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Running head: FEEDING INTERVENTIONS

Feeding Interventions for Preterm Infants Jillian Battson & Nicole Quisao Touro University Nevada

FEEDING INTERVENTIONS Feeding Interventions for Preterm Infants Introduction Objectives The following research question facilitated the selection of research studies for review: What are effective occupational therapy interventions for preterm infants with feeding difficulties? The authors intention for conducting this systematic review of the research

literature was to determine the most effective feeding interventions for preterm infants within the scope of occupational therapy (OT). OT practitioners provide feeding interventions in infants and young children with feeding difficulties to enhance feeding performance (Howe & Wang, 2013). The current question will assist OT practitioners in providing the most effective evidencebased feeding interventions for preterm infants. Statement of Problem An infant is classified as preterm if they are born before 37 weeks gestational age (GA) (Hunter, 2010). Preterm births affect nearly 500,000 infants each year, equating to 1 in every 9 infants born in the United States (Centers for Disease Control and Prevention [CDC], 2013b). Currently, practitioners may utilize a variety of treatment interventions within the neonatal intensive care unit (NICU) to facilitate development of feeding performance. The NICU is a complex and highly specialized unit within the hospital, specifically intended for infants born preterm, or those critically ill (Hunter, 2010). When treating preterm infants, healthcare practitioners must consider the complex nature of the infants health status while integrating appropriate strategies to increase feeding performance. These strategies ultimately promote medical stability and earlier discharge from the NICU. Identification of the effectiveness of various feeding interventions allows practitioners to develop standardized protocols tailored for

FEEDING INTERVENTIONS

preterm infants. Given that there are many variables that impact oral feeding performance, it may be advantageous to identify specific interventions. Typically, practitioners in the NICU focus on facilitation of oral feeding skills. Preterm infants attainment of oral feeding is a prerequisite and criterion for discharge from the NICU (American Academy of Pediatrics, 1998). Addressing interventions for preterm infants with feeding difficulties will build a foundation of pertinent knowledge and evidence regarding effective clinical practice (Howe & Wang, 2013). It is critical for OT practitioners to establish the professions presence within this area of practice. OT practitioners have the skill set and knowledge base to collaborate with various healthcare practitioners within this setting. Addressing this issue will allow educators to inform OT students of the most relevant and supported intervention strategies to apply for this population. Students trained in effective feeding strategies will be more equipped as practitioners entering into the field of practice. Examining the effectiveness of feeding interventions will refine and advance knowledge and theory within the scope of OT in the NICU. Research should be aimed at identifying outcomes associated with specific interventions of feeding performance within this population. Furthermore, addressing this issue would permit practitioners to define and classify feeding interventions based on specific feeding skills of preterm infants. Programs may be developed based on preterm infants diagnoses and medical status to further guide intervention planning. These programs could have specific intervention guidelines for practitioners as a reference for implementation of feeding interventions. Establishing effective feeding interventions may result in positive outcomes for the growing population of preterm infants. OT practitioners can provide education to caregivers regarding specific strategies to promote feeding competencies outside of the NICU setting upon discharge. As previously discussed, feeding interventions are typically delivered within the NICU setting. They

FEEDING INTERVENTIONS may be conducted effectively by various healthcare professionals including: occupational, physical, or speech and language therapists (Garber, 2013). Therapeutic services addressing

feeding interventions are covered and reimbursable under OT billing codes. Feeding is identified as an activity of daily living and is within the OT scope of practice. Background Literature Preterm infants inability to orally feed safely and successfully is common and results in delayed hospital discharge (Lau & Smith, 2012). A greater percentage of infants die from preterm-related complications than any other single problem (CDC, 2013a). The total number of weeks the infant was in utero before birth is defined as GA (Hunter, 2010). Establishment of safe and successful oral feeding during hospitalization will naturally progress to a more accelerated transition from gavage feeding to independent oral feeding (IOF), minimizing future complications (Lau & Smith, 2012). Gavage feeding consists of passing a small gastric tube through the preterm infants mouth or nose into the stomach, which provides a passageway for introduction of essential nutrients (Medhurst, 2005). Feeding is a complex developmental skill that requires the integration of breathing, sucking, and swallowing, impacting overall motor stability and incoming sensory stimuli (Howe & Wang, 2013). Non-nutritive sucking (NNS), dry sucking with a pacifier, has been suggested to facilitate the development of sucking behavior in preterm infants (Hunter, 2010). According to a study by Goff (1985), NNS is the initial rhythmic behavior that a preterm infant engages in and contributes to neurological development by facilitating internally regulated rhythms (as cited in Standley et al., 2010). Additionally, oral stimulation has been suggested to accelerate the process to attainment IOF (Arvedson, Clark, Lazarus, Schooling, & Frymark, 2010). Oral stimulation consists of stimulation of perioral and intraoral structures including: cheeks, lips, jaw, gums, and

