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Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation

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Authors

Linda Crowe1, Anne Chang2, Karen Wallace3

Background - Methods - Results - Characteristics of Included Studies - References - Data Tables & Graphs


1Mothers' and Babies Health, Mater Medical Research Institute, South Brisbane, Australia [top]
2Mater Nursing Research Centre, Queensland Centre for Evidence-Based Nursing & Midwifery, A Collaborating Centre of the Joanna Briggs Institute, South Brisbane, Australia [top]
3Nursing Research Centre including QLD Centre for Evidence Based Nursing & Midwifery (a collaborating centre of The Joanna Briggs Institute)., Mater Health Services, Raymond Terrace, Australia [top]

Citation example: Crowe L, Chang A, Wallace K. Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD005586. DOI: 10.1002/14651858.CD005586.pub2.

Contact person

Linda Crowe

Mothers' and Babies Health
Mater Medical Research Institute
South Brisbane
Brisbane
Australia

E-mail: Linda.Crowe@mater.org.au

Dates

Assessed as Up-to-date: 12 March 2012
Date of Search: 05 March 2012
Next Stage Expected: 12 March 2014
Protocol First Published: Issue 1, 2006
Review First Published: Issue 4, 2012
Last Citation Issue: Issue 4, 2012

History

Date / Event Description
04 June 2008
Amended

Converted to new review format.

Abstract

Background

One of the most challenging milestones for preterm infants is the acquisition of safe and efficient feeding skills. The majority of healthy full term infants are born with skills to coordinate their suck, swallow and respiration. However, this is not the case for preterm infants who develop these skills gradually as they transition from tube feeding to suck feeds. For preterm infants the ability to engage in oral feeding behaviour is dependent on many factors. The complexity of factors influencing feeding readiness has led some researchers to investigate the use of an individualised assessment of an infant's abilities. A limited number of instruments that aim to indicate an individual infant's readiness to commence either breast or bottle feeding have been developed.

Objectives

To determine the effects of using a feeding readiness instrument when compared to no instrument or another instrument on the outcomes of time to establish full oral feeding and duration of hospitalisation.

Search methods

We used the standard methods of the Cochrane Neonatal Review Group, including a search of the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2), MEDLINE via EBSCO (1966 to July 2010), EMBASE (1980 to July 2010), CINAHL via EBSCO (1982 to July 2010), Web of Science via EBSCO (1980 to July 2010) and Health Source (1980 to July 2010). Other sources such as cited references from retrieved articles and databases of clinical trials were also searched. We did not apply any language restriction. We updated this search in March 2012.

Selection criteria

Randomised and quasi-randomised trials comparing a formal instrument to assess a preterm infant's readiness to commence suck feeds with either no instrument (usual practice) or another feeding readiness instrument.

Data collection and analysis

The standard methods of the Cochrane Neonatal Review Group were used. Two authors independently screened potential studies for inclusion. No studies were found that met our inclusion criteria.

Results

No studies met the inclusion criteria.

Authors' conclusions

There is currently no evidence to inform clinical practice, with no studies meeting the inclusion criteria for this review. Research is needed in this area to establish an evidence base for the clinical utility of implementing the use of an instrument to assess feeding readiness in the preterm infant population.

Plain language summary

Instruments for assessing readiness to commence suck feeds in preterm infants

Unlike babies born at term, who are able to breast or bottle feed soon after birth, preterm infants need time to learn to feed. This may take days or weeks after they are born. Preterm babies commence breast or bottle feeding at a time when the baby is deemed to be ready, as determined by healthcare professionals looking after the baby. The optimal timing of the introduction of suck feeds is unclear in both the literature and in practice. An individualised assessment specifically designed to assess an individual infant's readiness to commence breast or bottle feeding has been suggested as the best way to promote consistency in identifying when it is safe for an infant to commence suck feeding. A limited number of assessment tools to determine readiness have been developed. However, no randomised controlled studies were found that evaluated the benefit or risk of their use.

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Background

Description of the condition

One of the most challenging milestones for preterm infants is the acquisition of safe and efficient feeding skills (Hill 2002). The majority of healthy full term infants are born with skills to coordinate suck, swallow and respiration that allow safe oral feeding (Lau 2003). However, this is not the case for preterm infants who develop these skills gradually as they transition from tube feeding to suck feeds (Thoyre 2003; Dodrill 2008). This transition to full oral feeding is an important competency for the baby to attain prior to discharge home (Pickler 2003). Delays in discharge are often secondary to feeding difficulties, leading to increased financial costs (Simpson 2002). Strategies to avoid delays must be the focus of care without compromising the safety of the infant (McGrath 2004).

Introducing suck feeds as soon as the neurologic development and physical condition of the infant permits has been reported to have several advantages including shorter transition time to all suck feeds, greater maternal satisfaction and shorter hospital stay (Pridham 1993; Simpson 2002). However, feeding infants who are unable to safely commence feeding may lead to problems with respiration, growth and nutritional status, with infants being at higher risk of 1) aspiration pneumonia, 2) readmission to the neonatal intensive care unit (NICU), 3) fatigue, 4) increased energy expenditure, 5) hypoxia, 6) bradycardia and 7) deglutition apnoea (Hill 2002; Breton 2008). Therefore, careful timing is vital to ensure that the commencement of feeding is beneficial rather than detrimental to the health of the infant (McGrath 2004).

Factors influencing the preterm infant's ability to feed efficiently include neurobehavioural maturation, physiologic stability, control of tone, behavioural state organisation and coordinated sucking, swallowing and breathing (McGrath 2004). Successful coordination of feeding is also dependent on the adequate development of the structures of the upper airway including the lips, palate, jaw, tongue, pharynx, larynx and oesophagus (Hill 2002).

