The transition to oral feeding in low-risk premature infants: Relation to infant neurobehavioral functioning and mother–infant feeding interaction
Introduction
Among the central challenges of modern neonatal care is to provide adequate nutritional intake for the growth and development of the fragile premature infant [1], while supporting a favorable environment for the emerging mother–infant feeding relationship [2]. Successful feeding is a complex developmental process [3] and a major criterion for hospital discharge [4]. Feeding is therefore one of the most important tasks to be mastered by the mother–preterm infant dyad during the neonatal period. Although recent research has focused on the feeding difficulties of high-risk preterm infants [5], little is known about feeding difficulties in low-risk infants and on the relations between the infant's neurobehavioral functioning and the mother–infant feeding relationship at the transition from gavage to nipple feeding in the NICU.
Non-optimal neurobehavioral functioning is common among premature infants, even among those born at low-risk with uncomplicated hospitalization [6], [7]. Neurobehavioral maturation provides the necessary framework for the infant's ability to progress to oral feeding. Postural control, sleep–wake regulation, sucking maturation, and suck–swallow–breath coordination are known as neurobehavioral markers associated with the ability to feed orally [8], [9]. We propose that neurobehavioral dysfunctions, even when mild and discrete, are likely to be related to difficulties in regulating feeding at the neonatal period.
Studies on the sucking patterns of premature infants point to the emergence of an increasingly organized and mature feeding pattern over time [10]. Among the manifestations of this maturation is the infant's gradual transition from gavage to independent oral feeding during the hospitalization period [3], typically around 34 weeks postconceptional age [11]. Due to the anatomical, physiological, and neurobehavioral immaturity that accompany premature birth, the achievement of independent oral feeding during hospitalization is particularly challenging for the preterm infant and his/her mother. Reduced intestinal motility and absorption, delayed gastric emptying, low esophageal tone, poor coordination of suck and swallow, cardiovascular and respiratory instability, and difficulty in maintaining awake state are some of the common problems in the transition to oral feeding of preterm infants [9], [12], [13].
In addition to feeding orally, neurobehavioral functioning enables infants to display clear behavioral responses to environmental stimuli [7], [14], which in turn assist the mother in developing a sensitive feeding relationship that corresponds to the infant's signals. In general, premature infants are more dependent on the mother's sensitive and supportive care giving to reach optimal development [15]. At the same time, mothers of premature infants experience more anxiety and depression [16], tend to be more stimulating and intrusive, and show lower levels of sensitivity during interactions [17], [18]. The combination of sub-optimal infant neurobehavioral functioning and more intrusive parenting may disrupt the development of an optimal feeding relationship, a central context for the infant's growth and thriving.
The feeding and growth of premature infants remain major topics of concern for both parents and pediatric care teams [19], [20]. Nevertheless, neonatal intensive care has traditionally emphasized oral intake achievement and overlooked the quality of the mother–infant feeding interaction [21]. The role of early caregiving experiences in supporting the infant's physical, emotional, and cognitive development has been well-documented [22], [23]. However, few studies examined the achievement of oral feedings in low-risk premature infants within a comprehensive framework that considers neurobehavioral (e.g., integrity of neonatal reflexes, muscle tone, sensory-motor adaptation, state control, etc.), functional (e.g., suck and milk consumption rates; duration of transition), and relational–emotional (e.g., positive behaviors during the feeding interaction) components of the infant's feeding competencies during hospitalization.
In light of the above, the goal of the present study was to examine the relationships between the infant's neurobehavioral status prior to hospital discharge, the transition to oral feeding, and the mother–infant early feeding interaction in low-risk preterm infants. We hypothesized that a less optimal neurobehavioral status would be related to a longer and more complicated transition to oral feedings and to less efficient sucking behaviors prior to discharge. In addition, mothers of infants with a less optimal neurobehavioral status would engage in less appropriate feeding interactions, in terms of lower maternal adaptability and higher intrusiveness. Finally, we hypothesized that both functional and relational determinants of the feeding interaction would be uniquely predictive of the infant's robustness of feeding as well as of the level of maternal intrusive behavior during the feeding interaction.
