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Indian Pediatr 2016;53:
36-38 |
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Oromotor Stimulation
for Transition from Gavage to Full Oral Feeding in Preterm
Neonates: A Randomized controlled trial
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Poonam Bala, Rupinder Kaur, *Kanya Mukhopadhyay and
Sukhwinder Kaur
From National Institute of Nursing Education and
*Neonatal unit, Department of Pediatrics, PGIMER, Chandigarh, India.
Correspondence to: Dr Kanya Mukhopadhyay, Professor,
Neonatology Unit, Department of Pediatrics,
PGIMER, Chandigarh 160 012, India.
Email: [email protected]
Received: March 11, 2015;
Initial review: April 30, 2015;
Accepted: October 13, 2015.
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Objective: To assess the effect of additional
oromotor stimulation along with routine care on transition from gavage
to full oral feeding in preterm neonates.
Method: 51 neonates (28-34 weeks) randomized to
receive either oromotor stimulation along with routine care (n=25,
intervention), or routine care alone (n=26, control) (which
included Kangaroo mother care and non-nutritive sucking).
Results: Median (IQR) days to reach partial and
full spoon feed were significantly lesser [5(3-9.5) vs 10(5-15)
P=0.006; and 7(5-14.5) vs 12.5(7-21); P=0.03] in
intervention than in control group, respectively. A significantly higher
number (56%) in intervention group as compared to control group (31%)
achieved partial direct breast feeding at discharge (P=0.01).
Conclusion: Oromotor stimulation along with
routine care reduces the duration of gavage feeding in preterm neonates.
Keywords: Kangaroo mother care, Non-nutritive sucking,
Oromotor stimulation..
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In preterm neonates, optimal breast feeding is
limited due to several reasons e.g, illnesses, gut immaturity and
inadequate suck, swallow and breathing coordination due to poor oromotor
skills [1]. Many research studies show [2,3] that sensorimotor inter-ventions
are used to improve oral feeding in preterm babies which provide direct,
targeted input to the oral structures involved in feeding. Recent
studies [2,4,5] suggest that oromotor stimulation (OMS) programme (peri-
and intra-oral stimulation, with or without non-nutritive sucking)
applied to preterm infants during gavage feeding can improve sucking
abilities and reduces transition period from gavage to full oral
feeding, and improves the sucking pattern [6,7]. OMS and non-nutritive
sucking (NNS) also increase the probability of more preterm babies being
breastfed at discharge [8]. In the present study, we tested the
hypothesis that OMS in addition to NNS and Kangaroo mother care (KMC)
will be more effective in reaching early oral feeding and direct breast
feeding when compared with NNS alone.
Methods
This was a randomized controlled pilot study
conducted in a level III neonatal unit over four months. The study was
approved by the Institute’s research ethics committee. Inborn babies
between 28-34 weeks of gestation born consecutively, and admitted to
neonatal unit who were hemodynamically stable, reached full gavage
feeding and in transition from gavage to spoon feeds, receiving
non-nutritive sucking and KMC as routine care were eligible for the
study. Babies having respiratory distress, on continuous positive airway
pressure /Ventilator and having congenital malformations were excluded.
Eligible babies were randomized by using computer
generated random numbers after obtaining written informed consent from
parents and received either OMS along with routine care in the
intervention group or routine Care alone (NNS and KMC) in the control
group. Concealment of allocation was achieved by creating sequentially
numbered sealed opaque envelopes that were opened by the principal
investigator (not blinded) to assign intervention group.
Mother was trained by principal investigator how to
do OMS several times till she was confident. OMS was practiced by mother
five times a day before each feed, till discharge or till full direct
breast feed was achieved. Hand hygiene was taught to mother extensively.
OMS consisted of five steps, i.e., stroking cheeks, lips, jaw and
tongue, and rubbing gums [2]. During the study period, mother was
observed daily at least once per day during OMS. Control group was given
only NNS and KMC. NNS was performed before each feed and KMC was
practiced for 3-4 hours per day in both the groups.
Baseline demographic characteristics and previous
morbidities were recorded at enrolment. Assessment of feeding was done
initially at enrolment and then every fifth day till discharge or full
breast feed during hospital stay. Time taken to reach partial/full spoon
feed, and partial/full breast feed were recorded. Partial spoon feed was
defined as accepting nearly 50% of the total volume of milk by spoon and
50% by orogastric tube during each feed, and 1-2 full spoon feeds in a
day. Partial breast feed was defined as when baby was accepting full
breast feed for 5-6 times a day and rest of the feeds by spoon. Feeding
efficacy was assessed by volume of total spoon feed intake (ml/kg/feed)
and spoon feed intake rate per minute (mL/minute).
The primary outcome was to compare transition time
from full gavage feed to partial and full spoon feed. Secondary outcomes
were to assess total volume of milk by spoon at each feed and time
required to complete full spoon feed and partial direct breast feed at
discharge.