Differences have been shown in the ability of infants to engage in feeding behaviour at a particular gestational age through studies of preterm infant sucking (Nyqvist 1996; Lemons 2001). Although gestational age is a guide to expected maturity, disparities are evident in the rates that infants mature (Nyqvist 1999; Simpson 2002). Furthermore, a preterm infant's feeding ability may not always be consistent at each feed while infants are transitioning from gavage feeds (McGrath 2004). Differences in the sucking patterns between breast and bottle feeding have also been found and may impact significantly on the infant's ability to commence suck feeds (Thoyre 2003).

Studies examining current practices in neonatal nurseries have found that over 50% of nurseries have no specific policy or guideline on when to commence suck feeds with nurses predominantly using behavioural cues, gestation age and weight to determine readiness (Kinneer 1994; Siddell 1994).

Description of the intervention

A preliminary search revealed three instruments designed to aid neonatal care providers in determining preterm infants' readiness to commence feeding. The Preterm Infant Nipple Feeding Readiness Scale (PINFRS) was a 10-item scale that scored variables such as gestational age, post-conceptual age, colour and activity, state regulation, hunger cues and tone (McGrath 2003). However, this instrument has been renamed as the Feeding Readiness and Progression in Preterms Scale (FRAPPS) (McGrath 2008). The second instrument found, the Early Feeding Skill (EFS) assessment tool, not only aims to assess feeding readiness but also feeding skill and feeding recovery (Thoyre 2005). The feeding readiness section of the EFS consists of five items that assess an infant's readiness to commence oral feeds by observing it's tone, energy level, state of arousal and oxygen saturation (Thoyre 2005). Lastly, Fuginaga 2007 developed and tested an 18-item preterm infant oral feeding readiness instrument consisting of items in relation to corrected gestational age, behavioural state, global posture and tone, gag reflex, tongue movement and cupping, jaw movements and maintenance of an alert state. Each item was scored from 0 to 2 with a possible maximum score of 36.

All instruments were designed so that the infant being assessed for feeding readiness could pass or fail" These assessments aim to determine whether to attempt breast or bottle feeding and may easily be repeated prior to each feed while feeding is being established.

How the intervention might work

The use of a formal screening instrument that encompasses an individual infant's behaviour and development has been suggested as a way to improve the accuracy of determining when the infant is ready to commence feeding (McGrath 2003). It is thought that many premature babies may be ready to breast or bottle feed however, as this readiness is often not identified, they continue to be fed via a tube for longer than necessary. Alternatively, some babies who are slower at developing these skills may be introduced to breast or bottle feeding too soon. It is hypothesised that by identifying their readiness, neonatal care providers could ensure that infants have more successful feeding attempts and reduce the time taken to achieve all suck feeds and the possibility of adverse events. The use of a formalised instrument could also standardise measurement of feeding readiness and facilitate the documentation of feeding attempts.

Why it is important to do this review

The possible benefits of a screening instrument to assess feeding readiness must be weighed against the additional staff time required and other costs and possible detrimental effects such as introducing oral feeds when infants are not ready or withholding oral feeding. This review addresses the balance of benefits and risks of screening instruments for commencement of suck feeds in preterm infants in order to assist in establishing an evidence base for clinical decision-making.

Objectives

The primary objectives

  1. To assess the effects of using a formal feeding readiness assessment instrument when compared to no formal instrument in preterm infants deemed ready to commence feeds based on general clinical grounds using the outcomes of time to establish full oral feedings and duration of hospitalisation.
  2. To assess the effects of different formal feeding readiness assessment instruments in preterm infants deemed ready to commence feeds based on general clinical grounds using the outcomes of time to establish full oral feedings and duration of hospitalisation.

The secondary objective of this review is to explore possible differential effects of applying a formal feeding readiness assessment instrument according to the following subgroups.

  1. Gestational age (GA) at birth:
    • extremely preterm (< 28 weeks),
    • moderately preterm (28 to 31 weeks),
    • mildly preterm (32 to 37 weeks)
  2. Chosen method of feeding:
    • breast or bottle feeding.

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Methods

Criteria for considering studies for this review

Types of studies

Randomised, quasi-randomised controlled trials (including cluster trials) in which an instrument is compared with either no assessment instrument or an alternate instrument. Cross-over trials were excluded.

Types of participants

Studies which enrolled preterm infants (< 37 weeks gestation) after being deemed ready to commence either breast or bottle feeds based on general clinical grounds. Exclusion criteria included congenital malformations, syndromes or severe neurological problems.

Types of interventions

  1. The experimental group involved infants who had been deemed ready on general clinical grounds and who were then assessed for readiness to commence oral feeding through the use of an instrument prior to the initiation of the first breast or bottle feed. The instrument had to include assessment of one or more of the following:
    1. motor development and abilities including posture, movement, tone, reflexes;
    2. behaviour state and cues including state of arousal and presence of feeding behaviour cues;
    3. physiological parameters;
    4. integrity of oral structures.
  2. The control group involved infants who were not assessed by any formal instrument as feeding was commenced once readiness was determined on general clinical grounds.
  3. A comparison group involved infants who had been deemed ready on general clinical grounds and who were then assessed for readiness to feed by an alternate feeding assessment instrument.

General clinical grounds was defined as a clinical impression, which may have included gestational age, medical stability or infant cues, but excluded the use of a formal assessment instrument. Instruments must have undergone psychometric evaluation including tests for criterion-related or construct validity. In groups where an instrument was used, infants had to pass prior to commencement of feeding. Physiological parameters included heart rate, respiration rate and oxygen saturation levels. Other physiological parameters used by individual trials were acceptable provided they were defined in the trial protocol.

Types of outcome measures

Primary outcomes
  1. Time from randomisation to full oral feeding (days).
  2. Duration of hospitalisation (days from randomisation until the end of the trial).
Secondary outcomes
  1. Time from randomisation to introduction of first feed (days).
  2. Age (post-conception age and days from birth) at establishment of full oral feeding.
  3. Daily weight gain (g/day or g/kg/day) from time of randomisation until the end of the trial.
  4. Breast feeding (partial or full) on hospital discharge (number of infants).
  5. Time from randomisation to regaining birth weight (days).
  6. Parental satisfaction (validated assessment tool).
  7. Number of apnoea or bradycardia episodes that required intervention from the caregiver (stimulation, oronasal suction, increase in delivery of oxygen, assisted ventilation).

