po feeding guidelines in nicu

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CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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PURPOSE 1. To provide guidelines for family, staff and physicians for the introduction and management

of oral feeding for high-risk infants. 2. To create positive feeding experiences while assisting infants to achieve full oral feeding

and to attempt to prevent the development of oral aversive behaviors.

UNDERLYING PRINCIPLES 1. Feeding is an active social interaction between caregiver and infant. 2. Development of oral feeding follows stages that can be identified.166,172 3. Stages are used to plan physiologically appropriate feeding experiences.172 4. Movement within and between stages may be bi-directional.

PRINCIPLES OF FEEDING ASSESSMENT 1. Continuous assessment of infant state and responses before, during and after non nutritive

sucking (NNS) as well as nutritive sucking (NS), is essential. 146, 152, 154,166 2. Providing interventions that are contingent on infant responses is needed to achieve specific

goals within each stage. 76, 152, 156 3. Reassessment of oral feeding process and plans should occur when:

3.1. Engagement/readiness cues are present and if positive signs persist: Identifiable hunger cues Increased/enhanced quiet alert state Stable physiologic responses

3.2. Disengagement/distress cues are present and if distress signs persist: Significant changes in heart rate (bradycardia, tachycardia) O2 saturation outside normal limits Color changes (pallor, cyanosis, mottled) Significant changes in respiratory status (rate, grunting, nasal flaring, retractions,

apnea) Loss of postural tone Loss of state

3.3. Feeding skills improve: Improved suck/swallow/breathe (SSB) coordination Satiety cues

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POINTS OF EMPHASIS 1. Most premature infants will be able to feed by mouth without difficulty as they approach term

gestation. 2. Gestational age and severity of illness may play a role in how long an individual infant

remains in any one stage. 3. There is a wide range in ability at various gestational ages. For example a healthy preterm

infant at 33 weeks adjusted age may be able to achieve total oral feedings while a 44 week adjusted age infant with chronic lung disease may not.

OVERVIEW OF THE ORAL FEEDING PRACTICE GUIDELINE: Non-oral stages

Pre-oral Stimulation Stage Page 3 Non-nutritive Sucking Stage Page 4

Nutritive Sucking Stages Stage I: Minimal oral intake (

CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title: ORAL FEEDING



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STAGES OF NEONATAL FEEDING Pre-Oral Stimulation Stage

GOALS INFANT CHARACTERISTICS INTERVENTIONS WHEN TO REFER Minimize negative oral stimulation8, 36, 52, 66, 76, 78 Promote behavioral organization Establish and maintain mothers milk supply 0 % oral intake

Responds adversely to handling Poor physiologic, motor & state regulation with or without stimulation 78, 127, 128, 129, 148 None to very weak oral reflexes (transient) 66 None to very weak non-nutritive skills 8, 36, 52, 66, 76, 78, 79 Not managing secretions (Neurological infants) 66

Use developmental care interventions to facilitate midline position and flexion which promotes hand to mouth experience and behavioral organization 78,127, 128, 129

Skin-to-skin care (Kangaroo care) Positive experiences to the facial area as tolerated by infant. 33

Sustained touch Kisses by family

Support the mother in initiating and maintaining lactation 11, 41 (See: Booklet: Breastfeeding Your Preterm Baby) Discuss with parents realistic expectations for initiation and progression of feeding 61, 185 Tube feeding only (Refer to Policy: 2-G-1 Gastric Tubes)

Refer to LC when mother: Has difficulty

establishing/ maintaining lactation

Experiences complications as a result of pumping

Has difficulty in accessing breast pump

Refer to OT when infant: Fails to progress or has

extreme hypersensitivity to oral touching

NB: first consider gestational age and severity of illness





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Non-Nutritive Sucking Stage GOALS

INFANT CHARACTERISTICS INTERVENTIONS WHEN TO REFER

Promote positive oral stimulation and NNS 66

Support the establishment and maintenance of mothers milk supply 0 % oral intake

Stable with handling and able to maintain physiologic, motor and state stability with NNS interventions148 Oral reflexes present or emerging Demonstrates licking and rooting By the end of this stage the infant will be able to demonstrate NNS by: Establishing and maintaining

latch Rhythmical sucking bursts Coordinating sucking and

breathing

Provide positive facial experiences and NNS: Infants fingers: position to support hand

to mouth contact to allow the infant to suck when needed171

Pumped breast: allows infant to nuzzle and practice sucking.

Skin-to-skin care (Kangaroo care) Soother/ pacifier: standard shaped

nipples are recommended 18, 66, 171 (no orthodontic, flat or bulb shaped pacifiers); never force a nipple into the infants mouth

Note: If baby has difficulty sucking and breathing, attempt to provide external pacing

Transition to Pairing NNS and Tube Feeding:

Consider placing a warmed drop of milk on the infants lip to promote the infant to bring their tongue forward to lick the milk

Once infant demonstrates coordination of NNS (breathing and sucking), all above methods of NNS can be combined with tube feeding (e.g. gavage feeding while nuzzling at breast)

Refer to LC when: There is a concern with

mothers milk supply Refer to OT: After first considering gestational age and severity of illness, refer to OT when infant: Is evasive or refusing NNS,

or having difficulty coordinating sucking and breathing (e.g. chronic lung disease, neurological impairment)