FEEDING INTERVENTIONS tongue (Boiron, Da Nobrega, Roux, Henrot, & Saliba, 2007). Successful IOF is dependent on neurological maturity to coordinate sucking, swallowing, and breathing, as well as adequate power of the oral musculature (Bragelien, Rokke, & Markestad, 2007). Feeding interventions addressing the transition to IOF should be introduced based on the maturity of the neurological system and the infants readiness to coordinate the suck, swallow, and breathe response (Standley et al., 2010). If feeding interventions are not introduced within the appropriate timeline, the following negative outcomes may occur: apnea, bradycardia, decreased oxygen saturation, and prolonged hospital stay (Standley et al., 2010). Non-oral feeding increases a

premature infants risk for developing oral-motor and oral-sensory impairments due to decreased oral feeding experiences (Schuberth, Amirault, & Case-Smith, 2010). Premature infants oral feeding experience 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). There is no specific evidence stating the prevalence and incidence of feeding problems in preterm infants. There is limited research specifically stating when preterm infants should transition to oral feeding. Preterm infants are introduced to oral feeding around 33 to 34 weeks post-menstrual age (PMA) with stable cardiopulmonary status (Lau, 2006). PMA is defined as the number of gestational weeks from the first day of the last menstrual period (Medhurst, 2005). Variations in preterm infant feeding protocols may be attributed to the lack of standardized practice within the NICU (Garber, 2013). Furthermore, there is a dearth of evidence specifically addressing the efficacy of feeding interventions within particular age groups as well as comprehensive evidence discussing the range of interventions for infants with feeding difficulties.

FEEDING INTERVENTIONS Currently, there are numerous feeding strategies that exist to facilitate oral feeding in preterm infants. These include: environmental modifications, behavioral interventions, physical

modifications, physiological interventions, and educational interventions (Howe & Wang, 2013; Arvedson et al., 2010). Specifically, a majority of the previous evidence supports NNS, oral support, and oral stimulation in facilitating premature infants feeding performance (Garber, 2013). Previous systematic reviews and meta-analyses conducted regarding the effects of interventions on feeding in preterm infants were either dated, only 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 to compare the effectiveness of the most frequently cited feeding interventions for preterm infants. Additionally, this review will include non-traditional feeding interventions, which fall within the scope of OT. Methods Inclusion Criteria Criteria for inclusion in this review include the following: (1) articles published after 2000, (2) articles peer-reviewed and published in scholarly journals, (3) articles published in the English language, (4) research studies categorized as I, II, III, or IV levels of evidence, (5) research studies included interventions designed to improve feeding, eating, and swallowing performance, (6) the reported interventions can be performed by practitioners within the scope of OT, and (7) participants in the research studies were classified as preterm infants with developmental delay, disability, or condition that affects development.

FEEDING INTERVENTIONS Exclusion Criteria Criteria for exclusion in this review include the following: (1) articles published prior to

2000, (2) non peer-reviewed articles published in non-scholarly journals, (3) articles published in non-English languages, (4) research studies categorized as V or VI levels of evidence, (5) research studies not designed to improve feeding, eating, or swallowing performance, (6) research studies with interventions performed outside the scope of OT, and (7) participants who were not classified as preterm infants at birth without developmental delay, disability, or condition that affects development. Procedures The systematic review search terms were determined by the authors. The search terms were used independently and in combination to obtain articles most relevant to the systematic review. The following terms were used during the screening procedure for article selection: feeding, occupational therapy, interventions, preterm, premature, neonatal, and neonates. Both authors of the systematic review conducted the screening procedures and article reviews. Each author screened articles by reviewing abstracts and/or titles prior to conducting individual article reviews. Authors independently reviewed articles utilizing the Critical Review Form for Quantitative Studies adapted from McMaster University prior to collaboratively peerreviewing and cross-analyzing research studies for quality control (Law et al., n.d.). Throughout the research procedure, various article databases were utilized for attainment of relevant research studies. The following databases were used: EBSCO Academic Search Complete, American Journal of Occupational Therapy Evidence Exchange, The Cochrane Library, CINAHL, and PubMed. Additionally, bibliographies of relevant and existing systematic reviews as well as scholarly-reviewed articles were hand-searched.

