Situation: Feeding Problems in Infancy
Feeding problems are a frequent complication for infants in the neonatal intensive care unit (NICU), with an estimated 80% of infants experiencing feeding difficulties during their NICU stay. Inadequate oral feeding (by volume) is one of the most common reasons for prolonged NICU stays. Feeding problems are common reasons for hospital readmission in the moderate and late preterm population. In a large multicenter retrospective study of premature infants born before 33 weeks gestation, less than 4% were discharged from NICU with feeding tubes (nasogastric or gastrostomy) for severe feeding problems. However, in the pediatric setting, a meta-analysis found that 42% of premature infants born before 37 weeks had ongoing feeding problems before four years of age. The 10x difference in the prevalence of feeding problems in NICU and pediatric settings implies that infants either have inadequate feeding skills at discharge or develop them later at home. The disparity in the literature begs the question of whether clinicians are adequately assessing feeding skill development in the NICU setting.
In severe cases, feeding problems in childhood cause immense stress to the child and family at mealtime. Pediatric Feeding Disorder (PFD) is defined as impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skills, and/or psychosocial dysfunction. While a skill-based approach to treating PFD is essential in the pediatric world, skill-based information is not fully appreciated in the NICU.
Background: Skill Based Feeding
Feeding management is central to the baby's physiological balance, growth, behavioral display of pleasure, and a nurturing relationship with the parent. The acquisition of safe and efficient nipple-feeding skills is a complex task and one of the most challenging milestones for most preterm or high-risk infants to achieve. Premature infants are at higher risk of feeding problems compared to term infants due to 1. Innate differences in muscle tone, state regulation, endurance, and suck-swallow-breathing coordination; 2. Disruption of in utero brain development due to decreased myelination and white matter disturbances, and 3. They have higher nutritional requirements per kilogram body weight than term infants and are less tolerant of high fluid volumes. Similarly, full-term infants with complex conditions and syndromes may have altered anatomy, physiology and neurodevelopment, which impact oral feeding.
Cue-based feeding (CBF) is considered best practice as infants transition to independent oral feeding skills. Cue-based feeding is a method that combines the use of non-nutritive sucking (NNS) to promote awake behavior for feeding, the use of behavioral assessment to identify readiness for feeding, and systematic observation of and response to infant behavior cues to regulate frequency, duration, and volume of oral feedings. CBF has been shown to have several benefits, such as earlier transition to oral feedings, reduced length of stay, improved physiological maturity, improved nutritional intake, and reduced stress on the family.
A wide range of infant feeding skill assessment tools exist; however, no gold-standard tool has been identified in the literature due to inadequate psychometric tests and feasibility. The study team developed an infant oral feeding skill assessment tool called the SMART Tool, which provides a numerical score before and after feed. The SMART tool evaluates feeding skills across five domains: State of arousal, motor tone, autonomic instability, response to stimulation, and total oral skills. These domains form the acronym of SMART Tool. The Synactive Theory of Development provided the theoretical basis for the SMART tool's design and also aligns with trauma-informed care principles, neonatal integrative developmental care model, life course health development intervention, and infant-family-centered developmental care. The post-feed SMART Tool score classifies the infant feeding skills into three categories: caution (25 to 60), developing (60 to 90), and capable (91 to 100). The SMART tool was designed to meet the needs of NICU clinicians, providing an objective measure of the safety and quality of feedings that can replace the traditional volume-driven approach. The SMART Tool was prospectively tested in four Level III Neonatal Intensive care units (NICU) in the Advocate Health system and shown to be valid and reliable for infant feeding skill assessment. This tool has been integrated into daily clinical usage at 15 NICUs within Advocate Health.
Analysis:
No neonatal feeding skill assessment at Discharge Historically, there has been a focus on the quantity (volume) of oral intake versus the quality (skill). The American Academy of Pediatrics requires "oral feeding sufficient to support appropriate growth" for infants as part of its criterion for hospital discharge. (American Academy of Pediatrics Committee on \& Newborn, 2008) This criterion perpetuates the focus on volume rather than skill for infant feeding in the NICU.
Clinicians' most significant assumption is that if an infant can complete oral feedings by volume, the infant is developmentally mature and has adequate feeding skills. No universal policy measures the infant's oral feeding skill level at discharge. The study team believes this is essential information for parents and pediatricians to know about infants' feeding skills, like hearing tests or heart screening. The study team believes that every neonatal discharge summary from the NICU should communicate the infant's feeding skill level to outpatient pediatricians so that they can monitor it closely. Doing so provides continuity of care about the safety and quality of feeds.
Plan: Evaluate skills at discharge
In this pilot retrospective study, the study team intends to evaluate the legitimacy of the assumption that if an infant can complete oral feedings by volume, the infant demonstrates mature, capable feeding skills. SMART Tool qualifies the oral feeding skill level as "caution," "developing," and "capable." If the assumption is valid, all infants with full oral feeds at discharge should be in the "capable" category. The first aim is to check if any infants were in the "caution" or "developing" categories at discharge. The second aim is to describe the distribution of feeding skills levels at discharge.
This study's most powerful impact is dispelling the assumption that "full oral feeds" are the same as "full skill development." This will be pilot data to enable us to do a prospective multicenter study to recheck this assumption on a larger dataset and categorize the feeding level in different situations.
In the future, this study can help us with two big impacts - 1. Change national policy on infant discharge to include some concepts of feeding quality, and 2. Identify those at risk of future pediatric feeding disorders earlier and monitor meaningful outcomes for family and society.
