INTERVENTIONS FOR THE ENHANCEMENT OF ORAL FEEDING IN PRETERM INFANTS

这个子项目是许多研究子项目中利用 资源由NIH/NCRR资助的中心拨款提供。子项目和 调查员(PI)可能从NIH的另一个来源获得了主要资金， 并因此可以在其他清晰的条目中表示。列出的机构是 该中心不一定是调查人员的机构。 目的：评价以下两种干预措施对早产儿30周内达到独立喂养的时间的影响： 1.吞咽运动的功效 2.俯卧位在口腔喂养中的效果 众所周知，早产儿很难从试管喂养过渡到口服喂养(奶瓶/母乳)，特别是那些出生于妊娠30周的早产儿(6)。这种困难经常导致住院时间延长，母婴团聚延迟，医疗费用增加。口腔喂养不良可能是由于口腔运动技能不成熟，吞咽紊乱或延迟，和/或吮吸、吞咽和呼吸不协调造成的。如果这些婴儿要安全喂养，即没有吸入物，并成功地完成所有的口服喂养，并有足够的每日体重增加，则后者是必不可少的。目前尚不清楚这种协调是在何时以及如何发展起来的。不协调的临床症状通常包括氧气饱和度降低，进食过程中出现呼吸暂停和心动过缓，和/或咳嗽/窒息。 我们最近开发了一种乳头装置，可以同时监测吸吮、吞咽和呼吸(3-6)。通过这个工具，我们对婴儿吸吮的发展有了一个了解，并建立了一个评估婴儿吸吮技能水平的5阶段量表(4)。从我们的研究中，我们注意到，非营养性吸吮，例如在奶嘴上，在营养性吸吮之前成熟。与营养吸吮相比，非营养性吸吮时吞咽的次数最少，我们推测吸吮技巧在吸吮、吞咽和呼吸协调之前就成熟了。 早产儿吞咽过程的成熟还不是很清楚。由杂乱无章和吞咽延迟引起的口腔喂养困难通常通过视频透视来诊断。对早产儿肺成熟的了解在过去十年中取得了显着进展，早产儿存活率的增加反映了这一点。然而，呼吸系统对口腔喂养过程中吞咽事件引起的气流定期中断的适应性尚不清楚。婴儿主要是腹式呼吸，这是由于胸腔执行器不成熟，限制了上胸的活动(1)。当吞咽频率增加时，这种限制会在多大程度上损害口腔喂养期间的吞咽呼吸过程，这一点尚不确定。 奶瓶喂养时，婴儿通常保持相对仰卧的姿势，类似于他们在母乳喂养时所用的姿势。然而，有口腔解剖异常的婴儿，如皮埃尔·罗宾综合征，或有脑膜膨出等情况的婴儿，以俯卧姿势喂养是有益的。总的来说，这种方法促进了它们在口服喂养过程中的呼吸(8)。当俯卧喂养用于患病的早产儿和足月儿时，也观察到了类似的好处(7)。 鉴于早产儿和早产儿妊娠30周，在他们长期住院期间，得到的最小刺激适合于他们不成熟的解剖结构和生理功能的发展，我们假设可以开发干预措施来弥补这种空白。由于吸吮、吞咽和/或呼吸可能导致口腔喂养困难，本方案将评估两种旨在改善吞咽和口腔喂养过程中吞咽-呼吸相互作用的干预措施。根据我们的议定书H#7469/GCRC#523，正在对改善吸吮的干预措施进行调查。

This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. To evaluate the effect of the following 2 interventions on time to attainment of independent oral feeding in preterm infants born < 30 weeks gestation: 1. Efficacy of a swallowing exercise 2. Efficacy of the prone position during oral feeding It is well recognized that preterm infants have difficulty transitioning from tube to oral feeding (bottle/breast), particularly those born < 30 weeks gestation (6). Such difficulty frequently leads to prolonged hospitalization, delayed mother-infant reunion and increased medical cost. Poor oral feeding may result from immature oral-motor skills, disorganized or delayed swallowing, and/or in-coordination of sucking, swallowing, and respiration. The latter is essential if these infants are to feed safely, i.e., with no aspiration, and successfully, i.e., capable of finishing all their feedings by mouth with adequate daily weight gain. There is no understanding of when and how such coordination develops. Clinical signs of in-coordination typically include oxygen desaturation, episodes of apnea and bradycardia during feeding, and/or coughing/choking. We have recently developed a nipple device that allows for the simultaneous monitoring of sucking, swallowing, and breathing (3-6). With this tool, we have gained an understanding of the development of sucking in infants and established a 5-stage scale that assesses the level of infant sucking skills (4). From our studies, we have noted that non-nutritive sucking, e.g., on a pacifier, matures before nutritive sucking (3). Insofar as swallowing is minimal during non-nutritive as compared to nutritive sucking, we speculate that sucking skills mature before sucking, swallowing, and breathing are coordinated. The maturation of the swallowing process in preterm infants is not well understood. Oral feeding difficulties resulting from disorganized and delayed swallow usually are diagnosed by videofluoroscopy. Knowledge of pulmonary maturation in preterm infants has progressed significantly over the last decade as reflected by the increased survival of the preterm population. However, the adaptability of the respiratory system to regular interruption of airflow resulting from swallowing events during oral feeding is unclear. Infants are primarily abdominal breathers as a result of the immaturity of the rib cage effectors that restrict the mobility of the upper chest (1). It is uncertain to what extent such limitation may impair the swallow-breathe process during oral feeding when swallowing frequency is increased as it is the case during oral feeding. When bottle feeding, infants are held usually in a relatively supine position similar to that used when they are breastfeeding. However, infants with anatomical oral anomalies, e.g., Pierre Robin syndrome, or conditions such as meningocele have benefited from being fed in a prone position. In general, this approach has facilitated their respiration during oral feeding (8). Similar benefits have been observed when prone feeding was used for sick preterm and full term infants (7). Given that preterm infants <30 weeks gestation, during their prolonged hospitalization, receive minimal stimulation appropriate for the development of their immature anatomical structures and physiological functions, we hypothesize that interventions can be developed to compensate for such void. Inasmuch as oral feeding difficulty can arise from sucking, swallowing, and/or respiration, the present protocol will evaluate 2 interventions aimed at ameliorating swallowing, and the interaction of swallow-breathe during oral feeding. Interventions to improve sucking are being investigated under our protocol H# 7469/GCRC #523.