Fails to progress from this stage

Refer to Home Nutrition Support Service, OT, and Neonatal Transition Team (NTT) or Pediatric Home Care when: Infant is to be discharged

home on any amount of tube feeding





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Nutritive Sucking Stage I: Minimal Oral Intake CRITICAL STAGE (





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Fatigues easily (falls asleep) Difficulty initiating feeding Head bobbing Loss of postural tone Loss of state

Breastfeeding: Nuzzle at breast: encourages infant to root, smell, touch, lick, taste, or latch 31, 42, 44

If infant has difficulty with strong milk ejection reflex, try placing infant on a partially pumped breast 85

If infant behavior is disorganized at breast, try NNS (moms finger, infant fist, pacifier); once organized try placing back on breast

Pair tube feeding with nuzzling at breast Refer to Pamphlet Breastfeeding Your

Premature or Sick Infant Bottle Feeding: Check for excessive milk flow: release

pressure or change nipple before feeding Swaddle to promote organized behavior152

Provide postural stability147, e.g. side lying157 on pillow with head elevated

Begin all feedings with 1-2 minutes NNS 32,64, 74, 89, 93 to help organize infant state and skills

Place a drop of milk on the lip before feeding to help the infant organize for oral feeding

Use low flow single-hole nipple 21, 40, 56, 80, 97,163,172 (losing liquid is OK to allow the infant to adjust volume).

Do not allow the infant to become distressed. Do not jiggle or turn nipple to stimulate NS;

this practice is contraindicated 152,173

refuses NS - Difficulty managing

secretions (Aspiration may be silent)

Persistent feeding induced apnea and bradycardia

Poor or unsustained latch i.e. an excessive wide jaw excursion

Failure to progress from this stage

Refer to Home Nutrition Support Service, OT and NTT or Pediatric Home Care when: Infant is to be

discharged home on any amount of tube feeding





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Nutritive Sucking Stage II: Moderate Oral Intake (10% to





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Infants who demonstrate an ability to take 30% of required volume and 1.5ml during the first 5 minutes of feeding may attain oral feeding earlier than others. 40 Note: Infants may develop physiological instability if pushed at this stage and require ongoing monitoring of saturation and heart rate

External and self- pacing may still be indicated, particularly in the first few sucks of a feeding, and if infant has chronic lung disease157. External Pacing for breastfed infants may be necessary for mothers with strong milk ejection reflex: Strategies include: Having mother pump breast a little before feeding

85 Removing baby from breast during milk ejection

reflex Allowing baby to reorganize before placing back

on breast Encourage breastfeeding mothers to spend long blocks of time in nursery to facilitate cue-base feeding 42, 41 Nutritive Sucking Stage II interventions may be further matched to the percentage oral intake as follows: Stage IIA: 10% to





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Stage IIB: 25% to 10 minute oral feeding time BF/B opportunities dependent on infant cues;

aid to awake state ac Occasional full bottle taken

Stage IIC: 50% to





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Nutritive Sucking Stage III: Full Oral Feeding (80% oral feedings in a 24 hour period)

GOALS INFANT CHARACTERISTICS INTERVENTIONS

WHEN TO REFER

Full oral feeding that supports growth Feeding experience is positive to infant and caregiver

Sustains SSB throughout the feeding 24 , 28, 31, 66 Endurance to maintain nutritional intake to support growth Demonstrates clear hunger cues: Hand to mouth, rooting Increased motor activity Wakes to feed Demonstrates satiation cues: Slips off nipple at end of

feeding Falls asleep at end of feeding Most infants by 37-42 weeks adjusted age should be able to achieve Stage III of nutritive sucking 100, 134, 169

Continue side lying and external pacing as required Transition to cue base feeding before discharge; intervals between feedings may vary greatly throughout day 11, 73, 112,118,136,147,149,150,152,156,160 If infant demonstrates disengagement cues, delay feeding until infant cues again Consider no top-up if infant consumes >80% of feed Consider oxygen saturation monitoring for 24 hours during all states including feeding (especially infants with chronic lung disease) 10,71 Encourage breastfeeding mothers to spend long blocks of time in nursery to facilitate cue-base feeding, and to room in for 48 hours before discharge 42, 41 Before discharge, the infant should be transitioned to the nipple and feeding regime that parents are planning to use at home.31,73 This will enable matching of the infants skills to the nipple to be used. A commercial single hole, straight nipple is recommended. If the infant does not tolerate this nipple, then the hospital supplied low flow nipple should be sent home 24, 52, 66 Ideally infant should spend >3 days in stage III pre-discharge

Refer to LC when: Poor latch evident Poor milk transfer

suspected Poor weight gain Poor milk supply Refer to OT when: Infant discharged on total oral feeding but feeding skills are suspect 38: SSB

incoordination Poor endurance Prolonged

feedings > 45 minutes

Neurological impairment

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APPENDIX 1: DEFINITIONS External Pacing (imposed breaks) 52, 66, 76, 126,145,161 - caregiver assists the infant in appropriately interspersing breaths during sucking bursts, to facilitate organization and rhythmicity; to decrease fatigue; and provide time for the infant to clear the bolus from the mouth or throat. This will support respiration by promoting deep breathing. Some infants require the nipple to be removed from the mouth because the nipple remaining in the mouth will continue to stimulate a sucking reflex 52. As a result, the infant will not swallow and take a breath, or will be sucking air on the empty nipple. External Pacing is done in 2 ways 52, 66, 126 If infant is capable of limited self-pacing (swallows and breathes during pauses): Gently and

slowly roll infant forward with the bottle in the mouth until the milk is out of the nipple. Allow the infant to resume effective breathing, reorganize, and cue for readiness before rolling back to fill the nipple with milk again. If infant does not open mouth spontaneously, attempt to elicit rooting reflex. Verbalize infants cues for readiness to parents.