A sample size of convenience of 51 was planned due to
time constraints. Independent t test or Mann-Whitney U test and
chi square and Fisher’s exact test were used. A P value <0.05 was
considered significant.
Results
The base line characteristics and morbidities of the
two groups were similar (Table I). The median transition
time (d) to reach partial spoon feed and full spoon feed were
significantly less in intervention group as compared to control group (Table
II). A significantly (P<0.01) higher number of babies in
intervention group were discharged on partial direct breast feed and
spoon feed as compared to control group. No significant inter-group
difference was seen in other outcome variables like sucking pattern,
number of jaw movements/min and swallowing movements/min. The mean spoon
feed intake (mL/kg/per feed) and spoon feed ingestion rate (mL/min) were
higher at each assessment in intervention (12-16 mL/kg and 0.9-1.4 mL/min)
as compared to control group (10-12 mL/kg and 0.8-1 mL/min), though
statistically not significant. No harms or unintended effects like
desaturation, aspiration, apnea, hypothermia, bradycardia, or infection
were observed.
TABLE I Baseline Characteristics and Morbidities of the Study Population
Variables, mean (SD) |
Intervention (n=25)
|
Control (n=26) |
Gestational age (wk) |
30.9 (1.7) |
30.3 (1.5) |
Birth weight (g) |
1285 (283) |
1212 (323) |
Age at enrolment (d), median (IQR) |
11 (8.5-14.5) |
11.5 (8-17) |
Post conceptional age at enrolment (wk)
|
32.7 (1.6) |
32.4 (1.3) |
Weight at enrolment (g) |
1242 (250) |
1215 (277) |
Oro-gastric feed started, d (of life) |
2.7 (2.3) |
2.4 (1.6) |
Full oro-gastric feed achieved, d (of life) |
9.2 (3.6) |
10.8 (6.2) |
Male, n (%)
|
10 (40) |
16 (61)
|
Sepsis, n (%)
|
18 (72) |
15 (60) |
Culture-positive, n (%)
|
6 (24) |
10 (38) |
Hyaline membrane disease, n (%)
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13 (52)
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15 (58) |
Ventilation, n (%) |
15 (60)
|
16 (61) |
Noninvasive ventilation, n (%) |
11 (73) |
15 (94)
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TABLE II Transition Time From Gavage Feeding and Feeding Mode at Discharge
|
Transition time (d), Median (IQR) |
Feeding method |
Intervention, n=25
|
Control, n=26 |
P value |
Partial spoon feed
|
5(3-9.5) |
10(5-15) |
0.006 |
Full spoon feed
|
7(5-14.5) |
12.5(7-21) |
0.03 |
Partial breast feed
|
13(7-25) |
10(6-15) |
0.32 |
Feeding mode at discharge, n (%) |
Partial breast/spoon feed
|
14(56) |
8(31) |
0.01 |
Only spoon feed |
10(40) |
18(69) |
0.03 |
Discussion
This randomized controlled trial showed that when
additional OMS is combined with routine existing practices of KMC and
NNS, it further improves feeding abilities in preterm babies.
Spoon-feeding was achieved earlier in the intervention group as well as
significantly higher number of babies were on partial breast feed at
discharge.
A limitation of the study was small sample size due
to time constraints. Intervention and assessment could not be blinded
due to its nature. Though the mother was trained to do OMS, all the
sessions could not be monitored. The effect of intervention on attaining
full breast feed also could not be elicited as we discharged babies
early due to infrastructure constraints. A large multicentric study with
a longer follow up is required to confirm the effects found in this
pilot study.
Non-nutritive sucking alone positively benefits the
feeding pattern of neonates by achieving earlier oral feeds and shorter
hospital stay [9]. The statistically non-significant improvement in
volume and time for spoon feeding could be due to the fact that our
control group was also receiving NNS which also improves oral feeding
performance. Oro-motor stimulation program increases the overall daily
milk intake and milk transfer rate in addition to early transition from
gavage to spoon feed and also improve sucking pattern of preterm babies
[10]. Pre-feeding oral stimulation group attains independent oral
feeding faster and has consistently greater overall intake and rate of
milk transfer when compared with only sham-stimulation group [11]. When
non-nutritive sucking is added to oral stimulation it contributes to the
improvement of breastfeeding rates among preterm infants [8]. All these
findings were quite similar to our observations.
This study shows that it can be practiced in all
stable preterm neonates even in moderate preterm with positive effects.
Contributors: PB: helped in study design,
collected and analysed the data and drafted the manuscript; RK:
supervised data collection and reviewed the manuscript; KM:
conceptualized and designed the study, helped in data analysis and
critically reviewed the manuscript; SK: cross checked the data and
helped in review of literature. All authors approved the manuscript.
Funding: None; Competing interests: None
stated.
What This Study Adds
• Oromotor stimulation in addition to
non-nutritive sucking and Kangaroo mother care is more effective
in reducing transition time from gavage to oral feeding as
compared to these two interventions alone among stable preterms
of around 30 weeks gestational age.
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