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.

Experiences of Indonesian nurses in improving preterm oral feeding readiness in special care units: A qualitative descriptive study

Background

Many preterm infants face feeding difficulties during the transition from enteral to oral feeding due to organ immaturity, resulting in aspiration, airway instability, and oral feeding intolerance. These challenges can increase morbidity and mortality among preterm infants. Nurses play a vital role in providing interventions to minimize negative impacts and enhance the safety of preterm oral feeding.

Objective

This study aimed to explore the experiences of Indonesian nurses in improving preterm oral feeding readiness.

Methods

A qualitative descriptive study was conducted involving ten nurses working in intensive care units as participants through purposive sampling. Data were collected through semi-structured, in-depth interviews conducted from January to March 2023. Thematic analysis was applied for data analysis.

Results

Four key themes developed in this study: 1) comprehensive and holistic nursing assessment, 2) challenging and complex nursing issues, 3) the need for nutritional management skills, and 4) the necessity of collaborative support.

Conclusion

Nurses play a pivotal role in enhancing oral feeding readiness among premature infants. Their responsibilities include assessing oral feeding readiness, addressing nursing challenges, and implementing multidisciplinary stimulation involving parents. This study provides a foundational framework for developing interventions to improve preterm oral feeding readiness.

Factors Affecting Oral Feeding Ability in Indonesian Preterm Infants

Most preterm infants exhibit atypical and immature feeding skills. Even though preterm infants have fulfilled the oral feeding readiness criteria, they still do not have optimal oral feeding ability. This study aimed to determine various factors affecting oral feeding ability in Indonesian preterm infants who have fulfilled oral feeding readiness criteria but still have not been able to feed orally. A cross-sectional study included 120 preterm infants admitted to five tertiary hospitals in Jakarta, Indonesia. Participants were preterm infants born at 28-34 weeks gestational age who had fulfilled the oral feeding readiness as the inclusion criteria: (1) stable cardiorespiratory status, (2) have achieved full enteral feeding via orogastric tube (OGT) 120 mL/kg/day without vomiting or bloating, and (3) strong and rhythmic non-nutritive sucking (NNS) through objective measurement. Infants' oral feeding ability and various factors that were assumed to affect oral feeding ability, including physiological flexion postural tone, physiological stability, rooting reflex, self-regulation, behavioral state, and level of morbidity were evaluated. Chi-square and multivariate analysis with Poisson regression were performed. Results indicated that postural tone, rooting reflex, physiological stability, self-regulation, behavioral state, and level of morbidity were significantly related to oral feeding ability in preterm infants. The most influencing factors were self-regulation with a prevalence ratio (PR) of 1.96 (1.16-3.34; CI 95%) and p = 0.012, followed by postural tone, high morbidity, and behavioral state (PR 1.91; 1.59; 1.56; CI 95%, respectively). In conclusion, despite meeting the oral feeding readiness criteria, most preterm infants were still not able to feed orally. There are other factors affecting oral feeding ability in Indonesian preterm infants.

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.

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.