Abstract
Neonates born premature or who suffer brain injury at birth often have oral feeding dysfunction and do not meet oral intake requirements needed for discharge. Low oral intake volumes result in extended stays in the hospital (>2 months) and can lead to surgical implant and explant of a gastrostomy tube (G-tube). Prior work suggests pairing vagus nerve stimulation (VNS) with motor activity accelerates functional improvements after stroke, and transcutaneous auricular VNS (taVNS) has emerged as promising noninvasive form of VNS. Pairing taVNS with bottle-feeding rehabilitation may improve oromotor coordination and lead to improved oral intake volumes, ultimately avoiding the need for G-tube placement. We investigated whether taVNS paired with oromotor rehabilitation is tolerable and safe and facilitates motor learning in infants who have failed oral feeding. We enrolled 14 infants [11 premature and 3 hypoxic–ischemic encephalopathy (HIE)] who were slated for G-tube placement in a prospective, open-label study of taVNS-paired rehabilitation to increase feeding volumes. Once-daily taVNS was delivered to the left tragus during bottle feeding for 2 weeks, with optional extension. The primary outcome was attainment of oral feeding volumes and weight gain adequate for discharge without G-tube while also monitoring discomfort and heart rate (HR) as safety outcomes. We observed no adverse events related to stimulation, and stimulation-induced HR reductions were transient and safe and likely confirmed vagal engagement. Eight of 14 participants (57%) achieved adequate feeding volumes for discharge without G-tube (mean treatment length: 16 ± 6 days). We observed significant increases in feeding volume trajectories in responders compared with pre-stimulation (p < 0.05). taVNS-paired feeding rehabilitation appears safe and may improve oral feeding in infants with oromotor dyscoordination, increasing the rate of discharge without G-tube, warranting larger controlled trials.
Highlights
In the motor task of feeding, neonates are required to coordinate a complex and rapid sequence of sucking, swallowing, and breathing, all integrated with a typical respiratory rate of 40 breaths per minute
We investigated the within-individual changes in heart rate (HR) using a paired t-test to compare each participant’s baseline and the lowest HR prior to feed to the lowest HR during perceptual threshold (PT) within transcutaneous auricular VNS (taVNS) or control feeds, and unpaired t-tests for HR differences across taVNS or control feeds
Fiftyseven percent of treated infants were able to take all feeds by mouth within a mean of 16 days of treatment. taVNS-paired oral rehabilitation increased the likelihood of discharge without the need for gastrostomy tube (G-tube) implantation than did a historical retrospective comparison cohort who received standard feeding rehabilitation (Ryan and Gehle, 2019)
Summary
In the motor task of feeding, neonates are required to coordinate a complex and rapid sequence of sucking, swallowing, and breathing, all integrated with a typical respiratory rate of 40 breaths per minute. Feeding difficulty is the primary reason for delayed hospital discharge in preterm infants with brain dysmaturation or near-term/term infants with hypoxic–ischemic encephalopathy (HIE) who are otherwise clinically stable and ready for discharge (Adamkin, 2006; Lau et al, 2015; Jackson et al, 2016). This increases hospital costs and is associated with a negative impact on long-term neurodevelopment, with receptive and expressive language deficits (Adams-Chapman et al, 2013; Malas et al, 2015). Many infants do not show improvement by term equivalent age, even after many weeks of rehabilitation with therapists, and have a gastrostomy tube (G-tube) placed for adequate nutrition
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