Maintenance of behavioral status for the initiation of oral feeding in preterm infants with bronchopulmonary dysplasia

Objective: this study aimed at investigating the Schedule Oral Motor Assessment (SOMA) tool to be used with preterm infants and to compare its results with the Preterm Oral Feeding Readiness Assessment Scale (POFRAS) to start oral feeding. Methods: a cross-sectional and quantitative study, consisting in a sample of 45 healthy and clinically stable preterm infants, assessed at their first oral feeding with two tools: the Schedule Oral Motor Assessment and Preterm Oral Feeding Readiness Assessment Scale. Stata 10.0 software was used for data analysis. Results: 10 preterm infants with readiness for oral feeding showed normal oral motor function, and 16, presented with oral motor dysfunction, did not show readiness for feeding (p <0.05). The time of transition for full oral feeding was 13.5 (± 8.1) days for preterm infants with better results in both assessment tools, and 17.7 (± 10.9) days for those who did not show readiness for oral feeding and had oral motor dysfunction to initiate oral feeding, resulting in a given clinical relevance, even showing no significance (p> 0.05). Conclusion: these results suggest that the Schedule Oral Motor Assessment can be an adjunctive method for evaluation of the oral motor function at the first oral feeding in preterm infants.

Background: Gavage feeding is associated with adverse effects, such as irritations in the mouth, hyperactivity, problems in gag reflex, bradycardia, and the parents’ unacceptance. Accordingly, it is essential to undertake a comprehensive review of the effects of breast milk and other pleasant odors that may reduce the transition time from gavage to oral feeding in preterm infants. Objectives: Aim of review is to compare of effects of breast milk and other pleasant odors with the control group on the transition from gavage to oral feeding in preterm infants. Methods: In this systematic review, online English databases, such as PubMed, Scopus, ISI Web of Science, and Cochrane Library were systematically searched without any time limitation up to February 10, 2022. The modified Jadad scale was also used to assess the quality of the articles. The inclusion criteria comprised all clinical trials evaluating the effect of aromatherapy on odors on the transition from gavage to oral feeding in preterm infants. Results: 8 studies were assessed with the effects of aroma inhalation on the transition from gavage to oral feeding. Meta-analysis of these studies showed that preterm infants transitioned from tube feeding (gavage) to oral feeding earlier in the groups stimulated by pleasant odors (standardized mean difference [SMD]=₋0.47, 95% CI, ₋0.64%, ₋0.3%, heterogeneity, P=0.32; I2=13%, 8 trials) and odor of breast milk (SMD=₋0.61, 95% CI, ₋0.64%, ₋0.31%, heterogeneity, P=0.85, I2=0%, 6 trials) in comparison to the control group. Conclusions: Our meta-analysis supports using breast milk and other pleasant odors as a safe and noninvasive way of reducing the transition time from gavage to oral feeding in preterm infants. Health providers should use effective and family-friendly interventions to care for their premature infants.

