Improve Feeding Outcomes Research Articles

The effect of oral motor intervention with different initiation times to improve feeding outcomes in preterm infants: protocol for a single-blind, randomized controlled trial

BackgroundPremature infants commonly encounter difficulties with oral feeding, a complication that extends hospital stays, affects infants’ quality of life, and imposes substantial burdens on families and society. Enhancing preterm infants’ oral feeding skills and facilitating their transition from parenteral or nasal feeding to full oral feeding pose challenges for neonatal intensive care unit (NICU) healthcare professionals. Research indicates that oral motor interventions (OMIs) can enhance preterm infants’ oral feeding capabilities and expedite the transition from feeding initiation to full oral feeding. Nonetheless, the most suitable timing for commencing these interventions remains uncertain.MethodsThis is a single-blind, randomized controlled trial. Preterm with a gestational age between 29+0 to 34+6 weeks will be eligible for the study. These infants will be randomized and allocated to one of two groups, both of which will receive the OMIs. The intervention commences once the infant begins milk intake during the early OMIs. Additionally, in the late OMIs group, the intervention will initiate 48 h after discontinuing nasal continuous positive airway pressure.DiscussionOMIs encompass non-nutritive sucking and artificial oral stimulation techniques. These techniques target the lips, jaw, muscles, or tongue of premature infants, aiming to facilitate the shift from tube feeding to oral feeding. The primary objective is to determine the ideal intervention timing that fosters the development of oral feeding skills and ensures a seamless transition from parenteral or nasal feeding to full oral feeding among preterm infants. Furthermore, this study might yield insights into the long-term effects of OMIs on the growth and neurodevelopmental outcomes of preterm infants. Such insights could bear substantial significance for the quality of survival among preterm infants and the societal burden imposed by preterm birth.Trial registrationchictr.org.cn ChiCTR2300076721. Registered on October 17, 2023.

Contingent Mother's Voice Intervention Targeting Feeding in Hospitalized Infants with Critical Congenital Heart Defects.

Infants with critical congenital heart defects (CCHD) are at high risk for feeding challenges and neurodevelopmental delays; however, few interventions promoting the neurodevelopmental progression of feeding have been studied with this population. Contingent mother's voice has been successfully used as positive reinforcement for non-nutritive suck (NNS) in studies with preterm infants, leading to improved weight gain and more rapid cessation of tube feedings; however, this type of intervention has not been studied in infants with CCHD. This study aimed to determine whether an NNS-training protocol using the mother's voice as positive reinforcement and validated in preterm infants could improve oral feeding outcomes in hospitalized infants with CCHD undergoing cardiac surgical procedures. Infants were randomized to receive the contingent mother's voice intervention before or after cardiac surgery, with a control comparison group receiving passive exposure to the mother's voice after surgery. There were no significant differences in discharge weight, PO intake, length of stay, time to full feeds, or feeding status at 1-month post-discharge between infants who received contingent mother's voice compared to those who did not. There were significant differences in PO intake and time to full feeds following surgery based on infants' pre-enrollment PO status and severity of illness. At 1-month post-discharge, parents of infants in the intervention group expressed a higher rate of positive feelings and fewer concerns regarding their infant's feeding compared to parents of infants in the control group. While the current protocol of 5 sessions was not associated with improved feeding outcomes in infants with CCHD, it empowered parents to contribute to their infant's care and demonstrated the feasibility of using the mother's voice as positive reinforcement for infants with CCHD. Further study of timing, intensity, and duration of interventions leveraging the mother's voice in this population is needed. ClinicalTrials.gov Identifier: NCT03035552.

