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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 1  |  Page : 85-90

Effect of follow-up home-based oromotor stimulation on breastfeeding performance in preterm low-birth-weight infants: A randomized control trial


1 Department of Paediatric Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India
2 Department of Paediatrics, JNMC, Belagavi, Karnataka, India

Date of Web Publication18-Jan-2019

Correspondence Address:
Mr. Pushkar Topkar
KAHER Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_129_18

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  Abstract 


BACKGROUND: In preterm neonates, feeding problems are recognized as a challenging issue. Immaturity of the oromotor system, inability to generate a suck-swallow-breath pattern, and poor motor development are few factors contributing to feeding difficulties. Oromotor stimulation is one of the various techniques used to enhance breastfeeding in infants which is frequently given in hospitals. However, the effect of oromotor stimulation is given as a home-based program has not been studied.
OBJECTIVE: The objective of this study was to evaluate the effect of home-based oromotor stimulation on weight, sucking frequency, duration of transition from spoon-feeding to breastfeeding, and Latch breastfeeding assessment in preterm low-birth-weight infants.
MATERIALS AND METHODS: A randomized control trial was done on 40 preterm low-birth-weight infants where they were divided equally into intervention and control groups. Weight, Latch scores, and sucking frequency were noted at baseline. Routine Newborn Intensive Care Unit (NICU) care was given to infants in the control group whereas oromotor stimulation was given for 21 days as a home-based program to the intervention group. The outcome measures were evaluated on the 7th and the 21st day.
RESULTS: Oromotor stimulation improved the sucking frequency, Latch scores, and hastened the transition from spoon-feeding to breastfeeding as compared to the controlled group (P < 0.05). However, there was no statistically significant difference in the weight gain in the two groups (P > 0.05).
CONCLUSION: The present study concludes that home-based oromotor stimulation program is effective in improving sucking frequency, Latch scores, and duration of transition from spoon-feeding to breastfeeding in preterm low-birth-weight infants, although no significant changes were seen in the rate of weight gain between the groups. Oromotor stimulation should be added along with routine NICU care for preterm low-birth-weight infants to improve the breastfeeding performance.

Keywords: Breastfeeding, follow-up, home based, oromotor stimulation, preterm low birth weight


How to cite this article:
Topkar P, Metgud D, Machakanur V. Effect of follow-up home-based oromotor stimulation on breastfeeding performance in preterm low-birth-weight infants: A randomized control trial. Indian J Health Sci Biomed Res 2019;12:85-90

How to cite this URL:
Topkar P, Metgud D, Machakanur V. Effect of follow-up home-based oromotor stimulation on breastfeeding performance in preterm low-birth-weight infants: A randomized control trial. Indian J Health Sci Biomed Res [serial online] 2019 [cited 2019 Feb 17];12:85-90. Available from: http://www.ijournalhs.org/text.asp?2019/12/1/85/250383




  Introduction Top


According to the World Health Organization, the preterm newborn or premature is the one, born before the 37th gestational week.[1] Fifteen million babies are born premature every year. Almost 1 million infants die due to complications of preterm birth. In India, out of 27 million babies, 3.5 million babies are born premature. More than 1 out of 10 babies born in the world are preterm making it the second leading cause of death.[2]

Premature infants, who have relatively complicated neonatal courses, are at risk for developmental delays in motor skills. In preterm neonates, feeding problems are recognized as a challenging issue. It can be limited due to illnesses, gut immaturity, inadequate sucking, swallowing and breathing incoordination, and poor oromotor skills.[3] The brain injuries suffered by the preterm infants lead to neurobehavioral dysfunction. This leads to the difficulty in state regulation, motor organization, rhythmical sucking, and their ability to coordinate a suck-swallow-breath pattern. Studies speculated that feeding difficulties in preterm infants are more likely to result from inappropriate swallow-respiration interfacing than suck-swallow interaction.[4]

Feeding is one of the important functions in a neonate for their growth and development. Effective feeding is an important criteria for weight gain in preterm low birth infants. Sensory-motor intervention improves oral feeding. The sensory inputs, such as oral, tactile, kinaesthetic, vestibular, and auditory, can facilitate the development of existing rudimentary skills. Oral sensory motor stimulation is major focus as they provide direct targeted input to oral structures involved in feeding.[5]