FEEDING INTERVENTIONS Results Evidence Table The fifteen studies reviewed for this systematic review are displayed on Table 1. The table includes: study participants, interventions, outcome measures, results, and study limitations.

FEEDING INTERVENTIONS Table 1 Evidence Table


Author & Year Amaizu et al. (2008) Study Objectives To monitor changes over time of specific oral feeding skills of preterm infants transition from tube to oral feeding Level & Design Level 2 Cohort N 16 GA (weeks) 26-29 M = 27.5 Gender 8M 8F Interventions Monitored specific feeding skills as indirect markers for the maturational process of oral feeding musculature development Outcome Measures Oral feeding efficiency Maturation of perioral musculature Maturation of sucking Results Feeding efficiency in several skills improved, some decreased, & others remained unchanged Differences in COVs between the two GA groups demonstrate that despite similar oral motor feeding outcomes, maturation of certain feeding skills differed Transition time reduced (p < 0.0001) for stimulation + support & support groups. Gavage showed increased NNS pressure & sucking activity (p < 0.001) for stimulation & stimulation + support groups During transition revealed increases in NNS pressure & daily bottle feeds (p < 0.001) for the 3 experimental groups & in daily milk ingested (p = 0.002) for stimulation + support & support groups NG feeding was discontinued at 36.8 weeks vs. 36.3 weeks PMA, (p = 0.25) & infants were discharged at 37.8 weeks vs. 37.7 weeks, (p = 0.81) Intervention groups achieved oral feeding 9-10 days earlier vs. control group (p < 0.001) Proficiency (p < 0 .002) at time of 1-2 & 3-5 oral feedings per day Combined group attained IOF at significantly younger PMA than control (p = 0.020) & had clinically greater proficiency than T/K group (p = 0.020) & oral group LOS not significantly different between groups (p = 0.792)

Study Limitations Small sample size Lack of power analysis Nonrandomized sampling

Boiron et al. (2007)

To compare effects of oral stimulation vs. oral support on NNS & feeding parameters

Level 1 RCT

43

29-34 M = 31.2

23 M 20 F

Bragelien et al. (2007)

Fucile et al. (2011)

To investigate if daily stimulation of sucking & swallowing would lead to earlier ability to feed orally & earlier discharge To determine whether oral (O), tactile/kinesthetic (T/K), or combined (O +T/K) interventions enhance oral feeding performance & if combined interventions have additive synergistic effects

Level I RCT

36

< 36 weeks PMA

23 M 13 F

Oral stimulation group perioral & intraoral stimulation Oral support group chin & cheek support & aid to deglutition Oral stimulation & support combination of above groups Control no oral stimulation &/or oral support Stimulation group oral stimulation Control group no specific intervention O intervention stroking of cheeks, lips, gums, & tongue & NNS T/K intervention stroking of the head, neck, back, arms, & legs & passive ROM of arms & legs Combined intervention O + T/K Control intervention researchers hands in incubator but no touching

Maximum pressure & burst duration NNS pressure Sucking activity Bottle feeds Milk ingested Transition time