The transition to full oral feeding (FOF) is a critical milestone for discharge in preterm infants and reflects the maturation of multiple physiological systems, particularly swallowing-related neuromuscular coordination. Suprahyoid muscles play a key role in swallowing by enabling elevation of the hyoid–laryngeal complex and protecting the airway. However, the relationship between the structural development of these muscles and the achievement of oral feeding in preterm infants remains insufficiently explored. This prospective single-center observational study included 28 preterm infants born at ≤ 32 weeks of gestation. Suprahyoid muscle thickness (right and left digastric, right and left mylohyoid, and geniohyoid muscles) was measured by ultrasonography at two time points: within the first 72 h of postnatal life and at the time of full oral feeding. Somatic growth parameters, including body weight, body length, and head circumference, were recorded simultaneously. Changes in muscle thickness over time, correlations with somatic growth parameters, and the predictive value of early muscle thickness for time to achieve FOF were analyzed. All suprahyoid muscle thicknesses increased significantly between the early postnatal period and the time of FOF (all p < 0.001). At the time of FOF, digastric muscle thickness ranged approximately between 2.7 and 3.2 mm, mylohyoid muscle thickness between 1.6 and 2.0 mm, and geniohyoid muscle thickness between 3.0 and 3.6 mm, with values appearing to cluster within a relatively narrow range during successful transition to oral feeding. A positive correlation was observed between body weight and certain muscle thickness measurements, particularly left mylohyoid (r = 0.453, p = 0.015) and right digastric muscles (r = 0.386, p = 0.043). However, suprahyoid muscle thickness measured within the first 72 h did not independently predict the time required to achieve FOF in multivariable regression analysis.Conclusion: Suprahyoid muscle thickness increases significantly during the transition from early postnatal life to full oral feeding in preterm infants and appears to cluster within a relatively narrow range at the time of feeding maturation. Ultrasonographic evaluation of suprahyoid muscles may provide a non-invasive approach to describe structural changes associated with feeding maturation in preterm infants.What is Known:• The transition to full oral feeding in preterm infants reflects the maturation of multiple physiological systems, including suck–swallow–breathing coordination, and is a key determinant of discharge readiness.• Ultrasonography has been used as a non-invasive method to assess structural and functional aspects of muscles involved in feeding and swallowing.What is New:• Suprahyoid muscle thickness in preterm infants increases significantly from early postnatal life to full oral feeding and appears to cluster within a relatively narrow range at the time of feeding maturation.• Early postnatal suprahyoid muscle thickness does not independently predict the time to achieve full oral feeding, suggesting that feeding maturation is a multifactorial process beyond a single structural parameter.

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

Objective This review article aimed to explore the effect of oral motor intervention on oral feeding in preterm infants through a meta-analysis. Method Eligible studies were retrieved from four databases (PubMed, Embase, Cochrane Library, and Web of Science) up to July 2020 and screened based on established selection criteria. Thereafter, relevant data were extracted and heterogeneity tests were conducted to select appropriate effect models according to the chi-square test and I 2 statistics. Assessment of risk of bias was performed among the included studies. Finally, a meta-analysis was carried out to evaluate the effect of oral motor intervention in preterm infants according to four clinical indicators: transition time for oral feeding, length of hospital stay, feeding efficiency, and weight gain. Results Eighteen randomized controlled trials with 848 participants were selected to evaluate the effect of oral motor intervention on preterm infants. The meta-analysis results revealed that oral motor intervention could effectively reduce the transition time to full oral feeds and the length of hospital stay as well as increase feeding efficiency and weight gain. Conclusions Oral motor intervention was an effective way to improve oral feeding in preterm infants. It is worthy to be used widely in hospitals to improve the clinical outcomes of preterm infants and reduce the economic burdens of families and society. Future studies should seek to identify detailed intervention processes and intervention durations for clinical application.

Rationale, aims and objectivesThis article aims to provide evidence to guide multidisciplinary clinical practitioners towards successful initiation and long‐term maintenance of oral feeding in preterm infants, directed by the individual infant maturity.MethodA comprehensive review of primary research, explorative work, existing guidelines, and evidence‐based opinions regarding the transition to oral feeding in preterm infants was studied to compile this document.ResultsCurrent clinical hospital practices are described and challenged and the principles of cue‐based feeding are explored. “Traditional” feeding regimes use criteria, such as the infant's weight, gestational age and being free of illness, and even caregiver intuition to initiate or delay oral feeding. However, these criteria could compromise the infant and increase anxiety levels and frustration for parents and caregivers. Cue‐based feeding, opposed to volume‐driven feeding, lead to improved feeding success, including increased weight gain, shorter hospital stay, fewer adverse events, without increasing staff workload while simultaneously improving parents' skills regarding infant feeding. Although research is available on cue‐based feeding, an easy‐to‐use clinical guide for practitioners could not be found. A cue‐based infant feeding regime, for clinical decision making on providing opportunities to support feeding success in preterm infants, is provided in this article as a framework for clinical reasoning.ConclusionsCue‐based feeding of preterm infants requires care providers who are trained in and sensitive to infant cues, to ensure optimal feeding success. An easy‐to‐use clinical guideline is presented for implementation by multidisciplinary team members. This evidence‐based guideline aims to improve feeding outcomes for the newborn infant and to facilitate the tasks of nurses and caregivers.

