Systematic Review:

Feeding Interventions for Preterm Infants

Jillian Battson & Nicole Quisao

Introduction of TopicObjective• To determine the most effective feeding interventions for preterm

infants within the scope of occupational therapy (OT).

• Research question:

“What are effective occupational therapy interventions for preterm infants with feeding difficulties?”

Statement of Problem• 1 in 5 infants born in the United States are born preterm (Centers for

Disease Control and Prevention [CDC] , 2013b). • A greater percentage of infants die from preterm-related

complications than any other single problem (CDC, 2013a).• Attainment of oral feeding is a prerequisite & criterion for discharge

from the neonatal intensive care unit (NICU).

Background InformationTerm Definition

NICU Complex & highly specialized hospital unit aimed to care for infants who are born prematurely, or those critically ill (Hunter, 2010)

Preterm infant An infant born < 37 weeks gestational age (Hunter, 2010)

Gestational age (GA)

Total number of weeks the infant was in utero before birth (Hunter, 2005)

Post-menstrual age (PMA)

The number of gestational weeks from the first day of the last menstrual period (Medhurst, 2005)

Gavage feeding Passing a small gastric tube through the mouth or nose into the stomach to provide a passageway for introduction of essential nutrients (Medhurst, 2005)

Non-nutritive sucking (NNS)

“Dry” sucking with a pacifier (Hunter, 2010)

Oral-stimulation Stimulation of the perioral (e.g. cheeks, lips, & jaw) & intraoral (e.g. gums & tongue) structures (Boiron et al., 2007)

Independent oral feeding (IOF)

Neurological maturity to coordinate sucking, swallowing, & breathing, an adequate power of oral muscle & a mature sucking technique (Bragelien, Rokke, & Markestad, 2007)

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Background Information cont’d• Feeding is a complex developmental skill that requires the integration

of sucking, swallowing, & breathing (Howe & Wang, 2013).

• The oral experience of preterm infants differs from infants born at term; infants at term gain more swallowing experience with larger volumes over a longer duration of time prior to birth (Garber, 2013).

• Oral feeding is typically introduced at 33-34 weeks PMA (Lau, 2006).

• Current feeding interventions include:

– Environmental modifications

– Behavioral interventions

– Physical modifications– Physiological interventions

– Educational interventions

Background Information

• Existing evidence supports NNS & oral stimulation in facilitating premature infants’ feeding performance (Garber, 2013).

• Previous systematic reviews & meta-analyses conducted were either dated, evaluated one type of intervention on preterm infants, or lacked unified standardized protocol.

• The current systematic review will report on a more comprehensive body of evidence comparing the effectiveness of the most frequently cited feeding interventions for preterm infants.

Evidence TableLevel of Evidence Number of Articles

I – Randomized Controlled Trial

14

II – Two groups, non-randomized

1

III – One group, non-randomized

0

IV – Descriptive studies that include analysis of outcomes

0

V – Case reports & expert opinion that include narrative literature reviews & consensus statements

0

Methods

Search Terms Databases– Feeding– Interventions– Occupational therapy– Preterm – Premature– Neonatal– Neonates

– EBSCO Academic Search Complete

– AJOT Evidence Exchange– The Cochrane Library – CINAHL– Otseeker– PubMed

* Terms were used independently & in combination to obtain articles relevant to the systematic review.

Methods cont’dInclusion Criteria Exclusion Criteria

Published after 2000 Published prior to 2000

Peer-reviewed, scholarly journals Non-peer-reviewed, non-scholarly journals

English language Non-English language

Levels of evidence - I, II, III, or IV Levels of evidence - V or VI

Interventions to improve feeding, eating, & swallowing performance

Interventions not designed to improve feeding, eating, & swallowing performance

Within the scope of OT Outside the scope of OT

Preterm infants with developmental delay, disability, or conditions that affect development

Non-preterm infants without developmental delay, disability, or conditions that affect development

Results:Multi-Sensory Interventions

• Interventions centered on provision of multi-sensory techniques used to facilitate attainment of IOF.