Impact of Extubation Time on Feeding Outcomes after Neonatal Cardiac Surgery: A Single-Center Study

This study aimed to examine the impact of timing of extubation on feeding outcomes in neonates after surgery for congenital heart disease. This was a single-center retrospective study between December 2014 and June 2020. Patients were divided into three categories: extubated in the OR (immediate), extubated in the intensive care unit (ICU) between 0 and 3 days post-procedure (early), and extubated >3 days post-procedure (delayed). Comparing the immediate and early groups, we found no difference in time to first enteral feed (1.3 days (1.0-3.4) vs. 2.3 days (1.1-3.3), p = 0.27). There was no difference in time to first oral feed (2.0 days (1.1-4.5) vs. 3.1 days (1.8-4.4), p = 0.34) and time to goal feed (6.0 days (3.2-8.3) vs. 6.9 days (5.0-9.0), p = 0.15)). There was no difference in all oral feeds at one year: 88% vs. 98%, p = 0.16. The delayed extubation group performed significantly worse on all measures. Immediate and early extubation displayed no differences in feeding outcomes and length of stay in this study, while delayed extubation performed worse on all measures. Thus, we believe that clinicians should emphasize extubation within 3 days post-surgery to improve feeding outcomes while minimizing time hospitalized.

Effect of Contingency Paradigm-Based Interventions on Developmental Outcomes in Young Infants: A Systematic Review.

The purpose of this systematic review was to identify controlled trials evaluating the efficacy of contingency paradigm-based interventions to improve feeding, motor, or cognitive outcomes during the first year of life. Seventeen studies, including 10 randomized controlled trials, incorporating contingency paradigm-based interventions were identified. Three of 3 trials reported improvements in nutritive sucking using pacifier-activated lullaby in preterm infants before term age. Seven of 12 trials reported improvements in reaching, manual exploration, and kicking behaviors in term and preterm infants; and 6 of 10 trials reported gains in early cognition using sticky mittens and contingent toys. Contingency paradigm-based interventions can improve feeding outcomes in the neonatal intensive care unit in very preterm infants, and increase reaching, and perceptual-cognitive behaviors in term infants. Future research is needed to establish contingency paradigms as an effective early intervention strategy. This review synthesizes a body of literature on contingency paradigm-based interventions and highlights its potential paradigm-based interventions to improve developmental outcomes in infants.

Ketorolac and Predicted Severe Acute Pancreatitis: A Randomized, Controlled Clinical Trial.

Objective: We evaluated the effect of ketorolac on reducing the severity of acute pancreatitis.Design and Setting: Randomized clinical trial performed in a University hospital.Participants: There were 56 adult patients, with predicted severe acute pancreatitis, randomly divided into two groups.Methods: The patients in the study group received intravenous ketorolac, 10 mg, three times daily from the time of enrollment for a maximum of 5 days, as needed, along with standard medical treatment. Primary outcome measure was the change in the serum level of high sensitive C-reactive protein (hs-CRP). Patients were also followed up in terms of hospitalization duration, need for intensive care unit (ICU), organ failure development, persistent organ failure, pancreatic necrosis, nutritional assessment, and mortality. The study continued to gather clinical follow-up information up to 4 months.Results: Serum level of hs-CRP was significantly lower in the ketorolac group compared with the control group on days 3, 4, and 5. There were no significant differences in organ failure, pseudocyst formation, acute necrotic collection, mortality, and ICU transfer between groups. Days of hospitalization were significantly lower in the study group. The feeding start time was significantly shorter in the study group with no need for tube feeding in the ketorolac group. Frequency of NPO (not per oral) was significantly lower in the ketorolac group.Conclusion: The use of ketorolac may improve feeding outcomes and shorten length of hospitalization in predicted severe acute pancreatitis.

Recommendations and Outcomes for the Introduction of Complementary Foods for Children With Down Syndrome

Abstract Date Presented 04/13/21 The purpose is to begin to address the lack of consistent guidelines for when, and how, families should begin to introduce complementary foods for children with Down syndrome (DS). Semistructured interviews with 22 parents and 8 primary care providers were conducted and analyzed. Results indicated that no formal guidelines exist for this realm, and yet 17 of 22 children have experienced some level of feeding difficulty. Guidelines for feeding progression for this population are needed to improve feeding outcomes. Primary Author and Speaker: Erin Cochran Additional Authors and Speakers: Winifred Dunn

Feeding outcomes after paediatric cardiothoracic surgery: a retrospective review.