Lack of power analysis No drop-outs reported

Discontinuation of NG feeding Discharge home

Small sample size Lack of power analysis Lack of discharge planning protocol

Level I RCT

75

26-32 M = 26

49 M 26 F

Time to attainment of IOF Proficiency Volume transfer Volume loss

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Author & Year Fucile et al. (2012) Study Objectives To further explore the effects of an oral (O), tactile/kinesthetic (T/K), & combined (O + T/K) sensorimotor intervention on nutritive sucking, swallowing & coordination with respiration Level & Design Level I RCT N 75 GA (weeks) 26-32 M = 29 Gender 49 M 26 F Interventions O intervention perioral stimulation to the checks, lips, & jaw; intraoral stimulation to the gums & tongue; NNS T/K intervention stroking of the head, neck, shoulders, back, legs, & arms; passive range of motion of arms & legs Combined intervention O + T/K Control intervention researchers hands in incubator but no touching Oral support group feeding with oral support NNS group pacifier use before feeding Control group no specific intervention Outcome Measures Suck-swallow coordination Stage of sucking Swallow-respiration Suction & expression amplitudes Results Nutritive sucking skills O group achieved significantly more advanced stage of sucking (p = 0.035) Suck-swallow coordination no significant group, time or interaction effects for ratio (p = 0.181) Swallow-respiration coordination significant improvement (p = 0.039)

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Study Limitations Use of convenience sampling methods

Hill (2005)

To describe influence of oral support & NNS on feeding efficiency over time

Level I RCT

156

29-31 M = 30.2

NR

Whitney Mercury Strain Gauge

Hwang et al. (2010)

Examine the effects of the cheek & jaw support on the feeding ability of inefficient feeders

Level I RCD

20

25-36 M = 28.6

7M 13 F

Intervention group feeding with oral support Control group feeding without oral support

Feeding duration Percentage of volume ingested Percentage of leakage Intake rate Sucking frequency Mean volume ingested per suck Neonatal Behavioral Assessment Scale MARS pulse oximeter

Oral support & NNS are beneficial for preterm infants & both interventions have immediate & continuing effects on the amount of formula taken in 1st 5 min of feeding Effects on sucking pattern characteristics are mixed with continuing effects noted on the number & length of bursts after the use of oral support & NNS but not immediately after intervention Infants displayed a greater intake rate during the treatment feedings, during the first 5 min (p = 0.046) & throughout the entire feeding (p = 0.023) Percentage of leakage during the first 5 min feeding was smaller in the treatment condition vs. control condition (p = 0.040) No significant differences were found between the two conditions in the sucking, physiological, & alertness variables

Lack of ethical protocol No drop-outs reported

Administrators not blind to study conditions Small sample size Lack of power analysis Study conditions restrict coding accuracy Confounding variables

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Author & Year Lau et al. (2012) Level & Design Level 1 SBR

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Study Objectives Evaluate whether infants who benefited from NNOMT &/or iMT will demonstrate enhanced maturation of their OFS levels

N 75

GA (weeks) 26-32 M = 29.2

Gender NR

Interventions NNOMT group stroking the cheeks, lips, gum & tongue iiMT group stroking the head, neck, back, arms, & legs NNOMT + iMT group combination of both NNOMT & iMT Control group placed hands in isolette without touching the infant Control group NICU standard care Experimental group 1 NICU standard care & NNS program Experimental group 2 NICU standard care & swallowing exercise program NTrainer treatment orocutaneous stimulation through silicon pacifier Control group pacifier during gavage feeds Treatment group sensory-motor-oral stimulation & NNS Control group sham stimulation program

Outcome Measures SOF to IOF Overall transfer Proficiency Rate of transfer over the entire feeding

Results NNOMT &/or iMT have a direct positive impact on accelerating the maturation of infants oral feeding skills

Study Limitations Lack of power analysis Lack of ethical protocol informed consent No drop-outs reported

Lau et al. (2012)

To further evaluate the benefit of specific sucking & swallowing exercises vs. no treatment in accelerating attainment of IOF through faster maturation of infants oral feeding skills

Level I RCT

70

24-33 M = NR

37 M 33 F

SOF to IOF - days Overall transfer Proficiency Rate of transfer Oral feeding skills

Days from SOF to IOF vs. controls (212) were similar for the sucking group (192) & shorter for the swallowing group (152, p = 0.019) Swallowing group infants demonstrated more mature OFS levels than the controls

Lack of power analysis Cointervention

Poore et al. (2008)

To determine if NTrainer patterned orocutaneous therapy affects NNS &/or oral feeding success

Level I RCT

31

28-30 M = 29.3

16 M 15 F

Actifier NNS motor pattern stability Percent of oral feeding

Treated infants manifest a disproportionate increase in suck pattern stability & percent oral feeding, beyond that attributed to maturational effects alone IOF was attained significantly earlier in the treatment group than the control group, 38 16 days of life vs. 47 17 days of life, respectively (p < 0.001) Significant difference in LOS between the treatment group (41.9 17) vs. the control group (52.3 19 days (p < 0.01)