Search methods for identification of studies

The standard search methods of the Cochrane Neonatal Review Group External Web Site Policy were used.

Electronic searches

This included electronic searches of the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2010), MEDLINE via EBSCO (1966 to July 2010), EMBASE (1980 to July 2010), CINAHL via EBSCO (1982 to July 2010), Web of Science via EBSCO (1980 to July 2010) and Health Source (1980 to July 2010). The search strategy for each database is described in the appendices below. We did not apply any language restriction. We updated this search in March 2012.

Searching other resources

The meta-register of clinical trials (http://www.controlled-trials.com/mrct/active.html?noReg=true External Web Site Policy) and the US National Institutes of Health registry of clinical trials (http://clinicaltrials.gov/ External Web Site Policy) websites were searched for completed or ongoing trials. The authors also searched cited references from the retrieved articles. We contacted a number of researchers who had either previously published an article on the topic of feeding readiness or were known to have completed preliminary psychometric testing of an instrument measuring feeding readiness in order to identify any other studies that might meet the inclusion criteria.

Data collection and analysis

The standard methods of the Cochrane Neonatal Review Group External Web Site Policy were used.

Selection of studies

Two authors (LC, KW or AC) independently screened the title and abstract of all studies identified by the above search strategy. Articles identified as potentially relevant based on the title and abstract were retrieved in a full text format and were then reassessed for selection. Those studies that did not fulfil the inclusion criteria were excluded. The authors resolved any disagreements by discussion.

Data extraction and management

If eligible studies were found, two authors would have independently extracted and entered the data into tables using Revman 5 software.

Assessment of risk of bias in included studies

If eligible studies were found, it was planned that these studies would be evaluated independently by two review authors (LC, KW and AC) for methodological quality in accord with the methods of the Cochrane Neonatal Review Group.

Studies were to be assessed with regard to blinding of the randomisation, intervention and outcome as well as completion of follow-up. The results of this assessment would be added to the table 'Characteristics of Included Studies'. It was also planned that consideration would be given to the following methodological issues.

  1. Sequence generation: was the allocation sequence adequately generated?
  2. Allocation concealment: was the allocation adequately concealed?
  3. Blinding of participants, personnel and outcome assessors: was knowledge of the allocated intervention adequately prevented during the study? At study entry? At the time of outcome assessment?
  4. Incomplete outcome data: were incomplete outcome data adequately addressed?
  5. Selective outcome reporting: Were reports of the study free of suggestion of selective outcome reporting?
  6. Other sources of bias: was the study apparently free of other problems that could put it at a high risk of bias?

This data was to be reported in the 'Risk of bias' table.

For consistency, one review author (LC) was to act as the primary reviewer for all studies to be assessed and the secondary reviewer was to be one of the members of the review panel (AC or KW). It was planned that any differences between the review authors would be resolved either by discussion or by consensus after negotiation with the third review author (KW or AC).

Measures of treatment effect

Weighted mean difference (WMD) would have been calculated for continuous data and relative risk (RR) or risk difference (RD) for dichotomous data. For each treatment effect we planned to calculate a 95% confidence interval (CI).

Assessment of heterogeneity

If there were studies to synthesise in a meta-analysis, heterogeneity would have been assessed through the visual inspection of forest plots as well as by calculating the degree of heterogeneity statistically using the I2statistic. If statistical heterogeneity was found, the review authors would have searched for an explanation (inter-study variations, intra-study variations, methodological error, publication bias and control effect) and would have either removed the heterogeneous study or not conducted the meta-analysis depending on the explanation for and the degree of heterogeneity. An I2 statistic above 40% would have been considered moderate heterogeneity and a value over 75% considered as high.

Data synthesis

We planned to use the standard methods of the Neonatal Review Group to synthesise the data. If there were eligible studies to conduct a meta-analysis, weighted mean difference with a 95% confidence interval would be used for the continuous variables and relative risk and risk difference with 95% confidence interval for categorical variables. Number needed to treat (NNT) and number needed to harm (NNH) also would have been calculated if appropriate. To conduct the meta-analysis, it was planned to use a fixed-effect model. If any cluster trials were included in the review these studies would have been analysed separately from non-cluster trials using the inverse variance (IV) method, in consultation with the Cochrane Neonatal Review Group statistician. Data analysis was to be undertaken by using RevMan 5 software. If there were studies not suitable for meta-analysis then results of these studies would have been summarised either in narrative form or in tables. Instruments were to be analysed using separate comparisons according to the type of instrument.

Subgroup analysis and investigation of heterogeneity

Subgroup analysis was planned for the following subgroups, if data were available: gestational age at birth (extremely preterm < 28 weeks; moderately preterm 28 to 31 weeks; and mildly preterm 32 to 37 weeks) and chosen method of feeding (breast or bottle feeding). Post hoc subgroup analysis would be performed to detect the heterogeneous trials.

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Results

Description of studies

See: Characterstics of excluded studies.

Although the initial search found 955 publications, the number to be reviewed was reduced to 716 once duplicates were removed. Two review authors reviewed the titles and abstracts of all 716 publications. Only 44 articles were retrieved in the full text format for further consideration. However, no studies were found that met the inclusion criteria for this review.

With the 44 excluded articles, nine articles were found not to be research but a review of the literature. These nine articles were retrieved in the full text format to search the reference lists to ensure no studies were missed during the electronic searching of databases. Topics of the literature review articles included initiation of and transition to suck feeds (Lemons 1996; Ross 2002; Thoyre 2003; McGrath 2004; Frischknecht 2005; Fernández 2007; Lau 2007; Breton 2008) as well as the diagnostic tools used to determine feeding readiness (da Costa 2008).