Feeding difficulty is a known complication of congenital heart surgery. Despite this, there is a relative sparsity in the available data regarding risk factors, incidence, associated symptoms, and outcomes. In this retrospective chart review, patients aged 0-18 years who underwent congenital heart surgery at a single institution between January and December, 2017 were reviewed. Patients with feeding difficulties before surgery, multiple surgeries, and potentially abnormal recurrent laryngeal nerve anatomy were excluded. Data collected included patient demographics, feeding outcomes, post-operative symptoms, flexible nasolaryngoscopy findings, and rates of readmission within a 1-year follow-up period. Multivariable regression analyses were performed to evaluate the risk of an alternative feeding plan at discharge and length of stay. Three-hundred and twenty-six patients met the inclusion criteria for this study. Seventy-two (22.09%) were discharged with a feeding tube and 70 (97.22%) of this subgroup were younger than 12 months at the time of surgery. Variables that increased the risk of being discharged with a feeding tube included patient age, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score, procedure group, aspiration, and reflux. Speech-language pathology was the most frequently utilised consulting service for patients discharged with feeding tubes (90.28%) while other services were not frequently consulted. The median length of stay was increased from 4 to 10 days for patients who required an enteral feeding tube at discharge. Multidisciplinary management protocol and interventions should be developed and standardised to improve feeding outcomes following congenital heart surgery.

A Study Regarding the Recommendations and Outcomes for the Introduction of Complementary Foods for Children With Down Syndrome

Abstract Date Presented 03/26/20 The purpose is to begin to address the lack of consistent guidelines for when and how families should begin to introduce complementary foods for children with Down syndrome. Semistructured interviews with 22 parents and 8 primary-care physicians were conducted and analyzed. Results indicated no formal guidelines exist for this realm, and yet, 17 of 22 children with Down syndrome have experienced some level of feeding difficulty. Guidelines for feeding progression for this population are needed to improve feeding outcomes. Primary Author and Speaker: Erin Cochran Additional Authors and Speakers: Katherine Breithaupt Contributing Authors: Lauren Williams, Tess Sorensen

Standardized Perioperative Feeding Protocol Improves Outcomes in Patients With d-Transposition of the Great Arteries Undergoing Arterial Switch Operation.

To determine whether the presence of a standardized feeding protocol improves outcomes in a subset of neonates undergoing cardiac surgery. Retrospective cohort study. Cardiovascular ICU at a freestanding academic children's hospital. Neonates with a diagnosis of d-transposition of the great arteries undergoing arterial switch operation from January 2007 to June 2017. Initiation of perioperative feeding protocols. Patients were evaluated before and after implementation of standardized perioperative feeding protocols in neonates with d-transposition of the great arteries undergoing arterial switch operation. Low-risk patients born after initiation of nurse-driven protocols were compared with a similar historical group. Data obtained included time to achievement of feeding goals, with primary outcome being weight gain at hospital discharge. Other measures analyzed included duration of mechanical ventilation and postoperative hospital length of stay. Overall, 33 patients in the protocol group were compared with 44 patients in the historical group. No significant baseline differences existed between the two cohorts. The protocol group achieved improved feeding outcomes in nearly all measured categories, including introduction to enteral feeds preoperatively (91% vs 59%; p < 0.01) and earlier attainment of postoperative full enteral feeds of 120 mL/kg/d (2 vs 5 d; p < 0.01). Protocol patients had significantly improved weight gain at the time of discharge (60 vs 1 g; p < 0.01), while achieving shorter postoperative length of stay (10.1 vs 12.6 d; p = 0.04). An aggressive, but safe, perioperative feeding protocol implemented in a homogenous low-risk neonatal cardiac surgical population improves feeding outcomes, including increased weight gain, as well as decreased postoperative length of stay. Consideration for perioperative feeding protocol implementation and further study should be given.