No drop outs reported Lack of power analysis

Rocha et al. (2007)

Determine whether sensory-motor-oral stimulation & NNS gavage feeding enhances oral feeding performance

Level 1 RCT

98

26-32 M = 30.3

NR

Length of hospital stay SOF IOF

Results do not indicate if sensorymotor-oral stimulation is beneficial alone

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Author & Year Standley et al. (2010) Level & Design Level I RCT

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Study Objectives To evaluate the effect of the pacifier-activated lullaby system (PAL) on cessation of gavage feeding due to oral feeding achievement

N 68

GA (weeks) <32 M = 29.2

Gender 33 M 35 F

Interventions Treatment group 1 one 15-min PAL trial Treatment group 2 three 15-min PAL trials Control group received no PAL

Outcome Measures Total number of days prior to nipple feeding Days of nipple feeding Discharge weight Overall weight gain

Results At 34 weeks, PAL trials significantly shortened gavage feeding length & 3 trials were significantly better than 1 trial At 32 weeks, PAL trials lengthened gavage feeding & female infants learned to nipple feed significantly faster than male infants PAL babies went home sooner after beginning to nipple feed Infants introduced to oral feeding earlier attained IOF significantly earlier Transition time from full tube feeding to all oral feeding was shorter for intervention group Both groups demonstrated similar increase in overall transfer & rate of milk transfer from introduction of oral feeding until achievement of 1st successful oral feeding Intervention group achieved increased alertness during 1st 5 min of intervention, which correlates to length of stay (p < 0.05) Proportion of nippled (teat) intake increased significantly faster for the intervention group (p = 0.0001) Infants in intervention group were discharged at mean of 36.54 weeks, 1.6 weeks earlier than control infants (p < 0.05)

Study Limitations Small sample size Study condition bias

Simpson et al. (2002).

To determine whether transition from tube to all oral feeding can be accelerated by the early introduction of oral feeding

Level I RCT

29

<30 M = 27.7

18 M 11 F

Intervention group initiated oral feeding 48 hours after achieving full tube feeding Control group oral feeding introduced at discretion of the attending physician

Oral feeding progress Oral feeding performance

Small samples size Lack of power analysis Lack of discharge planning criteria Sampling bias

WhiteTraut et al. (2002)

To determine whether auditory, tactile, visual, & vestibular intervention (ATVV) reduced the length of hospitalization by increasing proportion of alert behavioral state & improving feeding progression

Level I RCT

37

23-31 M = 26.5

18 M 19 F

Intervention group ATVV stimulation Control group no specific intervention

Feeding progression Behavioral state

Small sample size High rate of attrition complicated detecting statistical differences Lack of power analysis

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Author & Year Yildiz et al. (2011) Level & Design Level I QE

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Study Objectives To assess the effect of pacifiers & lullabies on the transition period to total oral feeding, sucking success, & vital signs

N 90 Q U R C

GA (weeks) 30-34 M = 31.5

Gender 56 M 34 F

Interventions Pacifier group gavage fed without removal from incubators with pacifier implementation prior to feeding Lullaby group gavage feeding in incubator with modulated lullaby during feeding Control group no intervention except routine gavage feeding

Outcome Measures Transition to total oral feeding LATCH Breastfeeding Charting System Vitals

Results Group who proceeded to the oral feeding in the shortest period was the pacifier group (p < 0.05), followed by the lullaby group & the control group, respectively (p < 0.05) Highest sucking success was achieved by infants in the pacifier group (p < 0.05) followed by lullaby group (p < 0.05)

Study Limitations Nonrandomized sampling No drop-outs reported Cointervention

Abbreviation Key COV coefficients of variation GA gestational age IOF independent oral feeding iMT infant massage therapy LOS length of stay NICU neonatal intensive care unit NG nasogastric NNMOT nonnutritive oral motor therapy NNS non-nutritive sucking NR not reported OFS oral-feeding skills PMA post menstrual age QE quasi-experimental RCD randomized crossover design ROM range of motion SBR stratified block randomization SOF start oral feeding