• Treatment strategies within this category included: – Auditory, tactile, visual, & vestibular stimulation (ATVV) (White-

Traut et al., 2002)

– Oral (O), tactile & kinesthetic (T/K), or O+T/K stimulation (Fucile, Gisel, McFarland, & Lau, 2011; Fucile, McFarland, Gisel, & Lau, 2012)

– Pacifier-activated lullaby (PAL) system (Standley et al, 2010).

• The evidence from a review of the articles suggests that multi-sensory interventions are effective for premature infants with feeding difficulties.

Results cont’d:Multi-Sensory Interventions

Article Results

White-Traut et al., 2002 – Facilitated increased alertness, faster transition to nipple feeding, & earlier discharge from the hospital.

Standley et al., 2010 – Shortened gavage feeding length, increase female infant’s proficiency to nipple feed, & promote earlier discharge from the hospital.

Fucile et al., 2011; Fucile et al., 2012

– Achieved earlier oral feeding, greater rate of transfer, decreased volume loss, & enhanced proficiency of swallow-respiration-coordination.

Results cont’d:Physiological Interventions

• Studies were categorized based on the interventions’ effect on the preterm infants physiological development.

• The reviewed studies fell into themes similar to that of a previous systematic review conducted by Howe & Wang (2013) based on the targeted feeding behavior:

– Preparatory interventions

– Feeding skills

– Environmental support

Results cont’d:Physiological Interventions

Category Interventions

Preparatory – Sensorimotor oral stimulation & NNS– Swallowing exercises– Oral support & NNS– Ntrainer orocutaneous stimulation– Non-nutritive oral-motor therapy (NNOMT) & infant massage

therapy (iMT)– (Hill, 2005; Lau et al., 2012; Lau & Smith, 2012; Poore et al., 2008; Rocha et al., 2007)

Feeding Skills – Oral stimulation &/or oral support– Early introduction to oral feeding,– Daily stimulation of sucking & swallowing– Development of oral feeding skills over time– Pacifiers or lullabies – (Amaizu et al., 2008; Boiron et al., 2007; Bragelien et al., 2007; Simpson et al., 2002; Yildiz & Arikan,

2011)

Environmental Support

– Oral support – (Hwang et al., 2010)

Results cont’d:Physiological Interventions

Article Preparatory Intervention Results

Rocha et al., 2007 – Sensorimotor oral stimulation & NNS during gavage feeding accelerates attainment of earlier IOF & hospital discharge.

Lau & Smith, 2012 – Demonstrated increased maturity in oral-feeding skills (OFS) in swallowing exercise program & shorter days to attainment of IOF.

– Days to attainment of IOF in the NNS program were not accelerated.

Hill, 2005 – Use of oral support as well as NNS increases the amount of formula intake & immediate/continued effects on feeding efficiency.

– Effect of NNS on sucking-pattern characteristics were mixed.

Lau et al., 2012 – NNOMT &/or iMT have a direct positive impact on accelerating maturation of OFS.

Poore et al., 2008 – NTrainer patterned orocutaneous stimulation demonstrated accelerated NNS development & oral-feeding success.

Results cont’d:Physiological Interventions

Article Feeding Skill Intervention Results

Boiron et al., 2007 – Shorter gavage to IOF transition time for oral stimulation + support intervention, & oral support intervention.

– During gavage, increase NNS pressure & sucking activity with the oral stimulation intervention, & oral stimulation + support intervention.

Simpson et al., 2002

– Introduced to oral feeding 48 hours after full gavage feeding, attained earlier IOF & shorter gavage to oral feeding transition time.

Yildiz et al., 2011 – Pacifier intervention & the lullaby intervention progressed to IOF over a shorter period of time.

– The highest sucking success was achieved by infants in the pacifier intervention, followed by the lullaby intervention.

Results cont’d:Physiological Interventions

Article Feeding Skill Intervention Results cont’d

Bragelien et al., 2007

– Oral stimulation intervention did not result in earlier discontinuation from gavage feeding or in an earlier discharge from the hospital.

Amaizu et al., 2008

– Feeding efficiency improved as premature infants’ transition from gavage to oral feeding

– The two experimental groups demonstrated that despite similar oral-motor feeding outcomes, the maturation of certain feeding skills differed based on GA.

Article Environmental Support Intervention Results

Hwang et al., 2010 – Displayed a greater intake rate during both the first five minute period & throughout the entire feeding.

