Suzanne M. Thoyre

The early feeding skills assessment for preterm infants.

Preterm infants develop the skills necessary to begin oral feeding as their health stabilizes and as they reach a postconceptional age that supports coordination of breathing and swallowing with oral-motor functioning. The time from initiation of oral feeding to full oral feedings (with adequate intake for growth and maintenance of physiologic stability) can vary from days to months for the preterm infant. The approach to feeding the infant during this transition period must be developmentally supportive and tailored to meet the needs of the individual. To accomplish this, caregivers—notably nurses and parents—need to communicate about the specific skills that the infant has gained, about skills that are emerging, and about skills that the infant has not yet developed. The Early Feeding Skills (EFS) Assessment is a checklist for assessing infant readiness for and tolerance of feeding and for profiling the infant’s developmental stage regarding specific feeding skills: the abilities to remain engaged in feeding, organize oral-motor functioning, coordinate swallowing with breathing, and maintain physiologic stability. This article introduces the EFS.

Patterns of distress in African-American mothers of preterm infants.

Objective: To examine inter-relationships among stress due to infant appearance and behavior in the neonatal intensive care unit (NICU), parental role alteration stress in the NICU, depressive symptoms, state anxiety, posttraumatic stress symptoms, and daily hassles exhibited by African-American mothers of preterm infants and to determine whether there were subgroups of mothers based on patterns of psychological distress. Method: One hundred seventy-seven African-American mothers completed questionnaires on their psychological distress at enrollment during infant hospitalization and 2, 6, 12, 18, and 24 months after term. Results: Psychological distress measures were intercorrelated. There were four latent classes of mothers: the low distress class with low scores on all measures; the high NICU-related stress class with high infant appearance and parental role stress and moderate scores on other measures; the high depressive symptoms class with high depressive symptoms and state anxiety and moderately elevated scores on NICU-related stress and posttraumatic stress symptoms; the extreme distress class with the highest means on all measures. Infants in the high stress class were sicker than infants in the other classes. The extreme distress class mothers averaged the lowest educational level. The classes differed on distress measures, worry about the child, and parenting stress through 24 months with the extreme distress class having the highest values. Conclusion: Although different types of maternal psychological distress were substantially related, there were distinct subgroups of mothers that were identifiable in the NICU. Moreover, these subgroups continued to differ on trajectories of distress and on their perceptions of the infants and parenting through 24 months after term.

Factors contributing to preterm infant engagement during bottle-feeding

BACKGROUND Preterm infants have difficulty maintaining engagement throughout early oral feedings, which can lead to less efficient feeding and prolonged feeding skill development. OBJECTIVE To examine contributions of the infant, mother, and feeding context to infant engagement during bottle-feeding. METHODS Bottle-feedings of very-low-birthweight infants (n = 22) by their mothers were observed. Infant and maternal behaviors were coded and synchronized with physiologic measures. At completion of the feeding, the mothers were interviewed, and their working model of feeding coregulation was scored. Feedings were subdivided into feeding episodes (n = 114). Using multilevel linear regression analyses, four dyadic characteristics (working model of the caregivers role as coregulator, birthweight, postconceptional age, baseline oxygen saturation) and five episode characteristics (readiness at episode onset, episode baseline oxygen saturation, mean oxygen saturation during the episode, maternal feeding behavior, and phase of feeding) were examined as potential predictors of feeding episode engagement. RESULTS Conditions observed during the feeding observation explained most of the variation in engagement. Engagement was more likely to occur during the early phase of feeding (p <.05), during feeding episodes that began with infant readiness (p <.05), and during feeding episodes with higher mean oxygen saturation during the episode (p <.05). Feeding episodes with less jiggling of the nipple had a significantly greater amount of engagement (p <.05). CONCLUSIONS The ability of the preterm infant to maintain engagement during bottle-feeding cannot be explained by characteristics of the infant or by the prefeeding condition of the infant alone. Rather, engagement is coregulated by the caregiver and the infant throughout the feeding. Strategies to assist infants in maintaining physiologic stability during bottle-feeding and further study of effective and contingent caregiver feeding behaviors are needed.

Coregulated approach to feeding preterm infants with lung disease: effects during feeding.