FEEDING INTERVENTION Narrative Synthesis

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Seventeen articles were included in the final review, and fifteen studies met the authors inclusion criteria. Participants within these studies included preterm infants who were dependent on gavage feeding in the NICU, a special care nursery, or a newborn critical care center. Finally, these participants were classified as preterm infants born between 23-36 weeks GA. The results were categorized according to the types of feeding interventions. Specifically, two themes were identified: multi-sensory interventions, and physiological interventions. Studies included within the physiological interventions were further subcategorized as preparatory, feeding skills, and environmental support interventions. Multi-sensory interventions. Multi-sensory interventions were defined as treatment strategies centered on provision of multi-sensory techniques used to facilitate attainment of IOF. Four studies were categorized into the multi-sensory feeding interventions within this systematic review of the literature. All four of the multi-sensory feeding interventions were randomized control trials (RCTs) (Fucile, Gisel, McFarland, & Lau, 2011; Fucile, McFarland, Gisel, & Lau, 2012; Standley et al., 2010; White-Traut et al., 2002). Treatment strategies within this category included: auditory, tactile, visual, and vestibular stimulation (ATVV) (White-Traut et al., 2002), oral intervention (O), tactile and kinesthetic intervention (T/K), or O+T/K stimulation (Fucile et al., 2011; Fucile et al., 2012), and pacifier-activated lullaby (PAL) system (Standley et al., 2010). The ATVV intervention is defined as providing infant directed talk via a soothing female voice (auditory) as the researcher massages the infant (tactile), followed by horizontal rocking (vestibular), while the researcher attempts to engage in eye-contact with the infant (visual) (White-Traut et al., 2002). The O, T/K, and O+T/K interventions are defined as follows: the O consisted of stroking of the cheeks, lips, gums, and tongue with NNS, the T/K consisted of

FEEDING INTERVENTION stroking of the head, neck, back, arms, and legs with passive range of motion, and the O+T/K combines both intervention protocols (Fucile et al., 2011). Fucile et al. (2012), modified their previous studys intervention protocol to the following: the O consisted of perioral stimulation (to the cheeks, lips and jaw), and intraoral stimulation (to the gums and tongue) with NNS, the T/K consisted of stroking of the head, neck, shoulders, back, legs, and arms with passive range of motion of arms and legs, and the O+T/K combines both intervention protocols. The PAL is defined as delivery of contingent music; the music sustains for 10 seconds and subsequently shuts off unless reactivated by another suck. Thus, the music stimuli are contingent on the preterm infants sucking behavior (Standley et al., 2010).

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The evidence from a review of the four RCTs suggest that multi-sensory interventions are effective for preterm infants with feeding difficulties (Fucile et al., 2011; Fucile et al., 2012; Standley et al., 2010; White-Traut et al., 2002). The evidence supports that multi-sensory interventions can facilitate increased alertness, faster transition to nipple feeding, and earlier discharge from the hospital (White-Traut et al., 2002). Multi-sensory interventions were also shown to shorten gavage feeding length, increase female infants proficiency to nipple feed, and promote earlier discharge from the hospital (Standley et al., 2010). Additionally, two of the RCTs found that multi-sensory interventions achieved earlier oral feeding, greater rate of transfer, decreased volume loss, and enhanced proficiency of swallow-respiration-coordination (Fucile et al., 2011; Fucile et al., 2012). Physiological interventions. In this systematic review, studies were categorized based on the interventions effect on the physiological development of preterm infants, specifically regarding the dynamic task of feeding. Eleven studies were categorized into the physiological feeding interventions within this systematic review of the literature. The levels of evidence of the

