require assistance in improving their sucking skills as one of the first coordinated muscular activities in infants. Hence, we need to quantitatively measure their sucking abilities for future studies on their sucking interventions. Here, we present a new device that can measure both intraoral pressure (IP) and expression pressure (EP) as ororhithmic behavior parameters of non-nutritive sucking skills in infants. Our device is low-cost, easy-to-use, and accurate, which makes it appropriate for extensive studies. To showcase one of the applications of our device, we collected weekly data from 137 premature infants from 29 week-old to 36 week-old. Around half of the infants in our study needed intensive care even after they were 36 week-old. We call them full attainment of oral feeding (FAOF) infants. We then used the Non-nutritive sucking (NNS) features of EP and IP signals of infants recorded by our device to predict FAOF infants' sucking conditions. We found that our pipeline can predict FAOF infants several weeks before discharge from the hospital. Thus, this application of our device presents a robust and inexpensive alternative to monitor oral feeding ability in premature infants.

Influence of taste stimulation on sucking pressure in newborn infants at term

PURPOSE

To verify the influence of a taste stimulus on the suction pressure, during the non-nutritive sucking (SNN), in newborns, healthy and with weight appropriate to the gestational age.

METHODS

Quasi-experimental study of the non-randomized clinical trial type with a convenience sample of 60 newborns (NB), 30 allocated in the study group (EG) and 30 in the control group (CG). The NB were evaluated for sucking pressure during the SNN in a pacifier. For the EG, a gustatory stimulus was added to the pacifier, moistened with colostrum. The CG did not receive any stimulus, other than the pacifier itself. The average, minimum and maximum pressures were measured with the equipment S-Flex®.

RESULTS

The SG presented mean and maximum sucking pressure significantly higher than the CG. In addition, there was a statistically significant difference between the groups for the second measurement of mean sucking pressure.

CONCLUSION

The results showed that the NB of the SG presented sucking pressures, average and maximum, significantly higher, when compared to the CG. The use of a taste stimulus associated with SNN modified the sucking pressure and seems to enhance oral skills.

The Impact of Infant and Maternal Factors on Oral Feeding Performance in Premature Infants

Aims: To identify infant and maternal factors associated with attainment of full oral feeding (FOF) in premature infants.Method: A retrospective study was performed on 89 premature infants (<34 weeks gestational age) from a tertiary care neonatal intensive care unit (NICU). Infant and maternal factors were concurrently assessed. Infant factors included gestational age, birthweight, continuous positive airway pressure assistance, mechanical ventilation support, and presence of neonatal morbidities including bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and intraventricular hemorrhages (IVH). Maternal factors included maternal age, first born, twin birth, and presence of mental health conditions including anxiety, stress, or depression.Results: A total of 89 premature infants were included in the sample. A stepwise linear regression model revealed that infants who received mechanical ventilator support and presence of maternal mental health conditions were significantly associated with time to attain FOF.Conclusions: Results suggest that oral feeding performance is influenced not only by infant's medical severity denoted by need for ventilator assistance, but also by presence of maternal anxiety, stress, and/or depression.

Partial Enteral Discharge Programs for High-risk Infants

Premature infants or infants born with complex medical problems are at increased risk of having delayed or dysfunctional oral feeding ability. These patients typically require assisted enteral nutrition in the form of a nasogastric tube (NGT) during their NICU hospitalization. Historically, once these infants overcame their initial reason(s) for admission, they were discharged from the NICU only after achieving full oral feedings or placement of a gastrostomy tube. Recent programs show that these infants can be successfully discharged from the hospital with partial NGT or gastrostomy tube feedings with the assistance of targeted predischarge education and outpatient support. Caregiver opinions have also been reported as satisfactory or higher with this approach. In this review, we discuss the current literature and outcomes in infants who are discharged with an NGT and provide evidence for safe practices, both during the NICU hospitalization, as well as in the outpatient setting.