Does frenotomy improve feeding outcomes in newborn infants with ankyloglossia?

Kaiser Permanente Family Medicine Residency of Washington, Seattle, WA The authors declare no conflicts of interest.

Oral Feeding Challenges in Children With Tracheostomy Can Improve Feeding Outcomes, Even With the Finding of Aspiration.

It has been suggested that oral feeding trial has therapeutic implications for improving oral-motor and swallowing function in infants and young children fed via an enteral tube or gastrostomy. This study aimed to investigate whether oral feeding challenges in children with tracheostomy could improve feeding outcomes, even with the finding of aspiration compared to those who did not receive oral feeding at all. Children (age <7 years) with tracheostomy who had thin fluid aspiration on videofluoroscopic swallowing study (VFSS) were included in this retrospective study. Enrolled children were then divided into two feeding method groups according to the physician's decision at the time of VFSS: oral feeding (OF) group and non-oral feeding (NOF) group. Data were obtained from 47 children (median age: 49.75 months, interquartile range [IQR]: 24.08–79.42). The incidence of pneumonia within 1 year after the VFSS was not different between NOF (n = 17) and OF (n = 30) groups. In OF group, 11 subjects achieved full oral feeding and 16 subjects were in partial oral feeding status 1 year after the VFSS. On the contrary, only one subject achieved full oral feeding and 5 subjects were in partial oral feeding status in NOF group (p < 0.001). Initial and follow-up penetration-aspiration scale on VFSS were different only in the OF group (p = 0.003). These results suggest that oral feeding challenges might be attempted even with the findings of aspiration in infants or young children with tracheostomy.

The Impact of Neurobehavior on Feeding Outcomes in Neonates with Congenital Heart Disease

To evaluate the association between neonatal neurobehavioral state and oral feeding outcomes following congenital heart disease (CHD) surgery. This single center retrospective cohort study described neonates undergoing cardiac surgery evaluated perioperatively with the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). We compared NNNS attention scores, which evaluates neonates' ability to orient and fixate on stimuli, with the feeding outcomes percentage of feeds taken orally at discharge and time to reach full oral feeds using regression analyses. Models were constructed for both preoperative and postoperative NNNS evaluations. Between August 2015 and October 2017, 124 neonates underwent 89 preoperative and 97 postoperative NNNS evaluations. In multivariable Cox regression, higher preoperative NNNS attention scores were associated with a shorter time to achieve full oral feeds (hazard ratio 1.4; 95% CI 1.0‒2.0; P=.047). This relationship was not seen for post-operative NNNS attention scores or percentage of oral feeds at discharge. Depending on the model, younger age at surgery, increased ventilator days, increased length of stay, and single or 2-ventricle anatomy with aortic arch obstruction were associated with lower percentage of oral feeds at discharge and/or delay in full oral feeds. Higher neonatal attention before cardiac surgery is associated with improved feeding outcomes. Prospective assessment of neonatal neurobehavioral state may be a novel approach to predict and target interventions to improve feeding outcomes in CHD. Future studies should examine the impact of intrinsic neurodevelopmental delay vs environmental adaptation on the neurobehavioral state of neonates with CHD.

Feeding Intervals in Premature Infants ≤1750 g: An Integrative Review.

The timely establishment of enteral feeds and a reduction in the number of feeding interruptions are key to achieving optimal nutrition in premature infants. Nutritional guidelines vary widely regarding feeding regimens and there is not a widely accepted consensus on the optimal feeding interval. To critically examine the evidence to determine whether there is a relationship to feeding intervals and feeding outcomes in premature infants. A systematic review of the literature in the following databases: PubMed, CINAHL, Embase and the Cochrane Library. The search strategy used the terms infant premature, low birth weight, enteral feeding, feed tolerance and feed intervals. Search results yielded 10 studies involving 1269 infants (birth weight ≤1750 g). No significant differences in feed intolerance, growth, or incidence of necrotizing enterocolitis were observed. Evidence suggests that infants fed at 2 hourly intervals reached full feeds faster than at 3 hourly intervals, had fewer days on parenteral nutrition, and fewer days in which feedings were withheld. Decrease in the volume of gastric residuals and feeding interruptions were observed in the infants fed at 3 hourly intervals than those who were continuously fed. Reducing the feed interval from 3 to 2 hourly increases nurse workload, yet may improve feeding outcomes by reducing the time to achieve full enteral feeding. Studies varied greatly in the definition and management of feeding intolerance and in how outcomes were measured, analyzed, and reported. The term "intermittent" is used widely but can refer to a 2 or 3 hourly interval.