A number of methods were found to assist staff in determining feeding readiness in the preterm infant population including a theoretical model (Pickler 2005), clinical guidelines (Premji 2000; Premji 2002; McCain 2003), protocols (McCain 2001; Premji 2004; Shaker 2007; Drenckpohl 2009), a clinical pathway (Kirk 2007) and scales or instruments (McGrath 2003; Thoyre 2005; Fuginaga 2007; Ludwig 2007).

Although there were two randomised trials (McCain 2001; McCain 2002) that evaluated the clinical utility of the implementation of a feeding protocol found in the search, these studies did not compare assessment of feeding readiness with no assessment but rather compared no non-nutritive sucking with the use of 10 minutes of non-nutritive sucking prior to assessing behavioural state as an indicator of feeding readiness. There were also two studies (Kirk 2007; Drenckpohl 2009) that used historical controls to evaluate their implementation into practice. Other articles related to methods to determine feeding initiation or transition were either a description of the method (Premji 2002; Premji 2004; McCain 2003; Pickler 2005; Thoyre 2005; Ludwig 2007; Shaker 2007) or psychometric testing of an instrument (McGrath 2003; Fuginaga 2007; Fujinaga 2007a; Neiva 2008; Rossarolla 2009). Psychometric testing of the instruments did not involve an experimental design but rather other non-experimental designs such as observational studies and expert panels.

A further three observational studies were found that described the psychometric testing of instruments that either did not measure or indirectly measured the construct of feeding readiness. The Dynamic-Early Feeding Scale (D-EFS) is an observational coding scheme to continuously code videotaped oral feeding (Thoyre 2009). This instrument should not be confused with another instrument developed by the authors, the Early Feeding Skills (EFS) (Thoyre 2005), which is described in the background of this review and contains a checklist of five questions to determine feeding readiness. The other two observational studies used an existing instrument, the Neonatal Oral Motor Assessment Scale (NOMAS) that measures infants' nutritive sucking behaviours. These studies investigated the NOMAS psychometric characteristics within a healthy preterm population (Howe 2007) and as an indicator of feeding readiness (Church 2006).

Other studies were found that contributed to the knowledge of feeding readiness and progression but did not involve assessment of feeding readiness. Staff surveys were used to document how staff decide to commence breast or bottle feeding (Kinneer 1994; Siddell 1994) as well as manage the transition period from tube feeding to all breast or bottle feeds (Dodrill 2008a). Current management of feeding initiation and progression has also been investigated using chart audits (Flint 2007; Dodrill 2008). Observational studies were utilised to explore factors that may relate to feeding readiness (Cagan 1995; McGrath 2002; Bühler 2004; McGrath 2005; Pickler 2005a; Bauer 2008) as well as interventions that may enhance preterm infants' ability to engage in feeding behaviour (White-Traut 2002; White-Traut 2005). The effects of feeding experience, maturity and morbidity on feeding milestones (Pickler 2009) as well sucking patterns (Cunha 2009) were also studied.

Risk of bias in included studies

No studies met the inclusion criteria.

Effects of interventions

No studies met the inclusion criteria.

Discussion

The absence of randomised or quasi-randomised studies evaluating the use of a formalised instrument to assess a preterm infant's readiness has resulted in this systematic review being unable to determine the effects of using such an instrument on the time to establish full oral feeding or duration of hospitalisation.

The excluded studies of this review show that there is an interest among researchers in how to best approach the dilemma of when to commence breast or bottle feeds. This review focused on validated instruments but there were a number of other methods found (for example care pathways, protocols, clinical guidelines) that could potentially aide clinicians in managing suck feeding initiation and progression. There were a few studies that demonstrated that the application of a feeding protocol may improve outcomes including the time taken to all suck feeds (McCain 2001; Kirk 2007; Drenckpohl 2009) and length of hospital stay (McCain 2001). The benefit of using a formalised instrument over other methods such as clinical judgement or a criterion such as gestational age is that an instrument ensures that a systematic and consistent method of assessing feeding readiness is utilised.

There were a number of instruments that specifically assessed feeding readiness, however the clinical utility of these instruments was not investigated in an experimental study. The studies were observational with their focus on establishing the validity and reliability of the tool (McGrath 2003; Fuginaga 2007; Fujinaga 2007a; Neiva 2008; Rossarolla 2009). The lack of any experimental studies to establish the clinical utility of the instruments may simply be that they are too newly developed to have undergone such testing. The absence of randomised or quasi-randomised trials may also be a reflection of the practical difficulties in ensuring that the comparison group is not exposed to the intervention, particularly in the situation where the use of an instrument is compared to normal clinical practice with direct caregivers collecting data.

Authors' conclusions

Implications for practice

There is no evidence to inform clinical practice with no studies meeting the inclusion criteria for this review.

Implications for research

Randomised or quasi-randomised trials are needed to evaluate the clinical utility of using an instrument to assess feeding readiness in the preterm infant population. Researchers need to also consider the use of a feeding readiness instrument in the preterm infant breastfeeding population as the majority of observational studies investigating feeding readiness and progression are predominately focused on bottle feeding.

Acknowledgements

We would like to thank Katie Welsh for assisting in formatting the protocol and Vicki Flenady for methodological advice and editorial input in regards to the development of the protocol. We would like to thank Kelly Dann for her assistance in formulating the search strategy as well as the expert panel who provided preliminary guidance on the topic selection: C Bagley, M Burris, P Dodrill, M Robken, C Lai, J Trotter and E Wilkes.

Contributions of authors

Linda Crowe (LC) was the primary reviewer and author, with the help of Karen Wallace (KW) and Anne Chang who both acted as secondary reviewers and aided in the discussion and editorial process.

Declarations of interest

Linda Crowe is undertaking preliminary testing of an instrument for commencement of breast feeds for use with preterm infants.

