The transition to oral feeding in low-risk premature infants: Relation to infant neurobehavioral functioning and mother–infant feeding interaction

https://doi.org/10.1016/j.earlhumdev.2008.07.006Get rights and content

Abstract

Background

The achievement of oral feeding is a critical task for the premature infant–mother dyad, yet neurobehavioral and relational factors associated with feeding difficulties of low-risk premature infants during hospitalization are not well understood.

Aim

To examine the relations between infant neurobehavioral functioning, the transition to oral feeding, and the emerging mother–infant feeding relationship in premature infants.

Study design and subjects

Ninety-seven low-risk premature infants (birth weight > 1000 g; gestational age > 30 weeks) and their mothers were followed at the NICU. Neurobehavioral functioning was assessed with the Rapid Neonatal Neurobehavioral Assessment Procedure.

Outcome measures

The duration of the transition to oral feeding and specific feeding difficulties during the transition were assessed. Infant feeding robustness, suck and milk transfer rates, and maternal adaptability, affect, intrusiveness and distractibility were coded from videotaped mother-infant feeding interactions prior to discharge from the NICU.

Results

Thirty percent of the infants presented feeding difficulties during the transition to oral feedings. Infants with abnormal neurobehavioral functioning (37% of the cohort) showed more feeding difficulties, slower suck rates, and lower feeding robustness, and their mothers displayed less adaptive and more intrusive behavior. Maternal intrusiveness was related to lower feeding robustness and to lower suck and milk transfer rates. Neurobehavioral functioning and maternal feeding behavior predicted feeding robustness.

Conclusions

Less intact neurobehavioral functioning in the neonatal period is related to difficulties during the transition to oral feeding and to less optimal early mother–infant feeding interactions. Low-risk premature infants with poor neurobehavioral functioning should receive special attention and care.

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.

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