If infant demonstrates no self-pacing: Then removal of the bottle for external pacing may be necessary. Allow the infant to suck 3-4 times on the milk filled nipple, then break suction and remove nipple from mouth and allow the infant to effectively breath, reorganize and cue for readiness. If infant does not open mouth spontaneously, attempt to elicit rooting reflex. Continue oral feeding only if infant demonstrates readiness cues. This allows the infant the choice to resume feeding. In this circumstance, the caregiver is pacing for the infant before distress cues are noted.

Gastroesophageal Reflux (GER): a return or backward flow of gastric contents into the esophagus. Milk Ejection Reflex ( MER): another term for let down or the strong release of milk generally occurring at the beginning of a feeding which may also occur several times during the feeding. Non-nutritive sucking (NNS): 24, 66, 149, 171 repetitive sucking bursts and pauses in the absence of nutrient flow; numerous sucks (approx. 6 8) can be taken before a swallow, because the infant needs to accumulate a large enough secretion bolus before a swallow is triggered; a mature NNS rate is 2 sucks per second; the premature infant pattern usually begins with single sucks with long or irregular pauses; purpose is as a state regulatory mechanism and to satisfy sucking desire. Nutritive Sucking (NS): 24, 66 occurs during active sucking for the purpose of nourishment; this pattern is complex and significantly more challenging than non-nutritive sucking; twenty-six muscles and six cranial nerves must be coordinated for the pharyngeal swallow itself, to occur safely and efficiently; sucking pressure consists of compression and suction; mature rate is one

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suck per second; Suck: Swallow Ratio is 1:1 but at the end of the feeding or with older infants may increase to 2:1(rate dependent on flow rate and size of oral cavity). Breastfeeding: - rate of sucking and suck: swallow ratio is variable and dependent on rate of milk flow Bottle feeding: - in the mature pattern, sucking bursts are longer at the beginning of the

feeding and become shorter with longer pauses over the course of the feeding; the return of bubbles into the bottle is a reflection of the liquid flow; strength of suck is reflected in the resistance to removing the nipple and the rate of flow.

Oral Feeding- nutritional intake by breastfeeding, cup feeding or bottle feeding. Suck/Swallow/Breathing Coordination (SSB): 24, 66, 76,164,169 Safe feeding requires precise coordination of processes that provide airway maintenance for breathing and airway protection during swallowing. Rhythmicity is the hallmark of normal feeding and is a reflection of smooth, split second coordination between sucking, swallowing and breathing. Immaturity or abnormality in any of these functions can have a profound effect on the other component and on the infants feeding ability. Assessment of SSB involves careful assessment of each of the components individually as well as the coordination and organization of all the components together Supplement Feeding: Feeding the infant via a mode other than the mothers chosen feeding goal-this may account for minimal amount of feed up to a complete feeding (100%). Tube Feeding: Nutritional intake by oral gastric, nasal gastric, nasal jejunal or gastrostomy tube.

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APPENDIX II. DEVELOPMENT OF PREMATURE INFANT FEEDING BEHAVIOR Breastfeeding 31, 41, 143, 168 It is important to be aware of mothers milk supply as only non nutritive sucking will be observed if supply is very low; higher milk flow requires more mature sucking patterns. Sucking bursts are related to the flow of milk.

Immature Mixed Mature Licking predominates Little rooting evident Shallow latch or

difficulty maintaining latch

Occasional short sucking bursts of ~ 3-5 sucks

Pattern of burst is ~1-5 sucks pause and breath

< 5 minutes of nutritive sucking

Some rooting evident Repeated short sucking

bursts of ~ 6-15 sucks Swallowing beginning to

be integrated into sucking burst

~ 6-10 minutes of nutritive sucking

Obvious consistent rooting Deep latch maintained Repeated long sucking

bursts of ~ 15-30 sucks Swallow audible Pattern of bursts - suck

swallow breath or suck suck swallow breath

> 11 minutes of sucking

Bottle Feeding 6, 47,50,75, 97, 100, 134, 151, 153, 159, 164

Immature Mixed Mature Predominantly

expression/compression rather than suction usually ~ 2-3/second

If suction is present it is of low amplitude

Pattern is irregular or arrhythmic

Expression/suction is not paired with swallow

< 50% of expressions/sucks are organized into bursts

90% of sucks

organized into bursts Pauses more regular

and short 10-40 sucks/burst

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Immature Feeding Patterns That May Require Intervention: 24, 66

1. Prolonged Sucking (can lead to feeding induced apnea): Baby has lengthy sucking bursts without inter-dispersing breaths at appropriate intervals. The baby has difficulty with pacing SSB. Baby often has a strong, rapid suck but may have difficulty initiating breathing even after the nipple has been removed. The infant may terminate sucking to recover during the pause. If unable to terminate sucking independently, the infant becomes apneic with oxygen desaturation, cyanosis or bradycardia.