Status and Influencing Factors of Parenteral Nutrition Practice for Late Preterm Infants in China

OBJECTIVES

To explore the status of parental nutrition practice of hospitalized late preterm infants and the factors influencing the clinical prescription.

METHODS

A multi-center, prospective cohort study was conducted during October 2015 to October 2017. Infants born after 34 weeks and before 37 weeks were enrolled from twenty-five hospitals in the Beijing area of China. Data of enteral and parenteral nutrition were collected.

RESULTS

A total of 1,463 late preterm infants were enrolled in this study, 53.9% of infants were supported by parenteral nutrition. Over 60% of 34 weeks' infants were on parenteral nutrition during the 2nd to the 4th day. Logistic regression analysis showed that gestational age(GA) (OR = 0.69, 95%CI 0.58-0.81), birth weight (OR = 0.41, 95%CI 0.26-0.65), hypoglycemia (OR = 2.77, 95%CI 1.90-4.04), small for gestational age (SGA) (OR = 2.18, 95%CI 1.34-3.55), feeding intolerance (OR = 6.41, 95%CI 1.90-21.59), neonatal respiratory distress syndrome (NRDS) (OR = 2.16, 95%CI 1.12-4.18), neonatal infection(OR = 1.56 95%CI 1.16-2.10), and slow enteral nutrition advancement rate (OR = 0.92, 95%CI 0.90-0.95) were factors influencing the administration of parenteral nutrition.

CONCLUSION

Over half of hospitalized late preterm infants were prescribed with parenteral nutrition. Infants with lower GA, lower birth weight, diagnosed with hypoglycemia, SGA, feeding intolerance, NRDS, neonatal infection, or a slower rate of enteral nutrition advancement had a higher likelihood of receiving parenteral nutrition.

Translation, Cultural Adaptation, Reliability, and Validity Evidence of the Feeding/Swallowing Impact Survey (FS-IS) to Brazilian Portuguese

The purpose of this study was to translate and adapt the Feeding/Swallowing Impact Survey (FS-IS) into Brazilian Portuguese and provide a validated instrument for caregivers of children with feeding/swallowing disorders. This cross-cultural study involved initial translation, synthesis of translations, back-translation, Committee of Experts, and pre-test. The sample consisted of 95 primary caregivers of children with feeding/swallowing disorders classified by Pediatric Dysphagia Evaluation Protocol (PDEP) in mild (n = 9), moderate-severe (n = 40), or profound (n = 46) dysphagia. Reliability and evidence of validity based on test content, response processes, internal structure and the relations to other variables were investigated. Internal consistency, test-retest, exploratory and confirmatory factor analysis were performed, in addition to the correlation with PedsQL™ Family Impact Module (PedsQL^TMFIM). The pre-test participants did not report any difficulties in understanding the translated version. The Brazilian Portuguese version of FS-IS (Pt-Br-FS-IS) presented Cronbach's Alpha of 0.83, Exploratory Factor Analysis verified that the instrument would not be unifactorial (KMO = 0.74 and Bartlett's sphericity test p < 0.001) and Confirmatory Factor Analysis confirmed the original model in three subscales with χ²/df = 1.23, CFI = 0.92, TLI = 0.90, RMSEA (90% CI) 0.049 (0.011-0.073) adjustment indexes and the ICC was excellent in all subscales and total score. The correlation with PedsQL™FIM was significant in the total score and subscales. This study successfully translated and cross-culturally adapted the FS-IS instrument to the Brazilian Portuguese language and the investigation of its reliability and validity evidence suggests that the Pt-Br-FS-IS is a reliable and valid tool to measure the impact of feeding/swallowing disorders on the quality of life of caregivers of affected children.