Differences between protocol and review

References were added to the background where appropriate, including the addition of a reference related to a tool developed by Fujingaga as well as a reference to the name change of the Preterm Infant Nipple Feeding Readiness tool.

The search strategy was also altered. The databases Oxford Database of Perinatal Trials and Pre-CINAHL were not searched. The original search terms in the protocol were also changed to fit with each database. See Appendices 1 to 7 (Appendix 1; Appendix 2; Appendix 3; Appendix 4; Appendix 5; Appendix 6; Appendix 7) for full details of the search strategy used for each database.

Changes to the wording of the text were made in the methods section of the review. A more comprehensive description of the assessment of risk of bias has been provided in the review. References to RevMan 4.2 software have been replaced by RevMan 5.

Additional tables

  • None noted.

Potential conflict of interest

  • None noted.

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Characteristics of studies

Characteristics of Included Studies

No included studies

Characteristics of excluded studies

Bauer 2008

Reason for exclusion

Does not compare methods to determine feeding readiness. This was an observational study involving clinical observation and assessment of feeding readiness and performance of preterm infants during the transition period from gavage to bottle feeding.

Breton 2008

Reason for exclusion

Literature review of introduction and transition to oral feedings.

Bühler 2004

Reason for exclusion

Does not compare methods of determining feeding readiness. An observational study examining factors that impact on commencement and transition to full oral feeding.

Cagan 1995

Reason for exclusion

Does not compare methods of determining feeding readiness. This study is an observational study examining behavioural state and feeding behaviours as indicators of feeding readiness.

Church 2006

Reason for exclusion

Does not compare methods of determining feeding readiness. This observational study examines the inter-rater reliability.

Cunha 2009

Reason for exclusion

Does not compare methods of determining feeding readiness. This study describes and compares the sucking patterns of very low birth weight preterm and full term infants.

da Costa 2008

Reason for exclusion

Literature review of diagnostic tools to determine feeding readiness and feeding performance.

Dodrill 2008

Reason for exclusion

Does not compare methods of determining feeding readiness.This study involves a retrospective chart audit examining early feeding milestones.

Dodrill 2008a

Reason for exclusion

Does not compare methods of determining feeding readiness. This study involves a survey of staff to investigate and document current transitional feeding practices.

Drenckpohl 2009

Reason for exclusion

Not a randomised or quasi-randomised study. This study uses a historical control to evaluate the implementation of a feeding protocol to initiate and advance feeds. Initiation is commenced at 30 weeks but no assessment is made.

Fernández 2007

Reason for exclusion

Not research but an article that discusses feeding readiness and the transition to suck feeds.

Flint 2007

Reason for exclusion

Does not compare methods of determining feeding readiness. This study involves an observational, retrospective cohort study design in which feeding milestones were examined.

Frischknecht 2005

Reason for exclusion

Not a study but an article that describes feeding readiness in preterm infants.

Fuginaga 2007

Reason for exclusion

Does not compare methods of determining feeding readiness. This is a descriptive, observational study.

Fujinaga 2007a

Reason for exclusion

Does not compare methods of determining feeding readiness.This is an observational study to test for inter-rater reliability.

Howe 2007

Reason for exclusion

Does not compare methods of determining feeding readiness. This is an observational study design to assess the validity and reliability of the Neonatal Oral Motor Assessment Scale.

Kinneer 1994

Reason for exclusion

Does not compare methods of determining feeding readiness. This study involved a survey of neonatal nurseries to find out how clinicians determine feeding readiness.

Kirk 2007

Reason for exclusion

Not a randomised or quasi-randomised study. This study compares a historical control with a study group. No psychometric testing reported.

Lau 2007

Reason for exclusion

Not primary research but a discussion article on feeding initiation and progression.

Lemons 1996

Reason for exclusion

Not research but an article discussing transition to breast or bottle feeds.

Ludwig 2007

Reason for exclusion

Not research but an article that describes a feeding readiness scale developed by authors as part of their change in feeding documentation.

McCain 2001

Reason for exclusion

This study does not evaluate the use of a feeding readiness indicator independently as the intervention incorporates a period of non-nutritive sucking. The effectiveness of assessing feeding readiness alone on the primary outcomes can not be established for this study.

McCain 2002

Reason for exclusion

This study does not evaluate the use of a feeding readiness indicator independently as the intervention incorporates a period of non-nutritive sucking. The effectiveness of assessing feeding readiness alone on the primary outcomes can not be established for this study.

McCain 2003

Reason for exclusion

Not a study but an article that describes an evidence-based guideline for the introduction oral feeding.

McGrath 2002

Reason for exclusion

Does not compare methods of determining feeding readiness. This is an observational study that looks at the association between alertness and ability to engage in nutritive sucking.

McGrath 2003

Reason for exclusion

Does not compare methods of determining feeding readiness. This study describes the content validity as well as an observational, pilot study of a feeding readiness scale.

McGrath 2004

Reason for exclusion

Not research but an article discussing feeding readiness in preterm infants.

McGrath 2005

Reason for exclusion

Does not compare methods of determining feeding readiness. This observational study explores factors associated with feeding readiness.

Neiva 2008

Reason for exclusion

Does not compare methods of determining feeding readiness. This study established content validity of non-nutritive sucking scoring system as well as reporting the use of the tool within an observational study.

Pickler 2005

Reason for exclusion

Not research. This article describes a theoretical model for feeding readiness in preterm infants.

Pickler 2005a

Reason for exclusion

Does not compare methods of determining feeding readiness and is part of a larger study. This study investigates the relationship between feeding readiness indicators and feeding performance.

Pickler 2009

Reason for exclusion

Does not compare methods of determining feeding readiness. Does not measure feeding readiness. This study examines the effects of feeding experience, maturity and morbidity on clinical milestones.

Premji 2000

Reason for exclusion

Does not compare methods of assessing feeding readiness but investigates the safety and efficacy of implementing a clinical practice guideline for nutritional management compared to no guideline.

