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O desafio do conhecimento: pesquisa qualitativa em saúde

Background
Non-nutritive sucking (NNS) is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants to improve the development of sucking behavior and the digestion of enteral feedings.

Objectives
To assess the effects of non-nutritive sucking on physiologic stability and nutrition in preterm infants.

Search methods
We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016), and CINAHL (1982 to 25 February 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials.

Selection criteria
Randomised controlled trials and quasi-randomised trials that compared non-nutritive sucking versus no provision of non-nutritive sucking in preterm infants. We excluded cross-over trials.

Data collection and analysis
Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported mean differences (MD) for continuous data, with 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses. We did not perform subgroup analyses because of the small number of studies related to the relevant outcomes. We used the GRADE approach to assess the quality of evidence.

Main results
We identified 12 eligible trials enrolling a total of 746 preterm infants. Meta-analysis, though limited by data quality, demonstrated a significant effect of NNS on transition from gavage to full oral feeding (MD −5.51 days, 95% CI −8.20 to −2.82; N = 87), transition from start of oral feeding to full oral feeding (MD −2.15 days, 95% CI −3.12 to −1.17; N = 100), and the length of hospital stay (MD −4.59 days, 95% CI −8.07 to −1.11; N = 501). Meta-analysis revealed no significant effect of NNS on weight gain. One study found that the NNS group had a significantly shorter intestinal transit time during gavage feeding compared to the control group (MD −10.50 h, 95% CI −13.74 to −7.26; N = 30). Other individual studies demonstrated no clear positive effect of NNS on age of infant at full oral feeds, days from birth to full breastfeeding, rates and proportion of infants fully breastfeeding at discharge, episodes of bradycardia, or episodes of oxygen desaturation. None of the studies reported any negative outcomes. These trials were generally small and contained various methodological weaknesses including lack of blinding of intervention and outcome assessors and variability on outcome measures. The quality of the evidence on outcomes assessed according to GRADE was low to very low.

Authors' conclusions
Meta-analysis demonstrated a significant effect of NNS on the transition from gavage to full oral feeding, transition from start of oral feeding to full oral feeding, and length of hospital stay. None of the trials reported any adverse effects. Well-designed, adequately powered studies using reliable methods of randomisation, concealment of treatment allocation and blinding of the intervention and outcome assessors are needed. In order to facilitate meta-analysis of these data, future research should involve outcome measures consistent with those used in previous studies.

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Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants.

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 hospitalisations.

Search methods
We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 22 February 2016), EMBASE (1980 to 22 February 2016), and CINAHL (1982 to 22 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

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 Cochrane Neonatal were used. Two authors independently screened potential studies for inclusion. No studies were found that met our inclusion criteria.

Main 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.

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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

Since the 19th century, devices termed incubators were developed to maintain thermal stability in low birth weight (LBW) and sick newborns, thus improving their chances of survival. Remarkable progress has been made in the production of infant incubators, which are currently highly technological devices. However, they still need to be improved in many aspects. Regarding the temperature and humidity control, future incubators should minimize heat loss from the neonate and eddies around him/her. An unresolved issue is exposure to high noise levels in the Neonatal Intensive Care Unit (NICU). Strategies aimed at modifying the behavior of NICU personnel, along with structural improvements in incubator design, are required to reduce noise exposure. Light environment should be taken into consideration in designing new models of incubators. In fact, ambient NICU illumination may cause visual pathway sequelae or possibly retinopathy of prematurity (ROP), while premature exposure to continuous lighting may adversely affect the rest-activity patterns of the newborn. Accordingly, both the use of incubator covers and circadian lighting in the NICU might attenuate these effects. The impact of electromagnetic fields (EMFs) on infant health is still unclear. However, future incubators should be designed to minimize the EMF exposure of the newborn.

The infant incubator in the neonatal intensive care unit: unresolved issues and future developments

BACKGROUND: non-nutritive sucking stimulation may anticipate the beginning of oral feeding and may influence the development of sucking in pre-term newborns. AIM: to describe the development of the sucking pattern and the effects of NNS. METHOD: participants of this study were 95 preterm newborns (PTNB), adequate for their gestational age (GA), born with GAs inferior or equal to 33 weeks, randomly distributed in three groups: Group 1 (G1) - control group - did not undergo NNS stimulation; Group 2 (G2) underwent NNS stimulation with orthodontic pacifier for premature infants; Group 3 (G3), underwent NNS stimulation with a gloved finger. All three groups of newborns underwent weekly NNS evaluations with a gloved finger and, after the beginning of the oral feeding (OF) they underwent NNS and nutritive sucking (NS) evaluations using a baby's mini milk bottle. RESULTS: In all three groups, except for the stress signs in NNS and coordination between sucking- swallowing-breathing in NS, as the corrected gestational age (GA at birth plus postnatal age) increased, the occurrence probability of all studied sucking characteristics (NNS and NS) rose. In the NNS: sucking began easily (SBE) with no differences between the groups regarding rhythm, strength and coordination between lips, tongue and jaw; there was a higher probability of labial sealing, of tongue central groove formation and of tongue peristaltic movements in G3; stress signs were higher in G2 (>37 weeks). In the NS: SBE, coordination between lips, tongue and jaw, volume of ingested milk per total time did not show differences between the groups; rhythm and coordination between sucking, swallowing and breathing were higher in G3, labial sealing was higher in G1 and G3 ( 33 weeks). CONCLUSION: the sucking pattern of PTNB developed due to the corrected gestational age, observing that NNS stimulation increased the occurrence probability of labial sealing, rhythm, tongue central groove formation, tongue peristaltic movements and coordination between sucking, swallowing and breathing. The gloved finger was the most effective instrument for NNS stimulation.

