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Systematic Review: Feeding Interventions for Preterm Infants

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  1. Systematic Review:Feeding Interventions for Preterm Infants Jillian Battson & Nicole Quisao

  2. Introduction of Topic Objective • 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).

  3. Background Information

  4. (The Happenings of the Higgins, 2013) (Cambridge University Hospitals, 2013) 1. NNS 2. NNS (Advanced Healthcare Network, 2013) (Design World, 2013) (Similac, 2013) 4. NTrainer 3. Oral support 5. NTrainer

  5. 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

  6. 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.

  7. Evidence Table

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

  9. Methods cont’d

  10. 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.

  11. Results cont’d:Multi-SensoryInterventions

  12. 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

  13. Results cont’d:Physiological Interventions

  14. Results cont’d:PhysiologicalInterventions

  15. Results cont’d:PhysiologicalInterventions

  16. Results cont’d:PhysiologicalInterventions

  17. 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).

  18. 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.

  19. 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.

  20. References • Advanced Healthcare Network. (2013). NTrainer [Image]. Retrieved from • 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 • 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 • Centers for Disease Control and Prevention. (2013a). National prematurity awareness month [Website]. Retrieved from • Centers for Disease Control and Prevention. (2013b). Preterm birth [Website]. Retrieved from • Design World. (2013). NTrainer device [Image]. Retrieved from 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

  21. 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 • 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

  22. 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 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 • The Happenings of the Higgins. (2013). NNS [Image]. Retrieved from • 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

  23. Questions?