Identification of premature infant states in relation to introducing oral feeding

Abstract

Background

Recognizing oral readiness signs in infants is vital when planning the introduction of oral feeding. However, with premature infants, this can be difficult to gauge accurately because of immature development.

Methods

Twenty three staff from a level 2 neonatal unit participated. A questionnaire elicited knowledge about oral readiness and other factors related to oral feeding with premature infants. Participant knowledge of the written Als (1986) infant state descriptors was completed. A comparison was made of the skills in identification of the various infant states on video without and with written descriptors (Als, 1986). Correlations investigated if years of experience and grade had any relation to accurate infant state identification.

Results

There was wide variation in the type of training about premature infant feeding participants had received. Participants (65%) recognized the importance of oral readiness signs in relation to feeding development. A Wilcoxon signed ranks test revealed no significant differences in ability to identify infant states without and with the written Als (1986) descriptors when observing infant video materials. When not using the written descriptors, there was a strong negative correlation between grade and the identification of the [Active sleep] state, (p < 0.01), and a strong positive correlation between grade and the identification of the [Drowsy] state, (p < 0.05). There were no strong correlations between grade and years working when using the written descriptors.

Conclusion

Oral readiness signs are important when introducing oral feeding with premature infants. However, accurate identification of oral readiness remains challenging.

Introduction

Premature infants are at risk of feeding difficulties, both establishing feeding, and maintaining competent feeding skills over time (Harding et al., 2015, Hawdon et al., 2000). For feeding to be successful, sucking, swallowing and breathing need to be coordinated, but is rarely established before 34 weeks gestation (Gewolb et al., 1999, Jadcherla, 2016). As premature infants develop, they begin to show oral readiness signs of either crying or becoming awake or alert before they are due their feed (Kish, 2013).

Introducing oral feeding with premature infants is influenced by a variety of factors including post menstrual age, variability with demonstration of infant behavioural states and physiologic stability (Eichenwald et al., 2001, Jadcherla, 2016; Ludwig, 2007). Premature infants with low gestational ages are more at risk of having a range of additional health needs and medical conditions (Moore et al., 2012). Significant health difficulties can delay the establishment of oral feeding with longer term implications for motor and sensory development during a period of critical brain development (Browne, 2008, Gewolb and Vice, 2006, Jadcherla, 2016; Moore et al., 2012).

As an infant matures, oral readiness signs are emerging although these signs may initially be variable (White-Traut et al., 2005). Alert states are associated with being an indicator of maturity as well as supporting successful oral feeding (Howe et al., 2007, Kish, 2013, Thoman, 1990, McCain, 1992, Pickler et al., 2006). Specifically, developments with both sucking and alert behaviours in older premature infants lead to better oral feeding (Kirk et al., 2007, White-Traut et al., 2013). There is variation in the identification of the most appropriate oral readiness state that supports successful oral feeding. Some authors comment that alert states, including quiet alert increase feeding efficiency (Griffith et al., 2017, Harding et al., 2014, McCain and Gartside, 2002, Medoff-Cooper et al., 2000), in contrast to the active awake state (McCain, 1992, Pickler et al., 2006). More recently, crying prior to a feed has been identified as a good predictor of feeding success (Griffith et al., 2017).

Published descriptors are available that define and describe the variety of infant states. Als (1986) refers to two sleep states, active sleep and deep sleep, as well as a distinct drowsy state. Alert states include active awake, quiet alert and crying. Similarly, Brazelton and Nugent (1995) also describe awake states as alert, active alert and crying. In addition, they describe the sleep states as drowsy, deep sleep and light sleep. Other researchers have used different ways of describing infant states in reference to their own work, and although Holditch-Davis (1990) refers to similar alert and sleep states as Als (1986) and Brazelton and Nugent (1995), she also describes additional drowsy states, namely, sleep – wake transition; drowsy and non – alert waking activity. Although these descriptive differences appear small, it possibly suggests that different practitioners identify similar infant states in qualitatively different ways.

Timing for the introduction of oral feeding with premature infants varies because of differing rates of maturation and the range of additional problems that the infants may experience (Griffith et al., 2017). Neonatal practitioners may focus on an infant's ability to manage oral stimulation in readiness to trial breast or bottle feeds, toleration of enteral feeding, weight gain and monitoring of infant states (Kirk et al., 2007). An important approach is cue based feeding, where the feeder is guided by the infant's responsiveness to feeding rather than volume (Ludwig and Waitzman, 2007). The cues that infants therefore produce are important for both carer interpretation and responsiveness, and can result in quicker discharge home (Chrupcala et al., 2015, Kirk et al., 2007, Wellington and Perlman, 2015).

There are some published assessment tools to support the assessment of neonatal feeding skills (Neonatal Oral Motor Assessment Schedule, NOMAS; Palmer, 1993; Early Feeding Skills Assessment; Thoyre et al., 2005; The SOFFI, Supporting Oral Feeding in Fragile Infants, Ross and Philbin, 2011). Currently, no randomized controlled trials have evaluated any of these assessment tools or those which are for determining oral readiness (Crowe et al., 2012, Da Costa et al., 2008). There are few studies which investigate healthcare practitioner and carer ability to identify infant oral readiness signs and states.