Premji 2002

Reason for exclusion

Not research but describes the development of a clinical practice guideline for feeding very low birth weigh infants.

Premji 2004

Reason for exclusion

Not research but describes the background and implementation of an oral feeding protocol.

Ross 2002

Reason for exclusion

Not research but an article describing the transition from gavage feeds to suck feeds in preterm infants.

Rossarolla 2009

Reason for exclusion

Does not compare methods of determining feeding readiness. This observational study established discriminant validity of the feeding readiness tool developed by Fujinaga.

Shaker 2007

Reason for exclusion

Not research but an article that describes a new feeding protocol.

Siddell 1994

Reason for exclusion

Does not compare methods of determining feeding readiness. This study involved a survey of neonatal nurseries to find out criteria used to determine feeding readiness.

Thoyre 2003

Reason for exclusion

Not research but an article that discusses the transition from gavage to suck feeds.

Thoyre 2005

Reason for exclusion

Not research but an article that describes the Early Feeding Skills Assessment checklist.

Thoyre 2009

Reason for exclusion

Does not compare methods of determining feeding readiness. This observational study looks at the validity and reliability of the Dynamics of Early Infant Feeding instrument.

White-Traut 2002

Reason for exclusion

Not testing an assessment instrument. The study tested the effects of an auditory, tactile, visual and vestibular (ATVV) intervention on feeding readiness and performance.

White-Traut 2005

Reason for exclusion

Secondary analysis to examine the relationship between behavioural state and the frequency of feeding readiness behaviours.

Characteristics of studies awaiting classification

  • None noted.

Characteristics of ongoing studies

  • None noted.

Additional tables

  • None noted.

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References to studies

Included studies

  • None noted.

Excluded studies

Bauer 2008

Bauer MA, Prade LS, Keske-Soares M, Haeffner LSB, Weinmann ARM. The oral motor capacity and feeding performance of preterm newborns at the time of transition to oral feeding. Brazilian Journal of Medical and Biological Research 2008;41(10):904-7.

Breton 2008

Breton S, Steinwender S. Timing introduction and transition to oral feeding in preterm infants: current trends and practice. Newborn and Infant Nursing Reviews 2008;8(3):153-9.

Bühler 2004

Bühler KEB, Limongi SCO. [Factors associated to oral feeding transition in preterm infants] [Fatores associados à transição da alimentação via oral em recém-nascidos pré-termo]. Pró-Fono: Revista De Atualização Científica 2004;16(3):301-10.

Cagan 1995

Cagan J. Feeding readiness behavior in preterm infants. Neonatal Network 1995;14(2):82.

Church 2006

Church PT, Keller C, Gilbert J, McCourt M, McAvoy I, Perrin E, et al. Serial Neonatal Oral Motor Assessment Scale as a measure of feeding readiness. In: Developmental Medicine and Child Neurology. Vol. 48. Boston, 2006:39.

Cunha 2009

Cunha M, Barreiros J, Gonçalves I, Figueiredo H. Nutritive sucking pattern--from very low birth weight preterm to term newborn. Early Human Development 2009;85(2):125-30.

da Costa 2008

da Costa SP, Bos AF. Sucking and swallowing in infants and diagnostic tools. Journal of Perinatology 2008;28(4):247-57.

Dodrill 2008

Dodrill P, Donovan T, Cleghorn G, McMahon S, Davies PSW. Attainment of early feeding milestones in preterm neonates. Journal of Perinatology 2008;28(8):549-55.

Dodrill 2008a

Dodrill P, McMahon S, Donovan T, Cleghorn G. Current management of transitional feeding issues in preterm neonates born in Queensland, Australia. Early Human Development 2008;84(10):637-43.

Drenckpohl 2009

Drenckpohl D, Dudas R, Justice S, McConnell C, Macwan KS. Outcomes from an oral feeding protocol implemented in the NICU. Infant, Child & Adolescent Nutrition 2009;1(1):6.

Fernández 2007

Fernández Díaz P, Rosales Valdebenito M. International connections. The transition from tube to nipple in the premature newborn. Newborn and Infant Nursing Reviews 2007;7(2):114-9.

Flint 2007

Flint A, Davies MW, Collie L, Palmer-Field K. Progression from gastric tube feeds to full suckle feeds and discharge home of preterm infants. Australian Journal of Advanced Nursing 2007;25(1):44-8.

Frischknecht 2005

* Frischknecht K. [Developmentally determined readiness for drinking] [Entwicklungsbedingte Bereitschaft zum Trinken]. Kinderkrankenschwester 2005;24(10):427-30.

Fuginaga 2007

Published data only (unpublished sought but not used)

Fuginaga CI, Rodarte Milena Domingos de Oliveira, Amorim NEZ, Gonçalves TC, Scochi CGS. An assessment of premature baby readiness for oral feeding: a descriptive study [Aplicação de um instrumento de avaliação da prontidão do prematuro para início da alimentação oral: estudo descritivo]. Revista Salus 2007;1(2):129-37.

Fujinaga 2007a

Fujinaga CI, Zamberlan NE, Rodarte Milena Domingos de Oliveira, Scochi CGS. [Reliability of an instrument to assess the readiness of preterm infants for oral feeding]. Pró-Fono: Revista De Atualização Científica 2007;19(2):143-50.

Howe 2007

Howe TH, Sheu CF, Hsieh YW, Hsieh CL. Psychometric characteristics of the Neonatal Oral-Motor Assessment Scale in healthy preterm infants. Developmental Medicine and Child Neurology 2007;49(12):915-9.

Kinneer 1994

Kinneer MD, Beachy P. Nipple feeding premature infants in the neonatal intensive-care unit: factors and decisions. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1994;23(2):105-12.

Kirk 2007

Kirk AT, Alder SC, King JD. Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology 2007;27(9):572-8.

Lau 2007

Lau C. Development of oral feeding skills in the preterm infant. [French] [Développement de l'oralité chez le nouveau-né prématuré]. Archives de Pediatrie 2007;14(Suppl 1):35-41.