Section snippets
Participants
Ninety-seven premature infants and their mothers participated in this study. Infants were born at the Sheba Medical Center Neonatal Intensive Care Unit (NICU), a level III medical center in Israel, from February 2004 to April 2006. A low-risk sample was selected to eliminate the potential effects of neurological damage and high psychosocial risk on feeding performance and early mother–infant interactions. Infants included in the study were of low medical risk, whose mean gestational age (GA)
Results
Medical and demographic information for the normal and abnormal NB groups are presented in Table 2. Infants with an abnormal NB assessment had lower GA and thus, statistical analysis was conducted with GA as covariate. Both groups were comparable on the other medical and demographic variables.
Discussion
This study is among the first to examine the relationships between infants' neurobehavioral functioning, the progression to oral feedings, and the mother–infant feeding relationship in low-risk premature infants prior to hospital discharge. Results indicate that non-optimal neurobehavioral functioning of low-risk premature infants in the neonatal period are associated with less favorable outcomes in both the functional and the relational domains of feeding. As hypothesized, infants with an
Acknowledgements
This study was supported by the US-Israel Bi-National Science Foundation (# 2001-241). We thank the participating families for their cooperation; Prof. Aron Weller for his mentorship; Dr. Ita Litmanovitz from the Meir Medical Center for participating in the reliability study; the medical team at the Sheba Medical Center: Department of Neonatology; and the research teams at the Developmental Neuropsychology Lab and the Early Development Lab at the Gonda Brain research Center.
References (45)
Gastrointestinal development and meeting the nutritional needs of premature infants
Am J Clin Nutr
(2007)- et al.
Occurrence of oxygen desaturation events during preterm infant bottle feeding near discharge
Early Hum Dev
(2003) - et al.
Premature newborns as social partners before term age
Infant Behav Dev
(1994) - et al.
Oral feeding in low birth weight infants
J Pediatr
(1997) - et al.
Mother and child's touch patterns in infant feeding disorders: relation to maternal, child and environmental factors
J Am Acad Child Adolesc Psych
(2004) - et al.
Developmental progression of feeding skills: an approach to supporting feeding in preterm infants
Semin Neonatol
(2002) Feeding outcomes of extremely premature infants after neonatal care
JOGN Nurs
(2007)- et al.
Evaluation, development, and implementation of potentially better practices in neonatal intensive care nutrition
Pediatrics
(2003) - et al.
Regional neonatal oral feeding protocol. Changing the ethos of feeding preterm infants
J Perinat Neonatal Nurs
(2004) Developmental transition from gavage to oral feeding in the preterm infant
Annu Rev Nurs Res
(2003)
Committee on fetus and newborn. Hospital discharge of the high-risk neonate—proposed guidelines
Pediatrics
Abnormalities in the coordination of respiration and swallow in preterm infants with bronchopulmonary dysplasia
Dev Med Child Neurol
Neurobehavioral comparison of low-risk preterm and full term infants at term conceptional age
Dev Med Child Neurol
Neurobehavioral functioning of healthy preterm infants of varying gestational ages
J Dev Behav Pediatr
Development of preterm infants: feeding behaviors and Brazelton neonatal behavioral assessment scale at 40 and 44 weeks' postconceptional age
Adv Nurs Sci
Neonatal oral–motor assessment scale: a reliability study
J Perinatol
Characterization of the developmental stages of sucking in preterm infants during bottle-feeding
Acta Paediatr
Early introduction of oral feeding in preterm infants
Pediatrics
Dynamics of the behavioral organization of the premature infant: a theoretical perspective
Postpartal anxiety and depression in mothers of term and preterm infants
Nurs Res
Mother–infant skin-to-skin contact and the development of emotion regulation
Early dyadic patterns of mother–infant interactions and outcomes of prematurity at 18 months
Pediatrics
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