2. Short Sucking Bursts: Infant only takes 1-3 sucks before pausing to breathe. Pattern is rhythmic but pauses are frequent and long compared to the bursts. This pattern may result in decreased intake due to respiratory compromise and/or swallowing dysfunction.

3. Disorganized Sucking: Characterized by very disorganized and uneven sucking pattern.

Duration of bursts and pauses vary considerably and there is an uncoordinated pattern of breathing and swallowing153, 165. Coughing and choking are frequent. Infants may be disorganized throughout the feeding or may begin organized and suddenly become disorganized. Causes: disorganized state and behavior, neurological deficit, respiratory problems158 or incompatible nipple flow rate.

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APPENDIX III. PARAMETERS FOR FEEDING ASSESSMENT 1. Heart Rate 6, 24, 66,173

Tachycardia: If baseline heart rate is elevated or heart rate dramatically increases and remains elevated for prolonged time. This indicates work of feeding may be excessive. Increases in 10 bpm during feeding are not uncommon. Larger increases may indicate that demands of feeding are excessive. However if an infant has a high baseline heart rate, even small increases in heart rate can indicate great physiologic stress.

Bradycardia: A drop in heart rate below 90 or 100 BPM. When observed with feeding, bradycardia is a significant and possibly life threatening event. Common causes include:

- Poor positioning during feeding - Aspiration, structural anomalies, vagally mediated laryngospasm - Prolonged sucking pattern and stretch receptors (sensory receptors) in

pharynx stimulated by large bolus - Presence of nasogastric tubes (touch-pressure receptors) or - Micro aspiration of food or by reflux (chemoreceptors)

2. Respiratory Status 24, 52, 66, 173

Respiratory rate should be evaluated at the beginning, mid and post-feeding and time required to return to baseline should be measured.

Respiratory rate is individual and depends on the infants ability to compensate for the reduction in ventilation imposed by feeding.

Increase RR leads to increase risk of incoordination of SSB and increase risk of aspiration.

For infants with respiratory compromise, a resting RR (when awake), 80 breaths/min. during pauses and prolonged recovery to baseline, indicate that work of breathing is too great and non-oral feeding is recommended until respiratory work during feeding is reduced.

Signs of respiratory distress: - Tachypnea = >60 breaths per min. Nasal flaring/blanching, - Retractions - Chin tugging, - Shallow catch breaths. - Neck extension/arching - O2 desaturation

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3. Oxygen Saturation 10, 24, 70, 66, 87, 131, 134, 173

Term and preterm infants experience slight but measurable oxygen desaturation with bottle feeding (dips with continuous sucking & return to baseline during intermittent sucking). However for compromised infants with borderline saturations, theses reductions can be significant. Sudden dips may be associated with apneic or bradycardic episodes, whereas a gradual decline may indicate inadequate respiratory support for feeding. Desaturation may be an isolated event and seen with out significant observable change e.g. no change in color. During breastfeeding, oxygen saturation levels usually remain higher and exhibit less fluctuation than during bottle feeding. 40, 70,162 Refer to Guideline: 2-P-3 Pulse Oximetry in Neonates.

4. Clinical Indications of Swallowing Dysfunction (risk for aspiration) 66 Choking during swallowing Inability to handle own oral secretions Noisy, wet upper airway sounds after individual swallows or increasing noisiness over

course of feeding Multiple Swallows to clear single bolus Apnea during swallowing History of frequent upper-respiratory infections or pneumonias

5. Aspiration can result from a primary swallowing dysfunction or from incoordination between sucking, swallowing, and breathing. Aspiration can be descending (during feeding) or ascending (during gastroesophageal reflux). 24 Sometimes aspiration occurs with fatigue towards the middle or end of a feeding and is referred to fatigue aspiration. 66, 126 Aspiration can be silent (no coughing present). It can only be confirmed with a videofluoroscopic swallow study (VFSS). 24, 126

6. Videofluoroscopic Swallowing Study (VFSS) is a radiographic study that evaluates the status and safety of the pharyngeal swallow. Barium is used to image pharyngeal structures and function. During the study, treatment techniques (altering the texture, temperature, and bolus size) are attempted to determine if swallowing can be improved. 66, 173

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CROSS REFERENCES MANUAL: 1. Booklet: Breastfeeding Your Preterm Baby 2. Book: From Here Through Maternity 3. Child Health Policy 2-G-1

SUBJECT/TITLE: On units On units Gastric Tubes: Neonates

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23. Holloway, E. (1994). Parent and occupational therapist collaboration in the neonatal intensive care unit. The American Journal of Occupational Therapy, 48(6), 535-538.

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47. Lau, C., Sheena, H. R., Shulman, R. J., & Schanler, R. J. (1997). Oral feeding in low birth weight infants. The Journal of Pediatrics, 130(4), 561-569.