Aim Preterm infants often encounter difficulty with attaining independent oral feeding. There is limited evidence on which factors influence the achievement of independent oral feeding. This study aimed to examine the relation between intrinsic neurophysiological factors and the attainment of independent oral feeding. Methods A retrospective study was conducted using data from a level II-III neonatal intensive care unit. The Oral Feeding in Preterm Infants Conceptual Model was used to identify intrinsic factors, including gestational age, sex, twin, respiratory support duration, intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, patent ductus arteriosus, and sepsis. Results A total of 282 infants (31.2 ± 2.4 wk) were included. The simple linear regression results revealed gestational age (β = –1.224, p ≤ 0.001), respiratory support duration (β = 0.216, p = 0.001), bronchopulmonary dysplasia (β = 0.6404, p < 0.001), patent ductus arteriosus (β = 3.197, p = 0.048) and sepsis β = 2.328, p = 0.042) were associated with the attainment of independent oral feeding. These variables were included in the multiple linear regression analyses, revealing gestational age, patent ductus arteriosus, and duration of respiratory support were significantly associated with the attainment of independent oral feeding. Conclusion Gestational age, duration of respiratory support and patent ductus arteriosus are key determinants of attaining independent oral feeding, underscoring the importance of considering these factors in clinical practice.

Objective To explore the effect of oral feeding promotion program, which combined utilization of preterm infant oral motor intervention (PIOMI) from abroad and the Chinese version of preterm infant oral feeding readiness assessment scale (PIOFRAS), on the performance, process and outcome of oral feeding in preterm infants. Methods A total of 62 infants born before 34 weeks of gestation were divided into control group and experimental group according to the order of admission. Both groups received the same routine care. The infants in the experimental group (n=30) received the assessment of oral feeding readiness by PIOFRAS before feeding, and were given oral massage and non-nutritive sucking for 5 minutes once a day. The intervention started from gavage feeding to total oral feeding. While the control group (n=32) received a sham intervention that nurses stood beside the warm box or the baby′s bed for 5 minutes once a day before feeding. The oral feeding performance, the corrective gestational age of initiation of oral feeding and achieving full oral feeding, daily bodyweight and length of hospital stay were recorded. Results The transitional time from the initiation of oral feeding to full oral feeding in experimental group was shorter than that in control group[(8.07±6.73) d vs (13.88±7.51)d], and the difference was statistically significant (t=3.200, P 0.05). Conclusions The oral feeding promotion program can improve the oral feeding of preterm infants. Key words: Preterm infant; Enteral nutrition; Oral motor intervention; Oral feeding

Preterm infants have imperfect neurological development, uncoordinated sucking-swallowing-breathing, which makes it difficult to realize effective oral feeding after birth. How to help preterm infants achieve complete oral feeding as soon as possible has become an important issue in the management of preterm infants. Non-nutritive sucking (NNS), as a useful oral stimulation, can improve the effect of oral feeding in preterm infants. This review aimed to explore the effect of NNS on oral feeding progression through a meta-analysis. We systematically searched PubMed, CINHAL, Web of Science, Embase, Cochrane databases, China's National Knowledge Infrastructure (CNKI), Wanfang and VIP database from inception to January 20, 2024. Search terms included 'non-nutritive sucking' 'oral feeding' and 'premature.' Eligibility criteria involved randomized controlled studies in English or Chinese. Studies were excluded if they were reviews, case reports, or observational studies from which valid data could not be extracted or outcome indicators were poorly defined. The meta-analysis will utilize Review Manager 5.3 software, employing either random-effects or fixed-effects models based on observed heterogeneity. We calculated the mean difference (MD) and 95% confidence interval (CI) for continuous data, and estimated pooled odds ratios (ORs) for dichotomous data. Sensitivity and publication bias analyses were conducted to ensure robust and reliable findings. We evaluated the methodological quality of randomized controlled trials (RCTs) utilizing the assessment tool provided by the Cochrane Collaboration. A total of 23 randomized controlled trials with 1461 preterm infants were included. The results of the meta-analysis showed that NNS significantly shortened time taken to achieve exclusive oral feeding (MD = -5.37,95%CI = -7.48 to-3.26, p<0.001), length of hospital stay(MD = -4.92, 95% CI = -6.76 to -3.09, p<0.001), time to start oral feeding(MD = -1.41, 95% CI = -2.36 to -0.45, p = 0.004), time to return to birth weight(MD = -1.72, 95% CI = -2.54 to -0.91, p<0.001). Compared to the NNS group, the control group had significant weight gain in preterm infants, including weight of discharge (MD = -61.10, 95% CI = -94.97 to -27.23, p = 0.0004), weight at full oral feeding (MD = -86.21, 95% CI = -134.37 to -38.05, p = 0.0005). In addition, NNS reduced the incidence of feeding intolerance (OR = 0.22, 95% CI = 0.14 to 0.35, p<0.001) in preterm infants. NNS improves oral feeding outcomes in preterm infants and reduces the time to reach full oral feeding and hospitalization length. However, this study was limited by the relatively small sample size of included studies and did not account for potential confounding factors. There was some heterogeneity and bias between studies. More studies are needed in the future to validate the effects on weight gain and growth in preterm infants. Nevertheless, our meta-analysis provides valuable insights, updating existing evidence on NNS for improving oral feeding in preterm infants and promoting evidence-based feeding practices in this population.