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eleven physiological studies are classified as Levels I through II including: 10 RCTs (Boiron et al., 2007; Bragelien et al., 2007; Hill, 2005; Hwang, Lin, Coster, Bigsby, & Vergara, 2010; Lau, Fucile, & Gisel, 2012; Lau & Smith, 2012; Poore, Zimmerman, Barlow, Wang, & Gu, 2008; Rocha, Moreira, Pimenta, Ramos, & Lucena, 2007; Simpson, Scheneler, & Lau, 2002; Yildiz & Arikan, 2011) and 1 cohort study (Amaizu, Shulman, Schanaler, & Lau, 2008). The studies within the psychological interventions fell into themes similar to that of a previous systematic review conducted by Howe and Wang (2013). The previous systematic review evaluated feeding interventions used and/or relevant to OT for children birth to five-years-old (Howe & Wang, 2013). The current systematic review specifically addresses OT interventions for the preterm infant. Within this theme, interventions can further be divided into three subcategories based on the targeted feeding behavior, which include: (1) preparatory interventions, (2) feeding skills, and (3) environmental support. Preparatory interventions. Preparatory interventions were defined as treatment strategies used in preparation prior to administration of feeding. Five studies included interventions that addressed preparatory behaviors which consisted of the following: sensorimotor oral stimulation and NNS, swallowing exercises, oral support and NNS, orocutaneous stimulation, and nonnutritive oral-motor therapy (NNOMT) and infant massage therapy (iMT) (Hill, 2005; Lau et al., 2012; Lau & Smith, 2012; Poore et al., 2008; Rocha et al., 2007). The evidence from a review of the previously mentioned articles supports the use of preparatory interventions for preterm infants with feeding difficulties. The evidence supports the use of sensorimotor oral stimulation and NNS during gavage feeding in attainment of earlier IOF and earlier discharge from the hospital (Rocha et al., 2007). Lau and Smith (2012) found that preterm infants participating in a swallowing exercise program demonstrated increased maturity in oral-feeding skill (OFS) levels.

FEEDING INTERVENTION Additionally, the length of time between the start of oral feeding and attainment of IOF was

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shorter for participants in the swallowing exercise program in comparison. However, the number of days to the attainment of IOF in the NNS program was not decreased (Lau & Smith, 2012). Evidence suggests the use of oral support as well as NNS increases the amount of formula intake along with the immediate and continued effects on feeding efficiency; however, the effects of NNS on sucking-pattern characteristics were mixed (Hill, 2005). NNOMT and/or iMT have a direct positive impact on accelerating maturation of preterm infants OFS (Lau et al., 2012). The findings regarding the effects of the NTrainer patterned orocutaneous stimulation demonstrated accelerated NNS development and oral-feeding success in preterm infants (Poore et al., 2008). Feeding skills. Feeding skills were defined as the prerequisite skills necessary to participate in oral feeding. Five studies included interventions that addressed feeding skills which consisted of the following: oral stimulation and/or oral support, early introduction to oral feeding, daily stimulation of sucking and swallowing, development of oral feeding skills over time, and effect of pacifiers or lullabies (Amaizu et al., 2008; Boiron et al., 2007; Bragelien et al., 2007; Simpson et al., 2002; Yildiz & Arikan, 2011). A study conducted by Boiron et al. (2007) found that the transition time from gavage to IOF was shorter for both the participants receiving the oral stimulation and oral support intervention, as well as the participants only receiving the oral support intervention. Also within this study, participants showed an increase in NNS pressure and sucking activity during gavage feeding within the oral stimulation intervention, as well as the stimulation and support intervention (Boiron et al., 2007). Infants who were introduced to oral feeding 48 hours after achieving full gavage feeding attained earlier overall IOF and shorter transition time from gavage feeding to oral feeding. Whereas, those participants who were introduced to oral feeding separately, at the discretion of the physician,

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progressed to IOF at a slower pace (Simpson et al., 2002). Yildiz & Arikan (2011) examined the effect of pacifier and lullaby interventions on the transition time to IOF and the infants sucking success. Participants, who received either the pacifier intervention or the lullaby intervention, progressed to IOF over a shorter period of time (Yildiz & Arikan, 2011). The highest sucking success was achieved by infants within the pacifier intervention, followed by the lullaby intervention (Yildiz & Arikan, 2011). Bragelien et al. (2007) found that receiving oral stimulation did not result in earlier discontinuation from gavage feeding or earlier discharge from the hospital. Amaizu et al. (2008) monitored specific feeding skills as indirect markers for the maturational process of oral feeding musculature development. Within this study, as preterm infants transitioned from gavage to oral feeding, feeding efficiency improved (Amaizu et al., 2008). Furthermore, the two experimental groups demonstrated that despite similar oral-motor feeding outcomes, the maturation of certain feeding skills differed based on GA (Amaizu et al., 2008). Environmental support. The authors defined environmental support as physical stability through cheek and jaw support (Hwang et al., 2010). The participants in the intervention group were given oral support while feeding; whereas, the control group did not receive any additional oral support (Hwang et al., 2010). The feeding performance of the participants was recorded during the initial five minute period, and again over the duration of the feeding (Hwang et al., 2010). The study found that infants displayed a greater intake rate during the treatment findings both during the first five minute period and throughout the entire duration of feeding. Furthermore, no significant differences were found between the two conditions in the sucking and physiological variables (Hwang et al., 2010).