48. Nyqvist, K. H., Sjoden, P. O., & Ewald, U. (1994). Mothers' advice about facilitating breastfeeding in a neonatal intensive care unit. Journal of Human Lactation, 10(4), 237-243.

49. Gonzales, I., Duryea, E. J., Vasquez, E., & Geraghty, N. (1995). Effect of enteral feeding temperature on feeding tolerance in preterm infants. Neonatal Network, 14(3), 39-43. 1A.

50. Conway, A. (1994). Instruments in neonatal research: Measuring preterm infant feeding ability, Part 1: Bottle feeding. Neonatal Network, 13(4), 71-74.

51. Wood, A. F. (1991). Factors affecting reciprocity between nurses and preterm infants during feeding. Journal of Perinatal & Neonatal Nursing, 4(4), 62-70.

52. Shaker, C. S. (1999). Nipple feeding preterm infants: An individualized, developmentally supportive approach. Neonatal Network, 18(3), 15-22.

53. Pridham, K. F., Sondel, S., Chang, A., & Green, C. (1993). Nipple feeding for preterm infants with bronchopullmonary dyplasia. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 22(2), 147-155.

54. Pickler, R. H., Frankel, H. B., Walsh, K. M., & Thompson, N. M. (1996). Effects of nonnutritive sucking on behavioral organization and feeding performance in preterm infants. Nursing Research, 45(3), 132-135.

55. Howard, C. R., deBlieck, E. A., tenHoopen, C. B., Howard, F. M., Lanphear, B. P., & Lawrence, R. A. (1999). Physiologic stability of newborns during cup- and bottle feeding. Pediatrics, 104(5), 1204-1207.

56. Mathew, O. P. (1988). Nipple units for newborn infants: A functional comparison. Pediatrics, 81(5), 688-691. 57. Daniels, H., Devlieger, H., Casaer, P., Ramaekers, V., Van Den Broeck, J., & Eggermont, E. (1988). Feeding,

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62. Ymington, A., Ballantyne, M., Pinelli, J., & Stevens, B. (1995). Indwelling versus intermittent feeding tubes in premature neonates. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(4), 321-326.

63. Shiao, S. P. (1997). Comparison of continuous versus intermittent sucking in very-low-birth-weight infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26(3), 313-319.

64. DiPietro, J. A., Cusson, R.M., OBrien Caught, M., & Fox, N.A. (1994). Behavioral and physiologic effects of nonnutritive sucking during gavage feeding in preterm infants. Pediatric Research, 36(2), 207-214.

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67. Hill, P. D., Hanson, K. S., & Mefford, A. L. (1994). Mothers of low birthweight infants: breastfeeding patterns and problems. Journal of Human Lactation, 10(3), 169-176.

68. Gill, N. E., Behnke, M., Conlon, M., & Anderson, G. C. (1992). Nonnutritive sucking modulates behavioral state for preterm infants before feeding. Scandinavian Journal of Caring Science, 6(1), 3-7.

69. Hill, A. S. (1992). Preliminary findings: A maximum oral feeding time for premature infants, the relationship to physiological indicators. Maternal-Dhild Nursing Journal, 20(2), 81-92.

70. Cagan, J. (1995). Feeding readiness behavior in preterm infants. Neonatal Network, 14(2), 82 71. Shiao, S. P., Brooker, J., & DiFiore, T. (1996). Desaturation events during oral feedings with and without a

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76. Comrie, J. D., & Helm, J. M. (1997). Common Feeding Problems in the Intensive Care Nursery: Maturation, Organization, Evaluation, and Management Strategies. Seminars in Speech and Language, 18(3), 239-261.

77. Mattes, R. D., Maone, T., Wagner-Page, S., Beauchamp, G., Bernbaum, J., Stallings, V., Pereira, G. R., Gibson, E., Russell, P., & Bhutani, V. (1996). Effects of sweet taste stimulation on growth and sucking in preterm infants. JOGNN, 25(5), 407-414.

78. Ancona, J., Shaker, C. S., Puhek, J., & Garland, J. S. (1998). Improving Outcomes Through a Developmental Approach to Nipple Feeding. Performance Improvement, Ideas & Innovations, 220-223.

79. Meyer-Palmer, M. (1998). Weaning from Gastrostomy Tube Feeding: Commentary on Oral Aversion. Pediatric Nursing, 23(5)

80. Mathew, O. P. (1991). Breathing patterns of preterm infants during bottle feeding: Role of milk flow. The Journal of Pediatrics, 119(6), 960-965.

81. Lehtonen, J., Kononen, M., Purhonen, M., Partanen, J., Saarikoski, S., & Launiala, K. (1998). The effect of nursing on the brain activity of the newborn. The Journal of Pediatrics, 132(4), 646-651.

82. Schrank, W., Al-Sayed, L. E., Beahm, P. H., & Thach, B. T. (1998). Feeding responses to free-flow formula in term and preterm infants. The Journal of Pediatrics, 132(3 Part 1), 426-430.

83. Case-Smith, J., Cooper, P., & Scala, V. (1989). Feeding Efficiency of Premature Neonates. The American Journal of Occupational Therapy, 43(4), 245-250.