Bottle-Feeding Intervention Detection in the NICU

Video-based monitoring of patients in the neonatal intensive care unit (NICU) has great potential for improving patient care. Video-based detection of clinical events, such as bottle feeding, would represent a step towards semi-automated charting of clinical events. Recording such events contemporaneously would address the limitations associated with retrospective charting. Such a system could also support oral feeding assessment tools, as the patient's feeding skills and nutrition are pivotal in monitoring their growth. We therefore leverage transfer learning using a pretrained VGG-16 model to classify images obtained during an intervention, to determine if a bottle-feeding event is occurring. Additionally, we explore a data expansion technique by extracting similar-feature images from publicly available sources to supplement our dataset of real NICU patients to address data scarcity. This work also visualizes and quantifies the gap between the source domain (ImageNet data subset) and target domain (NICU dataset), thereby illustrating the impact of expanding our training set for knowledge transfer proficiency. Results show an increase of over 18% in sensitivity after data expansion. Analysis of network activation maps indicates that data expansion is able to reduce the distance between the source and target domains.

Mechanisms and management considerations of parent-chosen feeding approaches to infants with swallowing difficulties: an observational study

Videofluoroscopy swallow studies (VFSS) and high-resolution manometry (HRM) methods complement to ascertain mechanisms of infant feeding difficulties. We hypothesized that: (a) an integrated approach (study: parent-preferred feeding therapy based on VFSS and HRM) is superior to the standard-of-care (control: provider-prescribed feeding therapy based on VFSS), and (b) motility characteristics are distinct in infants with penetration or aspiration defined as penetration-aspiration scale (PAS) score ≥ 2. Feeding therapies were nipple flow, fluid thickness, or no modification. Clinical outcomes were oral-feeding success (primary), length of hospital stay and growth velocity. Basal and adaptive HRM motility characteristics were analyzed for study infants. Oral feeding success was 85% [76-94%] in study (N = 60) vs. 63% [50-77%] in control (N = 49), p = 0.008. Hospital-stay and growth velocity did not differ between approaches or PAS ≥ 2 (all P > 0.05). In study infants with PAS ≥ 2, motility metrics differed for increased deglutition apnea during interphase (p = 0.02), symptoms with pharyngeal stimulation (p = 0.02) and decreased distal esophageal contractility (p = 0.004) with barium. In conclusion, an integrated approach with parent-preferred therapy based on mechanistic understanding of VFSS and HRM metrics improves oral feeding outcomes despite the evidence of penetration or aspiration. Implementation of new knowledge of physiology of swallowing and airway protection may be contributory to our findings.

Early breast expression for very low birth infants admitted to neonatal intensive care unit: the challenges of cesarean deliveries

AIM OF THE STUDY

In preterm infants, the use of human milk is associated with unique benefits. However, successful breast feeding rates and prolonged breastfeeding duration is often reduced in preterm infants. Nevertheless, early initiation of breast expression after birth is believed to be one of the major variables that should improve the odds of successful breastfeeding. Hence, we aimed to assess correlation between timing of milk expression initiation and volume produced in regards to mode-of-delivery.

MATERIALS AND METHODS

Prospective, observational study. Mothers delivering infants weighing < 1500 g measured 24-h milk volumes on days 1-7, 14, and 21.

RESULTS

Mothers delivering vaginally (N = 11) expressed milk sooner (3.82 ± 5.03 h) than mothers in the cesarean group (N = 42; 11.5 ± 9.1 h). There were no significant differences in daily number of expressions (i.e. day 1 3.6 ± 1.6 versus 2.5 ± 2.1, p = .125) or daily volume (i.e. day 1 - 7.5 ± 6.1 ml versus 11.6 ± 22.9 ml, p = .563), until day 6 from which, both were lower in the cesarean group (i.e. day 21 - number - 6.0 ± 1.3 versus 4.6 ± 1.7, p = .029; volume - 796 ± 465ml versus 435 ± 368ml, p = .018). Expressed volume initially did not correlate with earlier expression, however, latter expressed volume inversely correlated with earlier expression. In multivariate-analysis, mode of delivery, gestational age, and daily number of expressions were correlated with volumes on day 21 (p = .001).

CONCLUSIONS

Earlier human-milk expression is related to volumes on the second and the third week of lactation. This is overwhelmed by delivery mode, and by frequent milk expression from day 2. When early milk expression is not possible, more frequent milk expression might help increasing volumes.