Oral Feeding Difficulties in Children With Short Bowel Syndrome: A Narrative Review.

Children with short bowel syndrome (SBS) with associated intestinal failure may be unable to absorb sufficient nutrients to sustain life. Improvements in the medical management of SBS, including use of parenteral nutrition, has significantly increased life expectancy. Independence from parenteral nutrition further improves quality of life. However, children living with SBS often develop oral aversions and feeding difficulties. There is limited research and information on which to base interventions that will preserve and develop oral motor and feeding skills. The aims of this article are to explore what is known about children with SBS who exhibit oral aversion/feeding difficulties and to suggest research for possible future interventions that could help these children overcome oral aversion, eat orally, and increase participation and satisfaction in mealtimes. This review explores the complexity of feeding children with SBS. Three underlying themes emerged: physical, developmental, and social aspects of eating and mealtimes. Interdisciplinary teams are needed to effectively address these complex oral feeding problems. Accurate identification the underlying issues will allow healthcare providers to develop interventions to improve feeding outcomes for children with SBS. Future research should focus on evaluating the effectiveness of interventions that address each of the underlying issues.

Clinicians guide for cue-based transition to oral feeding in preterm infants: An easy-to-use clinical guide.

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.

The Effects of a Slow and Controlled Feeding Protocol for the Introduction of Oral Feeding for Infants

Abstract Date Presented 4/17/2015 Pacifier trainer as part of a therapeutic protocol to improve feeding outcomes in infants after cardiac surgery may be linked with decreased hospital length of stay and improved feeding outcomes. This approach mimics the natural progression that feeding infants have in the first few days of life.

Effects of the neonatal intensive care unit environment on preterm infant oral feeding.

To examine the effect of neonatal intensive care unit environmental characteristics (perceived levels of light and sound, and time of day) in open unit wards and single-family rooms (SFRs) on oral feeding outcomes in preterm infants. Data were collected at each scheduled oral feeding for 87 preterm infants from the first oral feeding until discharge. Data included the prescribed volume of feeding and the volume consumed, the infant's level of wakefulness before feeding, and the nurse's perception of light and sound. Data were collected on 5111 feedings in the ward unit and 5802 in the SFR unit from feedings involving 87 preterm infants. Light and sound were rated significantly lower in the SFR (χ2 = 139 and 1654.8, respectively). Feeding times of 9 am, 12 noon, and 3 pm were associated with the highest perceived levels of light and sound, regardless of unit design (P < 0.0001). Moderate light levels and feeding times of 12, 3, and 6 am were associated with improved feeding outcomes. Infants consumed a greater proportion of their prescribed feeding volume when fed in the open ward and when awake before feeding. Further study on the clinical effects of unit design is needed, as is study on the effects of environmental stimuli, so that interventions can be appropriately developed and tailored for infants needing the most support for optimal development.

Guidelines for Bottle Feeding Your Premature Baby

Prolonged use of gavage feedings is common in premature infants who have not yet acquired suck, swallow, and breathing coordination. Preterm infants must be developmentally mature to orally feed successfully. Als' Synactive Theory of Development offers a conceptual framework to facilitate understanding of how premature infants dynamically differentiate to attain developmental milestones such as oral feeding. Key clinical implications for neonatal nurses are contingent upon incorporating evidence-based research into practice and providing consistent quality care to improve feeding outcomes.