Preterm low-birth-weight infants have feeding difficulties due to underdeveloped oromotor system. To enhance feeding, various oromotor intervention techniques have been tried and found to be beneficial. Various studies done to determine the effect of oromotor stimulation program as a hospital-based program on duration of transition from spoon-feeding to breastfeeding, duration of hospital stay, and sucking frequency weight gain found that it is beneficial. Although Latch is an effective breastfeeding charting system that provides information about individual breastfeeding session, there is a paucity of literature on the use of this scale to find the effect of follow-up home-based oromotor stimulation on breastfeeding performance in preterm low-birth-weight infants. Hence, the present study is intended to study the effect of home-based oromotor stimulation program in preterm low-birth-weight infants.


  Materials and Methods Top


Ethical clearance was obtained from the Institutional Ethical Committee. Inclusion criteria were (1) preterm low-birth-weight infants ≤34 weeks of gestation, (2) hemodynamically stable, and (3) not on breastfeeding admitted in Newborn Intensive Care Unit (NICU) of tertiary care hospital. Exclusion criteria were (1) infants with congenital anomalies of the face, (2) neurological conditions, (3) severe respiratory distress, (4) cardiac anomalies, and (5) infants in ventilatory support. Eligible neonates were enrolled in the study after obtaining informed consent from the parents. Then, they were randomly allocated into two groups; (a) control group and (b) experimental group. Baseline information on weight of infants, sucking frequency, Latch breastfeeding assessment was recorded. Group A received routine NICU care. Group B received hospital-based intervention of one session of oromotor stimulation by the principal investigator both intraoral and extraoral stimulations for 5 min for 7 days. In NICU, neonates are fed every 2nd h. The intervention was given in the afternoon session before feeding. The perioral and intraoral stimulation was given by wearing sterile gloves as follows: (1) gently tapping the cheeks with the index finger; (2) stroking the cheek with the index finger from the base of the nose toward the ear, then return back to the corner of the lips on both sides; (3) gently stroking the area around the lips in a circular way, from the corner toward the center and to the other corner; (4) place the index and the middle fingers on the middle of upper lip or lower lip and quickly, but gently, stretch outward; and (5) rub the upper gum with gentle, but firm pressure from the center toward the back and return to the center for each side. Weight of infant, sucking frequency, duration of transition from spoon-feeding to breastfeeding, and Latch breastfeeding assessment were recorded after 7 days for both the groups. For Group B, the mother was trained by the therapist on day of discharge to give oromotor stimulation to their infants. Mothers were then asked to give oromotor stimulation before every feed at home during the daytime. After 15 days, mothers were called for follow-up, and information about weight of infant, sucking frequency, duration of transition from spoon-feeding to breastfeeding, Latch breastfeeding assessment was recorded [Figure 1].[6]
Figure 1: Consort chart of the study

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Statistical analysis

Within-group comparison of the weight, gestational age, and Latch scores was done using the Tukey's multiple post hoc procedures. Nominal data, i.e. weight and duration of transition from spoon-feeding to breastfeeding were analyzed using the paired t-test, and gender distribution was analyzed to explore the differences between the groups using the Chi-square test. Comparison of the postintervention outcome measures within the groups was done using the paired t-test and Wilcoxon signed-ranks test which was utilized to measure the difference between the group regarding weight, Latch scores, and sucking frequency. Correlation between outcome measures was done using Karl Pearson's correlation coefficient method. Probability values <0.05 were considered statistically significant and probability values <0.001 were considered highly significant. The Kolmogorov–Smirnov test was performed for normality which states that baseline characters were homogeneous.