Background:Very preterm (VP) infants are at risk for poor oral feeding endurance, early cessation of eating, poor fluid management with aspiration risk, behavioral distress, and unstable heart rate (HR) and oxygenation during feeding. Objective:The study aims to determine the preliminary effectiveness of a coregulated approach (CoReg) to oral feeding for VP infants at risk for lung disease. Methods:A randomized, within-subject, cross-over design was used with 20 VP infants requiring oxygen at the start of oral feeding. Infants were bottle-fed by the Usual Care approach and by the CoReg approach on two consecutive days for an average of four feedings each. Intervention components included coregulation of suck, swallow, and breathe rhythms using enhanced auditory assessment, infant-guided feeding onsets, and infant positioning in a semielevated, side-lying position. Infant physiology metrics (HR and SaO2) were collected continuously before and during the feeding. Behavioral and auditory indicators of regulation were coded continuously from videotape during the feeding. Results:Up to 75 feedings were analyzed (40 Usual Care and 35 CoReg) using repeated measures modeling. CoReg feedings were characterized by more frequent preparation of the infant for the feeding, were more commonly initiated in response to infant readiness cues, had more rest periods and breath regulation events, and had fewer sucking stimulation events. CoReg feedings had less SaO2 variability, decline, and time spent in a desaturated state; less HR fluctuation and decline; less behavioral disorganization; better fluid management; and less observed effort to breathe. Discussion:Support is provided for an approach to feeding vulnerable infants. Enhanced auditory assessment of infant feeding rhythms increases the responsiveness of the feeder and improves infant behavioral and physiological responses.

Decision Making Following a Prenatal Diagnosis of Down Syndrome: An Integrative Review

INTRODUCTION Prenatal screening for Down syndrome (DS) is a routine part of prenatal care in many countries, and there is growing interest in the choices women make following a prenatal diagnosis of DS. This review describes what is known about actual and hypothetical decision making following a prenatal diagnosis of DS and adds understanding about the factors that influence womens decision making. METHODS A search of empirical studies was conducted through electronic databases, major journals, and reference lists that were published in English between January 1999 and September 2010. Inclusion criteria were that the research explored attitudes toward continuation of pregnancy or induced abortion for DS and included at least 1 variable that explored factors influencing womens decision making following a prenatal diagnosis of DS. Studies that did not specify DS, unpublished manuscripts, review articles, and book chapters were excluded. RESULTS A total of 11 studies were identified that met the inclusion criteria. The decision to undergo an induced abortion varied depending on whether participants were prospective parents recruited from the general population (23%-33% would terminate), pregnant women at increased risk for having a child with DS (46%-86% would terminate), or women who received a positive diagnosis of DS during the prenatal period (89%-97% terminated). Multiple factors influence womens decision making following a diagnosis of DS, including demographic factors such as religion, maternal age, gestational age, number of existing children, and history of induced abortion. Psychosocial factors including perceived parenting burden/reward, quality of life for a child with DS, attitudes toward and comfort with individuals with disabilities, and support from others also are important influences. DISCUSSION Multiple factors influence the decisions pregnant women make following the diagnosis of fetal DS. Therefore, it is critical that health care providers who work with pregnant women are aware of these factors.

Perspectives on Sedation Assessment in Critical Care

Multiple studies have been undertaken to show that neurofunction monitors can correlate to objective sedation assessments. Showing a correlation between these 2 patient assessments tools may not be the correct approach for validation of neurofunction monitors. Two different methods of assessing 2 different modes of the patients response to sedation should not be expected to precisely correlate unless the desire is to replace one method with the other. We provide a brief summary of several sedation scales, physiologic measures and neurofunction monitoring tools, and correlations literature for bispectral index monitoring, and the Ramsay Scale and the Sedation Agitation Scale. Neurofunction monitors provide near continuous information about a different domain of the sedation response than intermittent observational assessments. Further research should focus on contributions from this technology to the improvement of patient outcomes when neurofunction monitoring is used as a complement, not a replacement, for observational methods of sedation assessment.

Challenges mothers identify in bottle feeding their preterm infants.

