Preterm infants are at risk to develop oral feeding difficulties because of their immature cardiorespiratory function, central nervous system, and oral musculature. In addition, primary and supervising caretakers commonly approach these difficulties with differing expectations and orders for advancing feedings. We developed a set of feeding guidelines for bottle and breast feeding based on a review of the literature, and experience from RNs and occupational therapists where data was inconclusive. We hypothesized that an infant-driven, consistent, standardized approach to oral feedings would result in a shorter time to full oral feeding. We designed a prospective cohort study beginning July 1, 2004 using randomized historical controls from July 1, 2002 to June 30, 2003. All preterm infants (≤ 37 weeks gestation at birth) hospitalized in our NICU, except those transferred to another facility before achieving full oral feeding, were evaluated. Infants were started on the guidelines once they were ≥ 30 weeks post-conceptional age (PCA), were no longer requiring positive pressure respiratory assistance, and were deemed safe to initiate oral feeding. The PCA at defined feeding milestones (start of oral feeding, 2 successful oral feedings per day, 4 successful oral feedings per day, NG tube out) was recorded. The same milestone data was recorded for the historical control patients by retrospective chart review. All data used in the preliminary analysis were continuous, and were analyzed by the unpaired t-test for normally distributed data and the Mann-Whitney test for non-normal data. The results of our pilot study (n=28 study, n=23 control) showed that when the milestones were compared between groups there was a trend for the infants on the guidelines to achieve each oral feeding milestone earlier. This comparison was statistically significant at the final milestone of full oral feeding (NG tube out), which showed that the infants on the guidelines achieved full oral feeding on average 6 days earlier than controls (252 days PCA - study group vs. 258 days PCA - control group, p=0.0214). The gestational age at birth and birth weights between the groups did not significantly differ (median 221 days PCA - study vs. 213 days PCA - control, p= 0.90; mean birth weight 1685g - study vs. 1728g - control, p=0.82). These results suggest that when infant-driven feeding guidelines are used to advance oral feeding in premature infants, full oral feeding is achieved more rapidly than in historical controls. A larger study is under way to confirm these findings, to identify risk factors for delayed feeding progression using maternal and infant demographic and hospital course data, and to adjust for the effect of such factors on the utility of the guidelines.
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