  Results Top


The demographic and baseline characteristics of the study population are in the control group and interventional group is summarized in [Table 1].
Table 1: Baseline characteristics of the study population

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We found that the sucking frequency, Latch scores, and weight in the control and intervention groups were not statistically significant before oromotor stimulation was implemented (P > 0.05). In Group A, there was a statistically significant difference in weight from day 1 to day 21 (P = 0.003). There was no significant difference in the weight from day 1 to day 7 (P = 0.482) and day 7 to day 21 (P = 0.07). In Group B, there was a statistically significant difference in weight from day 7 to day 21 (P = 0.009) and from day 1 to day 21 (P = 0.000) after giving the oromotor stimulation program. There was no significant difference in weight from day 1 to day 7 (P > 0.05). In Group A, there was a statistically significant difference in Latch scores from day 7 to day 21 (P < 0.05) and from day 1 to day 21 (P < 0.05). There was no significant difference in the Latch scores from day 1 to day 7 (P > 0.05).

In Group B, there was a statistically significant difference in the Latch scores from day 1 to day 7, from day 7 to day 21, and also from day 1 to day 21 (P < 0.05). Both the control and intervention groups showed a statistically significant improvement in the sucking frequency from day 1 to day 7, from day 7 to day 21, and from day 1 to day 21 [P < 0.05, [Table 2] and [Table 3].
Table 2: Comparison of outcome measures at different intervals within Group A

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Table 3: Comparison of outcome measures at different intervals within Group B

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There was no significant difference in the weight of the infants in both the groups on the 7th and 21st day of assessment. There was a statistically significant increase in the Latch scores of intervention group (6.25 ± 1.16) as compared to control group on the 7th day (5 ± 0.97) (P < 0.05). There was a statistically significant increase in the sucking frequency of intervention group (11.65 ± 2.18) as compared to control group (3.95 ± 4.74) after the 1st week of intervention (P < 0.05). After 3 weeks, there was a statistically significant increase in the Latch scores and sucking frequency of the intervention group as compared to the control group (P < 0.05). The duration of transition from spoon-feeding to breastfeeding was significantly lesser in the intervention group (7.250 ± 1.832 days) as compared to control group (13.750 ± 4.778 days) [P < 0.05, [Table 4].
Table 4: Comparison of outcome measures of infants between groups

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  Discussion Top


The present study aimed to find the effect of home-based oromotor stimulation program on feeding performance in prevalence of preterm low-birth-weight (PTLBW) infants. We found that oromotor stimulation program was effective in improving the sucking frequency, quality of breastfeeding as assessed by Latch scores, and the duration of transition from spoon-feeding to breastfeeding was hastened significantly postintervention. However, as opposed to our hypothesis that there will be an accelerated weight gain in the interventional group, they did not show any difference in the rate of weight gain as compared to their counterparts.

Within the 1st week of intervention, sucking was established in more number of infants in intervention group as compared to control group. In control group, sucking was established as natural growth and development aided by routine NICU care. Sucking was well established and better in intervention group that received oromotor stimulation intervention in addition to routine NICU care.

The sensory stimulus given leads to the elaboration of pyramidal neuron dendritic length and enhanced behavioral motor responses, i.e. in this case, the increased sucking frequency.[7] Our findings are consistent with the findings of Gaebler, who demonstrated higher nutritive sucking rate and rhythm after stroking and perioral prefeeding stimulation in healthy preterm neonates.[8] Oromotor stimulation reduces the oral hypersensitivity by normalizing sensations and restoring reflexes required for normal movement of the oral structures and improves the muscle strength required for sucking. It influences the brainstem central pattern generators which are responsible for the skill of sucking.[7]

The Latch is a valid and reliable tool to assess the quality of feeding of the infant. Within the first 7 days of intervention, the Latch scores of the intervention group showed a significant improvement after oromotor stimulation as a result of improved sucking of the infants. The hold of the infant and latching to the breast were improved due to the strengthening of the muscles required for sucking. As the suck-swallow reflex got regulated, the audible swallow also improved. Oromotor stimulation reduces the assistance required by the mother during feeding. These positive results can be attributed to the intervention being given by the professional.

