Effects of pre-feeding oral stimulation on oral feeding in preterm infants: A randomized clinical trial

https://doi.org/10.1016/j.earlhumdev.2013.12.011Get rights and content

Abstract

Objective

To evaluate the effect of early oral stimulation before the introduction of oral feeding, over the duration of concomitant tube feeding (“transition period”), the length of hospital stay and the breastfeeding rates upon discharge in preterm infants.

Study design

Preterm infants born between 26 and 33 weeks gestational age (n = 86), were randomized into an intervention and control group. Infants in the intervention group received an oral stimulation program consisting in stimulation of the oral structures for 15 min at least for 10 days, before introduction of oral feeding. Oral feeding was introduced at 34 weeks GA in both groups.

Results

Breastfeeding rates upon discharge were significantly higher in the intervention than in the control group (70% versus 45.6%, p = 0.02). There was no statistical difference between the two groups in terms of the length of the transition period or the length of the hospital stay.

The need for prolonged CPAP support (HR = 0.937, p = 0.030) and small size for gestational age at birth (HR = 0.338, p = 0.016) were shown to be risk factors for a prolonged transition period.

Conclusion

A pre-feeding oral stimulation program improves breastfeeding rates in preterm infants. The study results suggest that oral stimulation, as used in our specific population, does not shorten the transition period to full oral feeding neither the length of hospital stay.

Introduction

Oral feeding problems in preterm infants are of growing concern for society: cases of breast-feeding failures often result in delayed hospital discharge, maternal stress and long-term health problems. Sucking and swallowing are present in early foetal life but the coordination of sucking and swallowing and breathing and swallowing is thought not to occur before 32 and 33–34 weeks gestational age (GA) respectively. Even if the coordination of suck–swallow–breathe is not necessary to begin oral feeding, effective and safe oral feeding requires the adequate coordination of sucking, swallowing and respiration so as to avoid aspiration, apnea, bradycardia and oxygen desaturations., [1], [10], [11], [13], [20]. At present, in the absence of specific contraindications, oral feeding is commonly introduced at around 33 to 34 weeks GA. Usually, there exists a transition period of combined gavage and oral feeding which lasts days or weeks.

Accelerated maturation of the sucking reflex and earlier readiness for bottle-feeding are reported when preterm neonates are presented with non-nutritive sucking (NNS) opportunities during gavage feeding [4]. Recent evidence points to the fact that the sensory consequences associated with the production of NNS have beneficial effects on oral feeding performance and on the development of specific sucking skills [3], [6], [15], [17], [18].

Recent studies have suggested that an oral stimulation program combined with NNS applied to preterm infants for at least 10 days in the period of full gavage feeding can facilitate their oral feeding progress, improve breastfeeding rates among preterm infants and decrease the length of hospital stay, while no particular negative outcomes have been reported in the said studies [2], [7], [8], [9], [16], [17], [19].

In the present situation of our neonatal intensive care unit (NICU), as in the large majority of NICUs, preterm infants never receive oral stimulation before the introduction of oral feeding. Difficulties in the transition from tube to independent oral feeding are frequently observed, even for infants born after 32 weeks GA.

The objective of this study was to evaluate the effect of an oral stimulation program on the length of the transition period in preterm infants (primary outcome), on the length of hospital stays and on breastfeeding rates upon discharge (secondary outcomes).

Section snippets

Methods

In a prospective randomized controlled clinical trial, the effect of pre-feeding oral stimulation on the achievement of full oral nutrition within 15 days from offering oral feeding was investigated.

For an expected full-oral-feeding success rate of 95% in the intervention group versus 70% in controls, the minimal sample size needed to allow the detection of a difference between the two groups was 37 patients in each group, with a power of 80% and an alpha level of 5%.

A total of 101 preterm

Results

Over the whole course of the study, 116 preterm infants with gestational age between 26 and 33 weeks were admitted to the neonatal unit. 101 infants were included in the study protocol. Fifteen infants were excluded: eight presented exclusion criteria and seven had less than 10 stimulation sessions. 86 patients were finally analyzed (40 in the intervention group and 46 in the control group) (see Fig. 1).

Preterm infants in the intervention and in the control groups did not differ statistically

Discussion

The results of the present study show that oral pre-feeding stimulation can increase the breastfeeding rate in preterm infants born between 26 and 33 weeks GA.

The development of the sucking ability on the mother's breast may be enhanced by oral stimulation, which appears to account for why a greater number of infants in the intervention group could be fed by breast upon discharge. However, breastfeeding in a neonatal unit not only requires the ability for the preterm infant to suck on the

Conflict of interest

The authors declare no conflict of interest.

Acknowledgments

The authors would like to thank all the nurses who participated in the study at the Centre Hospitalier de Luxembourg. This study was supported by the Société Luxembourgeoise de Recherche en Pédiatrie (SOLUREP) and the perinatal health monitoring system, implemented at the CRP-Santé, Luxembourg.

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