Oral feeding readiness is a complex concept. More evidence is needed to approach the initiation of oral feedings in preterm infants. Recognition and support of oral feeding readiness may decrease hospital stays and reduce healthcare costs. To assess the accuracy of the pre-feeding section of the Mansoura Early Feeding Skills Assessment (MEFSA) score on the initiation of oral feeding in preterm infants and identify a cutoff point for oral feeding readiness concerning the oral feeding skill (OFS) level. Furthermore, to confirm the concordance between the MEFSA and the OFS level. Transversal and analytical study of 41 preterm infants. Infants were assessed before the first oral feeding by the pre-feeding section. Furthermore, the first oral feeding act is evaluated by the during-feeding section of MEFSA and OFS level. The cutoff point was estimated based on the OFS level and success using a receiver operating characteristic (ROC) curve. Pearson correlations were obtained between the pre-feeding and during-feeding sections, as well as the association between the during-feeding section and OFS score. MEFSA’s overall diagnostic accuracy was 82.5%. Cutoff points for oral feeding readiness were determined to be greater than 77 and greater than 77.5, concerning OFS level and oral feeding success, respectively. A moderate positive correlation coefficient existed between the pre-feeding and during-feeding sections of MEFSA. The pre-feeding section of MEFSA is a straightforward, quick instrument that can be used in clinical practice. It has a moderate to high accuracy in pinpointing the ideal time for readiness for oral feeding. However, more research is needed. We suggest combining the pre-feeding and during-feeding sections in clinical practice.

With the growing emphasis on neonatal developmental care, nurses are being encouraged to provide responsive feeding based on preterm infant behavioral cues. The responsive feeding approach has been shown to reduce stress stimuli, stabilize physiological maturity, and optimize neurodevelopment, making it an important model of care for preterm infants. Consequently, nurses who are proficient in recognizing the behavioral signals of oral feeding readiness in preterm infants are better able to facilitate the safe transition to oral feeding, thereby supporting infant growth and development. This study was designed to examine the associated factors of nurses in assessment of oral feeding in preterm infants. In this cross-sectional correlational study, neonatal nursing staff were recruited using convenience sampling. Data were collected using a demographic questionnaire, the Developmental Care Knowledge and Support Ability Scale, and the Recognition of Preterm Oral Feeding Readiness Scale. Independent t-tests, one-way analysis of variance, and Pearson's product-moment correlation were used in correlation analyses. Stepwise multiple regression was employed for the inferential statistics. Recognition of oral feeding readiness differed significantly by work unit. Specifically, nurses in the sick baby room recognized cues indicating oral feeding readiness more accurately than those in the NICU (t = -3.95, p < .01), while those with prior oral feeding training scored higher than those without (t = 2.03, p < .05). In addition, a positive correlation was found between recognition of oral feeding readiness and developmental care knowledge (r = .28, p < .05). The results of the stepwise regression identified three significant predictors of recognition of oral feeding readiness, which collectively explained 13.8% of the variance. These were: developmental care knowledge (β = 0.28, p < .01), work unit (β = 0.22, p < .001), and oral feeding training (β = 0.17, p < .001). In-service education on preterm oral feeding should be incorporated into the training provided to all nurses working with preterm infants to enhance their developmental care knowledge and improve their ability to recognize the signals of oral feeding readiness. Such targeted training may be expected to facilitate the successful implementation of developmental care practices and promote the safe transition to oral feeding in preterm infants.