84. Lemons. P.K. (2001). From gavage to oral feedings: just a matter of time. Neonatal Network, 20(3), 7-14. 85. Narayanan, I. (1990). Sucking on the emptied breast a better method of non-nutritive sucking than use of a

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33. 87. Medoff-Cooper, B. (1991). Changes in Nutritive Sucking Patterns with Increasing Gestational Age. Nursing

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Infants Requiring Assisted Mechanical Ventilation. Nursing Research, 42(5), 305-307. 89. Gill, N. E., Behnke, M., Conlon, M., McNeely, J., & Anderson, G. (1988). Effect of nonnutritive sucking on

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91. Case-Smith, J. (1988). An efficacy study of occupational therapy with high-risk neonates. American Journal of Occupational Therapy, 42(8), 499-506.

92. Goldson, E. (1987). Nonnutritive sucking in the sick infant. Journal of Perinatology, 7(1), 30-34. 93. Geggie, J. H., Dressler-Mund, D. L., Creighton, D., & Cormack-Wong, E. R. (1999). An interdisciplinary feeding

team approach for preterm, high-risk infants and children. Canadian Journal of Dietetic Practice and Research, 60(2), 72-77.

94. Siddell, E. P., & Froman, R. D. (1994). A national survey of neonatal intensive care units: Criterial used to determine readiness for oral feedings. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 23(9), 783-789.

95. Kennedy, C., & Lipsett, L. P. (1993). Temporal characteristics of non-oral feedings and chronic feeding problems in premature infants. Journal of Perinatal & Neonatal Nursing, 7(3), 77-89.

96. Freer, Y. (1999). A comparison of breast and cup feeding in perterm infants: Effects of physiologic parameters. Journal of Neonatal Nursing , 5(1), 16-21.

97. Lau, C., & Schanler, R. J. (2000). Oral feeding in premature infants: advantages of a self-paced milk flow. Acta Paediatrica, 89, 453-459.

98. Premji, S.S., & Paes, B. (2000). Gastrointestinal function and growth in premature infants: Is non-nutritive sucking vital? Journal of Perinatology, 1, 46-53.

99. Ramsay, M., & Gisel, E.G. (1996). Neonatal sucking and maternal feeding practices. Developmental Medicine and Child Neurology. 38, 34-47.

100. Lau, C., Alagugurusamy, R., Schanler, R.J., Smith, E.O., & Shulman, R.J. (2000). Characterization of the developmental stages of sucking 8n preterm infants during bottle feeding. Acta Paediatrica, 89, 846-854.

101. MacMullan, N.J., & Dulski. L.A. (2000). Factors related to sucking ability in healthy newborn. JOGNN, 29(4), 390-396.

102. Kuehl, J. (1997). Cup feeding the newborn: what you should know. The Journal of Perinatal and Neonatal Nursing , 56-60.

103. Hall, W.A., Shearer, K., & Kavanagh, R. (1996). Comparison of confidence between mothers who breastfed and formula fed their preterm infants. The Journal of Perinatal and Neonatal Nursing, 44-55.

104. Frakaloss, G., Burke, G., & Sanders, M.R. (1998). Impact of gastroesophageal reflex on growth and hospital stay in premature infants. Journal of Pediatric Gastroenterology and Nutrition, 26, 146-150.

105. Kelleher, K.J., Casey, P.H., Bradley, R.H., Pope, S.K., Whiteside, L., Barrett, K.W., Swanson, M.E., & Kirby, R.S. (1993). Risk factors and outcomes for failure to thrive in the low birth weight preterm infants. Pediatrics, 91(5), 941-948.

106. Rogers, B., Andrus, J., Msall, M., Aredson, J., Sim, J., Ross, T., Martin, D., & Hudak, M.(1998). Growth of preterm infants with cystic periventricular leukomalacia. Developmental Medicine and Child Neurology, 40, 580-586.

107. Sauve, R.S., & Geggie, J.H. (1992). Feeding problems in continuing care of preterm infants. The Canadian Journal of Pediatrics, April, 49-54.

108. Medcoff-Cooper, B. (2000). Multi-system approach to the assessment of successful feeding. Acta Paediatrica, 89, 393-398.

109. Medoff-Cooper, B., McGrath, J.M., & Bilker, W. (2000). Nutritive sucking and neurobehavioral development in preterm infants from 34 weeks PCA to term. MCN, 25(2), 64-70.

110. Hill, A.S., Kurkowski, T.B., & Garcia, J. (2000). Oral support measures used in feeding the preterm infant. Nursing Research, 49(1), 2-10.

111. Dowling, D. (1999). Physiological responses of preterm infant to breastfeeding and bottle-feeding with the orthodontic nipple. Nursing Research, 48(2), 78-85.

112. Pridham, K., Kosorok, M.R., Greer, F., Carey, P., Kayata, S., & Sondel, S. (1999). The effects of prescribed versus ad libitum feedings and formula caloric density on premature infant dietary intake and weight gain. Nursing Research, 48(2), 86-93.

113. Timms, B.J., DiFiore, J.M., Martin, R.J., & Miller, M.J. (1993). Increased respiratory drive as an inhibitor of oral feeding of preterm infants. The Journal of Pediatrics, 123(1), 127-131.