FEEDING INTERVENTION Discussion Synthesis of the evidence implies that there are diverse feeding interventions that may benefit preterm infants. The interventions reviewed within the current systematic review facilitate feeding efficiency, feeding skills, and the transition from gavage feeding to IOF. Feeding interventions should be conducted by skilled therapists with extensive knowledge and

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experience working with preterm infants within the NICU setting. Preterm infants will be treated in the NICU until discharged to the appropriate environment based on their attainment of IOF and medical status. The therapists should have competency in administering feeding interventions and modifying the feeding environment to best suit preterm infants. Additionally, therapists should be knowledgeable on intervention selection based on specific targeted outcomes for the preterm infant, ensuring a client-centered approach to intervention implementation. Implications for Occupational Therapy Practice Practitioners may utilize the evidence presented in this review to gain further knowledge regarding different approaches targeting feeding behaviors, to gain an understanding of which feeding intervention is most appropriate for specific feeding outcomes, and to establish feeding progression guidelines in the NICU setting. Garber (2013) discussed the importance of therapists receiving specialized training to become a lactation consultant. Practitioners within the NICU play an important role in providing education to family members and caregivers regarding feeding difficulties when caring for the preterm infant (Garber, 2013). This systematic review of the literature supports that interventions utilizing multi-sensory techniques are effective in facilitating: increased alertness and faster transition to nipple feeding (White-Traut et al., 2002), earlier discharge from the hospital (White-Traut et al., 2002; Standley

FEEDING INTERVENTION

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et al., 2010), shorter gavage feeding length (Standley et al., 2010), and earlier attainment of oral feeding and enhanced proficiency of swallow-respiration-coordination (Fucile et al., 2011; Fucile et al., 2012). Furthermore, interventions utilizing physiological strategies have been shown to effectively promote: earlier attainment of IOF (Lau & Smith, 2012; Rocha et al., 2007), increased maturity in OFS levels (Lau et al., 2012; Lau & Smith, 2012), progression to development of feeding efficiency (Hill, 2005), and accelerated NNS development and oralfeeding success (Poore et al., 2008). Finally, OT practitioners, other relevant healthcare professionals, or students should reference the specific details as outlined in the various intervention protocols in order to accurately replicate these feeding interventions. Implications for Research The results of this systematic review should not be generalized outside of the preterm infant population. Further studies are required to evaluate if the discussed interventions would be appropriate across other 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 occupational therapists. Finally, as previously discussed within this review, studies should be conducted specifically addressing the efficacy of feeding interventions within particular preterm age groups. Limitations There are several limitations to be considered when interpreting the results of this systematic review; only English articles published after 2000 in peer-reviewed scholarly journals were included for review. These discussed limitations may have restricted identification of other studies and interventions relevant to the preterm infant population. Although this systematic

FEEDING INTERVENTION review only included studies examining preterm infants, other variables, such as degree of prematurity and medical status, were not accounted for. Finally, interventions were not

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standardized across studies. For example, interventions varied in protocols, treatment schedule, and frequency of intervention. Conclusion Within this systematic review, we appraised a wide range of feeding intervention studies for preterm infants. A review of the evidence indicated that specific feeding approaches resulted in targeted outcomes in the areas of feeding efficiency, feeding skills, and transition from gavage feeding to IOF. However, the findings from this systematic review are limited in its generalizability to other pediatric populations outside of preterm infants. Additionally, across the spectrum of reviewed articles, the studies were inadequate in describing protocols in a standardized manner. OT practitioners referencing this systematic review should limit use of the results to appropriate populations and settings. The synthesis of evidence in this systematic review may aid in establishing feeding protocols for OT practitioners working with preterm infants in the NICU and determining the outcomes of specific feeding interventions.

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