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Sucking in preterm newborns and the sucking stimulation

Uncontrolled experimental study. Aim: quantify the impact noise of the 23 incubators functioning in the intensive and intermediate care units of a public university hospital in Ribeirao Preto-SP. Methodology: measuring occurred during incubator manipulation in a careful and in a rough way, considering the impact noise generated by the various situations in which the incubator was manipulated. Results: In practically all manipulation situations in both the careful and the rough way, group B presented higher NPS, followed by group A and D. Group C demonstrated the lowest NPS during the different manipulation situations. Even careful manipulation generated a strong noise level, and NPS almost always doubled or tripled when the same situation was realized roughly. Careful manipulation, together with lower incubator use time, revealed to be effective in reducing the noise produced during equipment manipulation.

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O ruído gerado durante a manipulação das incubadoras: implicações para o cuidado de enfermagem

Estudo bibliografico sobre succao nao-nutritiva em bebes prematuros. Objetivos: caracterizar e analisar a producao cientifica sobre succao nao-nutritiva em bebes prematuros e identificar como se processa a transicao da alimentacao gastrica para a oral, considerando a estimulacao da succao nao-nutritiva, seu inicio e evolucao. Metodologia: revisao de fonte secundaria (MEDLINE e LILACS). Resultado: condicao clinica estavel dos bebes pre-termo, sem alteracoes cardiorespiratorias, neurologicas e gastrointestinais. A idade gestacional variou de 30 a 35 semanas, e o peso, de 1400 a 1800g. O estimulo utilizado para succao nao-nutritiva foi chupeta ou bico de mamadeira, havendo variacao quanto ao tempo e frequencia de aplicacao do estimulo. Como impacto dos programas de estimulacao, houve alta hospitalar precoce e maior ganho de peso. Os autores ressaltam a escassa literatura sobre o assunto, principalmente a nacional, registrando que os artigos encontrados nao descrevem, detalhadamente, a transicao da alimentacao gastrica para oral, deixando uma lacuna que exige estudos posteriores.

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Sucção não nutritiva em bebês prematuros: estudo bibliográfico

OBJETIVOS: elaborar e validar o conteudo e a aparencia de um instrumento de avaliacao da prontidao do prematuro em iniciar a transicao da alimentacao gastrica para via oral. METODOS: para validacao do conteudo do instrumento e seu respectivo guia instrucional, estabeleceu-se um percentual minimo de concordância de 85% entre os "juizes ", fonoaudiologos com experiencia na area de neonatologia. RESULTADOS: obteve-se concordância acima de 85% nos itens avaliados. O instrumento e guia instrucional validados ficaram constituidos dos seguintes itens: idade corrigida, estado de organizacao comportamental (estado de consciencia, postura e tonus global), postura oral (labios e lingua), reflexos orais (procura, succao, mordida e vomito) e succao nao-nutritiva (movimentacao e canolamento de lingua, movimentacao da mandibula, forca de succao, succoes por pausa, manutencao do ritmo de succao por pausa e do estado alerta e sinais de estresse). CONCLUSOES: o instrumento e guia instrucional objetivam e sistematizam a avaliacao do bebe prematuro iniciar a transicao da alimentacao gastrica para via oral. Para o uso em unidades neonatais, ha necessidade de sua validacao clinica.

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Validação do conteúdo de um instrumento para avaliação da prontidão do prematuro para início da alimentação oral

BACKGROND: the transition from gastric to oral feeding of preterm infants is one of the greatest concerns of health professionals and therefore needs an objective criterion to support the beginning of this process. AIM: to test the reliability of an instrument that assesses the readiness of preterm infants for the transition from gastric to oral feeding. METHOD: the instrument is composed by the following items: corrected gestational age; behavioral state; global posture and tonus; lips and tongue posture; rooting, suck, bite and gag reflexes; tongue and jaw movements; tongue cupping; sucking strain; sucking and pause; maintenance sucking/pause; maintenance alert state and stress signs. The study was conducted at the Intermediate Care Unit of the Hospital de Clinicas da Faculdade de Medicina de Ribeirao Preto - University of Sao Paulo. The research sample consisted of 30 preterm infants who attended the following inclusion criteria: corrected gestational age <36 weeks and 6 days; clinically stable; absence of facial deformities; respiratory, cardiovascular, gastrointestinal and neurological disorders or syndromes that prevent or make oral feeding difficult; and not having received oral feeding of milk. The Kappa Test was used to verify interjudge reliability. RESULTS: the items that presented high reliability levels were: behavioral state, global posture and tonus, lips and tongue posture, gag reflex and maintenance of alert state. The items that presented satisfactory reliability levels were: rooting reflex, sucking and biting and jaw movement, sucking strain and sucking and pause. Only the items of tongue cupping, maintenance of sucking/pause and stress signs presented unsatisfactory reliability levels. CONCLUSION: in general, the items investigated by the assessment instrument presented adequate interjudge reliability.

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Reliability of an instrument to assess the readiness of preterm infants for oral feeding

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Cristina Ide Fujinaga

Papers

O ruído gerado durante a manipulação das incubadoras: implicações para o cuidado de enfermagem

Sucção não nutritiva em bebês prematuros: estudo bibliográfico

Validação do conteúdo de um instrumento para avaliação da prontidão do prematuro para início da alimentação oral

Reliability of an instrument to assess the readiness of preterm infants for oral feeding

Succión no-nutritiva en bebes prematuros: un estudio bibliográfico