– No significant differences were found between the two conditions in the sucking and physiological variables.

Implications for Occupational Therapy Practice

• Practitioners may utilize the evidence presented in this review to:

– Gain further knowledge regarding different approaches targeting feeding behaviors.

– Gain an understanding of which feeding intervention is most appropriate for specific feeding outcomes.

– Establish feeding progression guidelines in the NICU setting.

• Therapists may receive specialized training to become a lactation consultant (Garber, 2013).

• Practitioners provide education to family members & caregivers regarding feeding difficulties when caring for the preterm infant in the NICU (Garber, 2013).

Recommendations for Future Research

• Further studies are required to evaluate appropriateness of the stated interventions across various populations.

• Researchers should conduct additional studies that directly evaluate the effectiveness of individual interventions’ influence on feeding outcomes in preterm infants.

• Additional research should be conducted to establish a detailed feeding guideline protocol within the NICU for the OT profession.

• Studies should be conducted specifically addressing the efficacy of feeding interventions within particular age groupings based on prematurity.

Limitations

• Only articles published after 2000 were included for review.

• Only articles published in English peer-reviewed scholarly journals were included for review.

• Although this systematic review only included studies examining preterm infants, the infants’ degree of prematurity and medical status were not accounted for.

• Interventions were not standardized across studies:

– Interventions varied in protocols, treatment schedule, & frequency of intervention.

References• Advanced Healthcare Network. (2013). NTrainer [Image]. Retrieved from

http://nursing.advanceweb.com/News/New-Products/NTrainer-Promotes-Babies-Sucking-Skills.aspx

• Amaizu, N., Shulman, R. J., Schanler, R. J., & Lau, C. (2007). Maturation of oral feeding skills in preterm infants. Acta Paediatrica, 97(1), 61-67. doi: 10.1111/j.1651-2227.2007.00548.x

• American Academy of Pediatrics. (1998). Hospital discharge of the high-risk neonate-proposed guidelines. Pediatrics, 102(2), 411-417. Retrieved from

http://pediatrics.aappublications.org/content/102/2/411.full.pdf+html

• Boiron, M., Da Nobrega. L., Roux, S., Henrot, A., & Saliba, E. (2007). Effects of oral stimulation and oral support on non-nutritive sucking and feeding performance in preterm infants. Developmental Medicine & Child

Neurology, 49(6), 439-444. doi: 10.1111/j.1469-8749.2007.00439.x

• Bragelien, R., Rokke, W., & Markestad, T. (2007). Stimulation of sucking and swallowing to promote oral feeding in premature infants. Acta Paediatrica, 96(10), 1430-1432. doi: 10.1111/j.1651-2227.2007.00448.x

• Cambridge University Hospitals. (2013). NNS pacifier [Image]. Retrieved from http://www.cuh.org.uk/rosie/services/neonatal/nicu/developmental_care/support_comforting_baby.html

• Centers for Disease Control and Prevention. (2013a). National prematurity awareness month [Website]. Retrieved from http://www.cdc.gov/features/prematurebirth/

• Centers for Disease Control and Prevention. (2013b). Preterm birth [Website]. Retrieved from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/PretermBirth.htm

• Design World. (2013). NTrainer device [Image]. Retrieved from http://www.designworldonline.com/innovative-device-helps-preemies-eat/#_

• Fucile, S., Gisel, E.G., McFarland, D.H., & Lau, C. (2011). Oral and non-oral sensorimotor interventions enhance oral feeding performance in preterm infants. Developmental Medicine & Child Neurology, 53(9), 829-835. doi: 10.1111/j.1469-8749.2011.04023.x

• Fucile, S., McFarland, D. H., & Lau, C. (2011). Oral and nonoral sensorimotor interventions facilitate suck-swallow-respiration functions and their coordination in preterm infants. Early Human Development, 88(6), 345-

350. doi: 10.1016/j.earlhumdev.2011.09.007

References cont’d• Garber, J. (2013). Oral-motor function and feeding intervention. Physical and Occupational Therapy in Pediatrics, 33(1),

111-138. doi: 10.3109/01942638.2012.750864

• Hill, A. S. (2005). The effects of nonnutritive sucking and oral support on feeding efficiency of preterm infants. Newborn and Infant Nursing Reviews, 5(3), 133-141. doi: 10.1053/j.nainr.2005.04.004

• Howe, T., & Wang, T. (2013). Systematic review of interventions used in or relevant to occupational therapy for children with feeding difficulties ages birth-5 years. American Journal of Occupational Therapy, 67(4), 405-412. doi: 10.5014/ajot.2013.004564

• Hunter, J. G. (2010). Neonatal intensive care unit. In J. Case-Smith (Ed.), Occupational therapy for children (6th ed. pp. 649-677). St Louis, MO: Elsevier Mosby.