Purpose: To describe the challenges mothers identify in bottle feeding their preterm infants prior to discharge from the NICU. Design: Mothers bottle fed their infants in the NICU while being videotaped. Following the feeding, a semifocused interview was conducted with the mother using playback of the videotaped feeding to enhance exploration of the experience of feeding. Sample: The participants were 22 mothers of preterm infants (≤1,500 grams). Main Outcome Variable: Mothers’ challenges in feeding preterm infants. Results: Mothers identified three major categories of challenge: ensuring safety during the feeding, ensuring adequate intake of calories, and advancing the feeding plan once home. Mothers described strategies they used to meet these challenges and discussed the implications some of these strategies held for them.

Factors associated with feeding progression in extremely preterm infants.

BackgroundAmong infants born prematurely, competence at oral feeding is necessary for growth and hospital discharge. Extremely preterm (EP) infants (28 weeks of gestational age [GA]) are at risk for a variety of medical complications, which can limit the infant’s capacity to develop oral feeding competence. ObjectiveThis study examined feeding progression by assessing timing of acquisition of five early feeding milestones among EP infants and the impact of immaturity and medical complications. DesignA chart review was conducted for 94 EP infants who participated in a larger longitudinal randomized study. Feeding progression was defined as infants’ postmenstrual age (PMA) at five milestones: first enteral feeding, full enteral feeding, first oral feeding, half oral feeding, and full oral feeding. GA at birth and five medical complications (neurological risk, bronchopulmonary dysplasia, necrotizing enterocolitis, patent ductus arteriosus, and gastroesophageal reflux disease) were used as potential factors influencing the feeding progression. Linear mixed models were used to examine feeding progression across the milestones and contributions of GA at birth and five medical complications on the progression, after controlling for milk type as a covariate. ResultEP infants gradually achieved feeding milestones; however, the attainment of the feeding milestones slowed significantly for infants with younger GA at birth and the presence of medical complications, including neurological risk, bronchopulmonary dysplasia, necrotizing enterocolitis, and patent ductus arteriosus but not gastroesophageal reflux disease. Milk type was a significant covariate for all analyses, suggesting that infants fed with breast milk achieved each of five milestones earlier than formula-fed infants. DiscussionImproved understanding of the timing of essential feeding milestones among EP infants and the contribution of specific medical conditions to the acquisition of these milestones may allow for more targeted care to support feeding skill development.

The Mother-Infant Feeding Tool

OBJECTIVE To describe the development and evaluation of an observation system to assess the process of mother-infant feeding interaction relevant to infant neuro-behavioral regulation: the Mother-Infant Feeding Tool. DESIGN Secondary analysis. SETTING Special care nursery just before discharge and in the home at 1 and 4 months postterm age. PARTICIPANTS Forty-three mother-infant dyads. METHODS Videotaped feeding interactions were examined to assess regulatory processes of mother-infant interaction. Data were collected at three times over the infants first 4 postterm months: before the infants discharge from the special care nursery and at 1 and 4 months postterm age in the home. RESULTS Across all three data points mothers rarely talked to their infants. CONCLUSION Further testing is needed, but the Mother-Infant Feeding Tool shows promise in assessing very early mother-infant feeding interactions.

Efficacy of semielevated side-lying positioning during bottle-feeding of very preterm infants: a pilot study.

Very preterm (VP, ⩽30 wk gestational age) infants are at risk for impaired lung function, which significantly limits their ability to eat. A semielevated side-lying (ESL) position is a feeding strategy that may improve oral feeding by supporting breathing during feeding. The study evaluated the efficacy of the ESL position compared with the semielevated supine (ESU) position on physiological stability and feeding performance of bottle-fed VP infants. Using a within-subject crossover design, 6 VP infants were bottle-fed twice on 1 day, in both the ESL and ESU positions in a random order. Physiological stability (heart rate, oxygen saturation [SaO2], and respiratory characteristics) and feeding performance (percent intake, proficiency, efficiency, and duration of feeding) were measured before and/or during feeding. Very preterm infants fed in the ESL position demonstrated significantly less variation in heart rate, less severe and fewer decreases in heart rate, respiratory rate that was closer to the prefeeding state, shorter and more regular intervals between breaths, and briefer feeding-related apneic events. No significant differences for SaO2 or feeding performance were found. The findings indicate that the ESL position may support better regulation of breathing during feeding, thereby allowing VP infants to better maintain physiological stability throughout feeding.