114. Adams Weaver, K., & Anderson, G.C. (1988). Relationship between integrated sucking pressures and first bottle-feeding scores in premature infants. JOGNN, 17(2), 113-120.

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115. Morris, B.H., Miller-Loncar, C.L., Landry, S.H., Smith, K.E., Swank, P.R., & Denson, S.E. (1999). Feeding, medical factors, and developmental outcome in premature infants. Clinical Pediatrics, 38(8), 451-456

116. Pinelli, J., & Symington, A. (2000). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. The Cochrane Library, 3.

117. Conde-Agudelo, A., Diaz-Rossello, J.L>, & Belizan, J.M. (2000). Kangaroo mother care to reduce morbidity and mortality in low birth weight infants. The Cochrane Library, 1.

118. McCain, G.C., Gartside, P.S., Greenberg, J.M., & Lott, J.W. (2001). A feeding protocol for healthy preterm infants that shortens time to oral feeding. The Journal of Pediatrics 139(3), 374-9.

119. Meyer, E.C., Garcia Coll, C.T., Lester, B.M., Boukydis, C.F., McDonough, S.M., & Oh, W. (1994). Family-based intervention improves maternal psychological well being and feeding interaction of preterm infants. Pediatrics, 93(2), 241-246.

120. Olivet, L.W., Law Harrison, L., Sherrod, R.A., Jeon, J. (1990). The feeding as an outcome measure in teaching parents of preterms. NCAST National News, 6(4), 1-3.

121. Singer, L.T., Davillier, M., Preuss, L., Szekely, L., Hawkins, S., Yamashita, T., & Baley, J. (1996). Feeding interactions in infants with very low birth weight and bronchopulmonary dysplasia. Developmental and Behavioral Pediatrics, 17(2), 69-76.

122. Lobo, M.L. (1992). Parent-infant interaction during feeding when the infant has congenital heart disease. Journal of Pediatric Nursing, 7(2), 97-105.

123. Farel, A.M., Reeman, V.A., Keenan, N.L., & Huber, C.J. (1991). Interaction between high-risk infants and their mothers: the NICAST as an assessment tool. Research in Nursing and Health, 14, 109-118.

124. Rochat, P., Goubet, N., & Shah, B.L. (1997). Enhanced sucking engagement by preterm infants during intermittent gavage feedings. Developmental and Behavioral Pediatrics, 18(1), 22-26.

125. Daley, H.K., & Kennedy, C.M. (2000). Meta analysis: effects of interventions on premature infants feeding. Journal of Perinatal and Neonatal Nursing, 14(3), 62-77.

126. Evans Morris, S. & Dunnklein, M. (2000). Pre-feeding Skills. Second Edition. Therapy Skill Builders. 127. Als, H., Lawhon, G., Duffy, F., McAnulty, G., Gibes-Grossman, R., & Blickman, J. (1994). Individualized

developmental care for the very low-birth-weight preterm infant. JAMA, 272(11), 853-9858. 128. Becker, P., Gruneald, P., Moorman, J., & Stuhr, S. (1991). Outcomes of developmentally supportive nursing

care for very low birth weight infants. Nursing Research, 40(3), 150-155. 129. Buehler, D.M., Als, H., Duffy, F., McAnulty, G., & Liederman, J. (1995). Effectiveness of individualized

developmental care for low-risk preterm infants: Behavioral and electrophysiologic evidence. Pediatrics, 96(5), 923-932.

130. Thorye, S. M. (2001). Challenges mothers identify in bottle-feeding their preterm infants. Neonatal Network, 20(1), 41-50.

131. Craig, C.M., Lee, D.M., Freer, Y.N., and Laing, I.A. (1999). Modulations in breathing patterns during intermittent feeding in term infants and preterm infants with brochopulmonary dysplasia. Developmental Medicine and Child Neurology, 41(9), 616-24.

132. Hill, A.S. & Rath, L. (1999). The relationship between drooling, age sucking pattern characteristics and physiologic parameters of preterm infants during bottle-feeding. Research for Nursing Practice, 1(2), 8 pages (http://www.graduatereasearch.com/hill.htm).

133. Wheeler, J., Chapman, C., Johnson, M., & Langdon, R. (2000). Feeding outcomes and influences within the neonatal unit. International Journal of Nursing Practice, 6(4), 196-206.

134. Gewolb, I.H., Vice, F.L., Schweitzer-Kenney, E.L., Taciak, V.L., & Bosma, J.F (2001). Developmental patterns of rhythmic suck and swallow in preterm infants. Developmental Medicine and Child Neurology, 43(1), 22-7.

135. Gewolb, I.H., Bosma, J.F, Taciak, V.L, & Vice, F.L. (2001). Abnormal developmental patterns of suck and swallow rhythms during feeding in preterm infants with bronchopulmonary dysplasia. Developmental Medicine and Child Neurology, 43(), 454-9.

136. Waber, B., Hubler, E.G. & Paddon, M.L. (1998). A comparison of outcomes in demand versus scheduled formula fed premature infants. Nutrition in Clinical Practice, 13(3), 132-5.

137. Cagan, J.B.Z. (1993). Feeding readiness behavior in preterm infants. Doctoral Dissertation, Rush University College of Nursing, Illinois.