• Hwang, Y.-S., Lin, C.-H., Coster, W. J., Bigsby, R., & Vergara, E. (2010). Effectiveness of check and jaw support to improve feeding performance of preterm infants. American Journal of Occupational Therapy, 64(6), 886-894. doi: 10.5014/ajot.2010.09031

• Lau, C. (2006). Oral feeding in the preterm infant. NeoReviews, 7(1), e19-e27. doi: 10.1542/neo.7-1-e19

• Lau, C., Fucile, S., & Gisel, E. G. (2012). Impact of nonnutritive oral motor stimulation and infant massage therapy on oral feeding skills of preterm infants. Journal of Neonatal-Perinatal Medicine, 5(4), 311-317. doi:

10.3233/NPM-1262

• Lau, C., & Smith, E. O. (2012). Interventions to improve the oral feeding performance of preterm infants. Acta Paediatrica, 101(7), e269-e274. doi: 10.1111/j.1651-2227.2012.02662.x

• Medhurst, A. (2005). Feeding protocols to improve the transition from gavage feeding to oral feeding in healthy premature infants: A systematic review. Evidence in Health Care Reports, 3(1), 1-25. Retrieved from http://joannabriggs.org/Documents/HCR_2005_3_1.pdf

• Poore, M., Zimmerman, E., Barlow, S. M., Wang, J., & Gu, W. (2008). Patterned orocutaneous therapy improves sucking and oral feeding in preterm infants. Acta Paediatrica, 97(7), 920-927. doi: 10.1111/j.1651-

2227.2008.00825.x

References cont’d• Rocha, A. D., Moreira, M. E. L., Pimenta, H. P., Ramos, J. R. M., & Lucena, S. L. (2007). A randomized study of the efficacy

of sensory-motor-oral stimulation and non-nutritive sucking in very low birthweight infant. Early Human Development, 83(6), 385-388. doi: 10.106/j.earlhumdev.2006.08.003

• Schuberth, L. M., Amirault, L. M., & Case-Smith, J. (2010). Feeding intervention. In Case-Smith (Ed.), Occupational therapy for children (6th ed. pp. 446-473). St Louis, MO: Elsevier Mosby.

• Similac. (2013). Oral support [Image]. Retrieved from http://similac.com/baby-development/premature-baby/nutrition-needs

• Simpson, C., Schanler, R. J., & Lau, C. (2002). Early introduction of oral feeding in preterm infants. Pediatric, 110(3), 517-522. doi: 10.1542/peds.110.3.517612

• Standley, J. M., Cassidy, J., Grant. R., Cevasco, A., Szuch, C., Nguyen, J., . . . Adams, K. (2010). The effect of music reinforcement for non-nutritive sucking on nipple feeding of premature infants. Pediatric Nursing, 36(3), 138- 145. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20687305

• The Happenings of the Higgins. (2013). NNS [Image]. Retrieved from http://ashleyandjeremyhiggins.blogspot.com/

• White-Traut, R. C., Nelson, M. N., Silvestri, J. M., Vasan, U., Littau, S., Meleedy-Rey, P., . . . Patel, M. (2002). Effect of auditory, tactile, visual, and vestibular intervention on length of stay, alertness, and feeding progression in preterm infants, Developmental Medicine & Children Neurology, 44(2), 91-97. doi: 10.1017/S0012162201001736

• Yildiz, A., & Arikan, D. (2010). The effects of giving pacifiers to premature infants and making them listen to lullabies on their transition period for total oral feeding and sucking success, Journal of Clinical Nursing, 21(5-6),

644- 656. doi: 10.1111/j.1365-2702.2010.03634.x

Questions?