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

We included 19 studies of poor quality with small numbers of participants. Study findings suggest that oral stimulation interventions can shorten the transition to oral feeding, reduce length of hospital stay and decrease time spent on parenteral nutrition. No studies looked at longer-term outcomes of the interventions (i.e. beyond six months). Studies have reported no effect on breast feeding outcomes nor on weight gain. These studies were small and most were of low or very low methodological quality. Review authors identified no high-quality studies that could support the efficacy, effectiveness and safety of oral stimulation interventions. Larger, well-designed RCTs are needed to help inform parents and caregivers about the possible benefits and harms of this intervention. 3 Oral stimulation for promoting oral feeding in preterm infants (Review)

Preterm infants (< 37 weeks' postmenstrual age) 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. To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' postmenstrual age (PMA).To conduct subgroup analyses for the following prespecified subgroups.• Extremely preterm infants born at < 28 weeks' PMA.• Very preterm infants born from 28 to < 32 weeks' PMA.• Infants breast-fed exclusively.• Infants bottle-fed exclusively.• Infants who were both breast-fed and bottle-fed. We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 25 February 2016). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles. Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention in preterm infants and reporting at least one of the specified outcomes. One review author searched the databases and identified studies for screening. Two review authors screened the abstracts of these studies and full-text copies when needed to identify trials for inclusion in the review. All review authors independently extracted the data and analysed each study for risk of bias across the five domains of bias. All review authors discussed and analysed the data and used the GRADE system to rate the quality of the evidence. Review authors divided studies 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. This review included 19 randomised trials with a total of 823 participants. Almost all included trials had several methodological weaknesses. Meta-analysis showed that oral stimulation reduced the time to transition to oral feeding compared with standard care (mean difference (MD) -4.81, 95% confidence interval (CI) -5.56 to -4.06 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days), as well as the duration of initial hospitalisation compared with standard care (MD -5.26, 95% CI -7.34 to -3.19 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days).Investigators reported shorter duration of parenteral nutrition for infants compared with standard care (MD -5.30, 95% CI -9.73 to -0.87 days) and compared with another non-oral intervention (MD -8.70, 95% CI -15.46 to -1.94 days). They could identify no effect on breast-feeding outcomes nor on weight gain. Although the included studies suggest that oral stimulation shortens hospital stay, days to exclusive oral feeding and duration of parenteral nutrition, one must interpret results of these studies with caution, as risk of bias and poor methodological quality are high overall. Well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should use reliable methods of randomisation while concealing treatment allocation, blinding caregivers to treatment when possible and paying particular attention to blinding of outcome assessors.

Background and Objectives Given the positive effects of stimulation with maternal breast milk odor and non-nutritive sucking on premature infants’ feeding skills, the present study was conducted to examine the effect of combining two stimuli, including non-nutritive sucking and maternal breast milk odor, on the time of achieving independent oral feeding in premature infants. Materials and Methods The present clinical trial was conducted at Mahdieh and Shohada-e Tajrish Hospitals of Tehran in 2016. A total of 32 neonates with a fetal age of 28-32 weeks for whom gavage feeding was started entered the study and were divided into a group of non-nutritive sucking combined with olfactory stimuli and another group of non-nutritive sucking only. The stimulations were performed in both groups at the first five minutes of gavage, three times per day, over ten consecutive days. Weight gain, the time of achieving frequent oral feeding and chronological age at the time of discharge from the hospital were recorded as measures of the effectiveness of the interventions. The results of the interventions were analyzed and compared in SPSS-18. Findings and Conclusion Non-nutritive sucking combined with maternal breast milk odor leads to a lower post-menstrual age at the first oral feeding, independent oral feeding and discharge from the hospital in premature infants, but has no effects on their daily weight gain and weight at the time of discharge. These results show the effectiveness of combining maternal breast milk odor and non-nutritive sucking as two separate stimuli in achieving oral feeding and earlier discharge from the hospital.