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138. Shiao, S.P.K, Chang, Y., Lannon, H., & Yarandi, H. (1997). Meta-analysis of the effects of nonnutritive sucking on heart rate and peripheral oxygenation: research from the past 30 years. Issues in Comprehensive Pediatric Nursing, 20, 11-24.

139. Dowling, D.A., Meier, P.P., DiFiore, J.M., Blatz, M.A. & Martin, R.J. (2002). Cup-feeding for preterm infants: mechanics and safety. Journal of Human Lactation, 18(1), 13-20.

140. Malhotra, N., Vishwambaran, L., Sundaram, K.R., & Narayanan, I. (1999). A controlled trial of alternative methods of oral feeding in neonates. Early Human Development, 54(1), 29-38.

141. Martin, M., and Shaw, N.J. (1997). Feeding problems in infants and young children with chronic lung disease. Journal of Human Nutrition and Dietetics, 10 (5), 271-275.

142. Meier, P.P., Brown, L.P., Hurst, N.M., Spatz, D.L., Engstrom, J.L., Borucki, L.C., & Krouse, A.M. (2000). Nipple Shields for preterm infants: Effect on milk transfer and duration of breastfeeding. Journal of Human Lactation, 16(2), 106-114.

143. Nyqvist K.H.., Sjoden P., Ewald U. (1999). The development of preterm infants' breastfeeding behavior. Early Human Development, 55: 247-264.

144. Brazelton TB.(1984). Neonatal Behavioral Assessment Scale 2nd edition. Philadelphia: J.B. Lippincott Co. 145. Als H. Manual for Naturalistic Observation of Newborn Behavior: Preterm and Full term Infants. (1984). Boston

MA: The Children's Hospital. 146. McGrath, J.M & Medoff-Cooper, B. (2003). Alertness and feeding competence in extremely early born preterm

infants. Newborn and infant nursing reviews, 9(3), p. 174-186. 147. Ludwig, S.M. (2007). Oral feeding and the late preterm infant. Newborn & infant nursing reviews, 7(2), p. 72-75. 148. Pickler, R.H. (2005). A model of feeding readiness for preterm infants. Neonatal intensive care, 18(4), p. 17-22. 149. Pridham, K.F., Kosorok, M.R., Greer, F., Kayata, S., Bhattacharya, A. & Grunwald, P. (2001). Comparison of

caloric intake and weight outcomes of an ad lib feeding regime for preterm infants in two nurseries. Journal of advanced nursing, 35(5), 751-759.

150. Pridham, K.F., Schroeder, M., Brown, R. & Clark, R. (2001). The relationship of a mothers working model of feeding to her feeding behaviour. Journal of advanced nursing, 35(5), 741-750.

151. Medoff-Cooper, B., McGrath, J.M. & Shults, J. (2002). Feeding patterns of full-term and preterm infants at forty weeks postconceptual age. Journal of developmental and behavioral pediatrics, 23, 231-236.

152. McGrath, J.M. & Braescu, A.V.B. (2004). State of the science: Feeding readiness in the preterm infant. Journal of Perinatal & Neonatal Nursing, 18(4), 353-368.

153. Lau, C., Smith, E.O. & Schanler, R.J. (2003). Coordination of suck-swallow and swallow respirationg in preterm infants. Acta Pediatrica, 92, 721-727.

154. Howe, T., Sheu, C., Hinojosa, J., Lin, J. & Holzman, I.R. (2007). Multiple factors related to bottle-feeding performance in preterm infants. Nursing Research, 56(5), 307-311.

155. Thoyre, S.M. (2007). Feeding outcomes of extremely premature infants after neonatal care. JOGNN, 36, 366-376.

156. Kirk, A.T., Alder, S.C. & King, J.D. (2007), Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology, 27, 572-578.

157. Clark, L., Kennedy, G., Pring, T. & Hird, M. (2007). Improving bottle feeding in preterm infants: Investigating the elevated side-lying position. Infant, 3(4), 154-158.

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ACKNOWLEDGEMENT We wish to thank the following staff for their

dedication and contribution to the Regional Neonatal Oral Feeding Protocol:

Joanna Chan Jo Chang Donna Dressler-Mund Tanis Fenton Darlene Goodwin Sharon Harvey Heather Howarth Maureen Jobson Lucy Kim

Linda Kostecky Ruth Kovacs Karen Lasby Toni MacDonald Laurie McCormack Debbie McNeil Carolyn Miron Cathy Orton Shahirose Premji

Jennifer Reed Pattie Schumacher Jeanne Scotland Edie Scott Tammy Sherrow Ann Smith Marilynne Steward Carol Turko April von Platen

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DISCLAIMER All content in this policy and/or procedure is copyright, Calgary Health Region. All rights reserved. This information, and as amended from time to time, was created expressly for use by Calgary Health Region staff and persons acting on behalf of the Calgary Health Region for guiding actions and decisions taken on behalf of the Calgary Health Region. The Calgary Health Region accepts no responsibility for any modification and/or redistribution and is not liable in any way for any actions taken by individuals based on the information herein, or for any inaccuracies, errors, or omissions in the information in this policy and/or procedure. Any modification and/or adoption of this policy and/or procedure are done so at the risk of the adopting organization.

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