Lemons 1996

Lemons PK, Lemons JA. Transition to breast/bottle feedings: the premature infant. Journal of the American College of Nutrition 1996;15(2):126-35.

Ludwig 2007

Published data only (unpublished sought but not used)

Ludwig SM, Waitzman KA. Changing feeding documentation to reflect infant-driven feeding practice. Newborn and Infant Nursing Reviews 2007;7(3):155-60.

McCain 2001

McCain GC, Gartside PS, Greenberg JM, Wright Lott J. A feeding protocol for health preterm infants that shortens time to oral feeding. Journal of Pediatrics 2001;139(3):374-9.

McCain 2002

McCain GC, Gartside PS. Behavioural responses of preterm infants to a standard-care and semi-demand feeding protocol. Newborn and Infant Nursing Reviews 2002;2(3):187-93.

McCain 2003

McCain GC. An evidence-based guideline for introducing oral feeding to healthy preterm infants. Neonatal Network 2003;22(5):45-50.

McGrath 2002

McGrath JM, Medoff-Cooper B. Alertness and feeding competence in extremely early born preterm infants. Newborn and Infant Nursing Reviews 2002;2(3):174-86.

McGrath 2003

Published data only (unpublished sought but not used)

McGrath JM. Pilot-testing of the Preterm Infant Nipple Feeding Readiness Scale (PINFRS). Proceedings of the Communicating Nursing Research Conference and WIN Assembly, "Responding to Societal Imperatives Through Discovery and Innovation", held April 10-12, 2003, Scottsdale, Arizona. In: Communicating Nursing Research. Vol. 36. 2003:289.

McGrath 2004

McGrath JM, Braescu AV. State of the science: feeding readiness in the preterm infant. Journal of Perinatal and Neonatal Nursing 2004;18(4):353-68.

McGrath 2005

McGrath J. Factors related to feeding readiness in early born preterm infants. In: 16th International Nursing Research Congress 14-16th July 2005. Hawaii: Sigma Theta Tau International, 2005:1p.

Neiva 2008

Neiva FCB, Leone C, Leone CR. Non-nutritive sucking scoring system for preterm newborns. Acta Paediatrica 2008;97(10):1370-5.

Pickler 2005

Published data only (unpublished sought but not used)

Pickler RH. A model of feeding readiness for preterm infants. Neonatal Intensive Care 2005;18(4):17-22.

Pickler 2005a

Pickler RH, Best AM, Reyna BA, Wetzel PA, Gutcher GR. Prediction of feeding performance in preterm infants. Newborn and Infant Nursing Reviews 2005;5(3):116-23.

Pickler 2009

Pickler RH, Best A, Crosson D. The effect of feeding experience on clinical outcomes in preterm infants. Journal of Perinatology 2009;29(2):124-9.

Premji 2000

Premji SSJ. Feeding practice guidelines for premature infants less than 1500 grams: efficacy and safety. PhD, McMaster University (Canada) 2000;254 p.

Premji 2002

Premji SS, Paes B, Jacobson K, Chessell L. Evidence-based feeding guidelines for very low-birth-weight infants. Advances in Neonatal Care 2002;2(1):5-18.

Premji 2004

Premji SS, McNeil DA, Scotland J. Regional neonatal oral feeding protocol: changing the ethos of feeding preterm infants. Journal of Perinatal and Neonatal Nursing 2004;18(4):371-84.

Ross 2002

Ross ES, Browne JV. Developmental progression of feeding skills: an approach to supporting feeding in preterm infants. Seminars In Neonatology 2002;7(6):469-75.

Rossarolla 2009

Rossarolla C, Menon MU, Scochi CGS, Fujinaga CI. Discriminatory validity of an instrument for evaluating preterm newborns' readiness for oral feeding [Validade discriminatória do instrumento de avaliação da prontidão para início da alimentação oral de bebês prematuros]. Revista da Sociedade Brasileira de Fonoaudiologia 2009;14:106-14.

Shaker 2007

Shaker CS, Woida AMW. An evidence-based approach to nipple feeding in a Level III NICU: nurse autonomy, developmental care, and teamwork. Neonatal Network 2007;26(2):77-83.

Siddell 1994

Siddell EP, Froman RD. A national survey of neonatal intensive-care units: criteria used to determine readiness for oral feedings. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1994;23(9):783-9.

Thoyre 2003

Thoyre SM. Developmental transition from gavage to oral feeding in the preterm infant. Annual Review of Nursing Research 2003;21:61-92.

Thoyre 2005

Published data only (unpublished sought but not used)

Thoyre SM, Shaker CS, Pridham KF. The early feeding skills assessment for preterm infants. Neonatal Network 2005;24(3):7-16.

Thoyre 2009

Thoyre S. Dynamic Early Feeding Skills: An observational system for coding the dynamics of early infant feeding. In: Advances in Neonatal Care. Vol. 9. Scottsdale, Arizona: 4th Annual NANN Research Summit, 2009:188-9.

White-Traut 2002

White-Traut RC, Nelson MN, Silvestri JM, Vasan U, Patel M, Cardenas L. Feeding readiness behaviours and feeding efficiency in response to ATVV intervention.. auditory, tactile, visual and vestibular. Newborn and Infant Nursing Reviews 2002;2(3):166-73.

White-Traut 2005

White-Traut RC, Berbaum ML, Lessen B, McFarlin B, Cardenas L. Feeding readiness in preterm infants: the relationship between preterm behavioral state and feeding readiness behaviors and efficiency during transition from gavage to oral feeding. The American Journal of Maternal Chld Health Nursing 2005;30(1):52-9.

Studies awaiting classification

  • None noted.

Ongoing studies

  • None noted.

Other references

Additional references

Fuginaga 2007a

Fuginaga CI, Rodarte Milena Domingos de Oliveira, Amorim NEZ, Gonçalves TC, Scochi CGS. An assessment of premature baby readiness for oral feeding: a descriptive study [Aplicação de um instrumento de avaliação da prontidão do prematuro para início da alimentação oral: estudo descritivo]. Revista Salus 2007;1(2):129-37.

Hill 2002

Hill AS. Toward a theory of feeding efficiency for bottle-fed preterm infants. Journal of Theory Construction & Testing 2002;6:75-81.

Lau 2003

Lau C, Smith EO, Schanler RJ. Coordination of suck-swallow and swallow respiration in preterm infants. Acta Paediatrica 2003;92(6):721-7. [MEDLINE: preterm, sucking and breathing coordination]

Lemons 2001

Lemons PK. From gavage to oral feedings: just a matter of time. Neonatal Network 2001;20(3):7-14. [MEDLINE: Preterm sucking]

McGrath 2008

McGrath, JM. Testing preterm infant's readiness to feed. Email 10th July 2008.

Nyqvist 1996

Nyqvist KH, Rubertsson C, Ewald U, Sjoden P-O. Development of the Preterm Infant Breastfeeding Scale (PIBBS): a study of nurse-mother agreement. Journal of Human Lactation 1996;12(3):207-19.

Nyqvist 1999

Nygvist KH, Sjoden P-O, Ewald U. The development of preterm infants' breastfeeding behavior. Early Human Development 1999;55(3):247-64.

Pickler 2003

Pickler RH, Reyna BA. A descriptive study of bottle-feeding opportunities in preterm infants. Advances in Neonatal Care 2003;3(3):139-46.

Pridham 1993

Pridham KF, Sondel S, Chang A, Green C. Nipple feeding for preterm infants with bronchopulmonary dysplasia. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1993;22(2):147-55.

Simpson 2002

Simpson C, Schanler RJ, Lau C. Early introduction of oral feeding in preterm infants. Pediatrics 2002;110(3):517-22.

Other published versions of this review

  • None noted.

Classification pending references

  • None noted.

[top]

Data and analyses

  • None noted.

Figures

  • None noted.

Sources of support

Internal sources

  • Qld Centre for Evidence Based Nursing and Midwifery Practice, Australia
  • Nursing Research Centre, Mater Health Services, South Brisbane, Queensland, Australia
  • Mater Research Support Centre, Mater Health Services, Australia

External sources

  • Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA
  • Editorial support of the Cochrane Neonatal Review Group has been funded with Federal funds from the Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA, under Contract No. HHSN275201100016C.

Feedback

  • None noted.

Appendices

1 CENTRAL search strategy

There were 92 results.

Each keyword was searched for in Title, Abstract or Keywords. There were 92 results for: (preterm or premature) and (feeding or breast or bottle) and (read* or commence or introduc* or start* or establish*).

2 MEDLINE search strategy

There was 367 results.

  1. S1 preterm or pre-term or premature or low birth weight or lowbirth weight or LBW
  2. S2 newborn* or new born* or baby or babies or neonat* or infant*
  3. S3 S1 and S2
  4. S4 (MH "Infant, Premature")
  5. S5 S3 or S4
  6. S6 commenc* or start* or begin* or readiness or Introduc*
  7. S7 breast fe* or breastfe* or bottle fe* or bottlefe* or nipple fe* or oral fe*
  8. S8 (MH "Bottle Feeding") or (MH "Breast Feeding") or (MH "Feeding Methods")
  9. S9 (MH "Feeding Behavior") or (MH "Sucking Behavior") or feeding behaviour or feeding behavior or sucking behaviour or sucking behavior
  10. S10 S7 or S8 or S9
  11. S11 S5 and S6 and S10

3 EMBASE search strategy

72 results

(neonat* OR infant * or newborn OR baby OR babies) AND (preterm OR pre-term OR premature) AND (bottle fe* OR breast fe* OR nipple fe* OR oral fe*) AND (commenc* OR readiness OR begin* OR introduc*)

4 CINAHL search strategy

There was 161 results.

  1. S1 preterm or pre-term or premature or low birth weight or lowbirth weight or LBW
  2. S2 newborn* or new born* or baby or babies or neonat* or infant*
  3. S3 S1 and S2
  4. S4 (MH "Infant, Premature")
  5. S5 S3 or S4
  6. S6 commenc* or start* or begin* or readiness or Introduc*
  7. S7 breast fe* or breastfe* or bottle fe* or bottlefe* or nipple fe* or oral fe*
  8. S8 (MH "Bottle Feeding") or (MH "Breast Feeding") or (MH "Infant Feeding")
  9. S9 sucking behaviour or sucking behavior or (MH Sucking Behavior") or feeding behavior or feeding behaviour
  10. S10 S7 or S8 or S9
  11. S11 S5 and S6 and S10

5 Health Source search strategy

Results 66

  1. S1 preterm or pre-term or premature
  2. S2 newborn* or new born* or baby or babies or neonat* or infant*
  3. S3 S1 and S2
  4. S4 breast fe* or breastfe* or bottle fe* or bottlefe* or nipple fe* or oral fe*
  5. S5 commenc* or start* or begin* or readiness or Introduc*
  6. S6 S3 and S4 and S5

6 Web of Science search strategy

150 results

Topic=(preterm or premature) AND Topic=(infant* or baby or babies or neonat* or newborn) AND Topic=(breastfe* or bottlefe* or nipplefe* or oral feeding) AND Topic=(commenc* or start* or readiness or introd* or establish*)Timespan=All Years. Databases=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH.

7 Cochrane search strategy

There were 22 results.

Each keyword was searched for in Title, Abstract or Keywords. There were 22 results for: (preterm or premature) and (feeding or breast or bottle) and (read* or commence or introduc* or start* or establish*).


This review is published as a Cochrane review in The Cochrane Library, Issue 4, 2012 (see http://www.thecochranelibrary.com External Web Site Policy for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback. The Cochrane Library should be consulted for the most recent version of the review.