Infants' weight was measured at baseline, 7th and 21st day. Weight should be checked regularly to determine the rate of weight gain in the infant. Studies suggest that normally, there is 5%–7% weight loss within first 2 weeks of life due to which we may not have found significant weight gain from baseline to 7th day and 7th day to 21st day.[9] Whereas we found significant weight gain from baseline to 21st day in both groups. In this study, there was no significant increase in the rate of weight gain in our intervention group as compared to the control group within the first 7 days. This can be attributed to the standard Kangaroo Mother Care (KMC) that was given to all the infants irrespective of the group of treatment. KMC is proven to improve the weight gain and physical growth in infants.[10],[11],[12] Furthermore, according to the current clinical practice in the study setting, adequate nutritional intake was checked by the doctors, wherein additional nutritional supplements were given to the infants to ensure appropriate daily weight gain. These findings are supported by a study conducted by Fucile et al., who also did not find any improvement in the weight gain after the sensorimotor intervention.[5]

The further home-based oromotor stimulation program from the 7th day to the 21st day was administered by the mother. The mothers showed a keen interest in the therapy when they noticed the positive effects in the initial week. This motivated them to learn the exercises and adhere to it at home. There was a significant increase in the sucking frequency in the intervention group as compared to the controls. Along with the interest of the mother, the home environment must have played an important role in the growth and development of infant. Studies have shown that factors in the home environment rather than medical factors are important for optimal feeding outcomes in preterm infants.[13]

Latch scores also improved significantly in both the groups but were profoundly improved in the intervention group. Home-based oromotor program with family support, friendly environment, and increased comfort decreased the burden and anxiety of the mother by reducing the amount of assistance required while breastfeeding. This also improves the milk production in the mother providing better nutrition to the infant and facilitates better bonding between the mother and infant.

There was a significant weight gain in intervention group than the control group during the home program period. This accelerated weight gain can be attributed to oromotor stimulation that improved the strength of the muscles required for sucking and swallowing.

Type of delivery was not taken into consideration in this study; however, it might play an important role in determining the health status of the mother. After cesarean section, mothers have difficulty in feeding the infants in sitting position. The mother's health also influences the feeding and nutrition of the child. The nipple problems, such as flat nipples or inverted nipples, can also contribute to breastfeeding performance which can lead to poor feeding outcomes. The amount of milk production is also a contributing factor in breastfeeding performance. The education of the mother was not taken into consideration as literacy can have better adherence to the home program. Specific home environment also plays a role in breastfeeding which may have influenced our results.

Along with the therapist giving oromotor stimulation in the hospital, when the exercises taught to the mothers were performed at home, there was a significant difference in sucking frequency, Latch, weight gain, and duration of transition from spoon-feeding to breastfeeding. This shows that there was good adherence to the home program as it was well understood and easy to administer. A study conducted on a single session oromotor stimulation program on breastfeeding in preterm infants did not show any improvement in their sucking frequency as opposed to our study.[14] In this study, the intervention was given over 3 weeks. Thus, we can say that a cumulative effect is required for improving the sucking frequency and causing an overall improvement in the feeding performance of preterm infants. The longer duration of the protocol facilitates general oral arousal which in turn improves the sucking frequency.

The sucking frequency is indirectly proportional to the duration of transition from spoon-feeding to breastfeeding. Higher the frequency and lesser the amount of time required for transition. In this study, we found an accelerated rate of transition from spoon-feeding to breastfeeding in the interventional group as compared to their controls, where they transited 6 days earlier. A study done on Premature Infant Oral Motor Intervention given for 7 consecutive days in 19 infants completed transition to total oral feeding 5 days earlier than their controls which are consistent with our results.[15] This can be attributed to the specific targeted sensorimotor input that enhanced the function of the systems involved in the oral feeding process. A study conducted by Bala et al., on 51 preterm neonates on oromotor stimulation also observed increased milk intake and accelerated rate of transition from gavage to spoon-feeding.[3] In a Cochrane review of 19 randomized trials showed that oral stimulation reduced the transition to oral feeding as compared to nonoral stimulation and standard care.[16] The decrease in the transition time is very essential for the development of the bond between the mother and the baby as well.

The benefits of breastfeeding in PTLBW infants are well established. Breastfeeding in NICU is influenced by various factors such as the availability of the mother, the specific time allotted for feeding the infant, and milk production along with the infant's ability to suck.[17] The development of the ability of the infant to suck is favored through oromotor stimulation, and the hospital staff should coordinate with the feeding schedules to enhance the effects of oromotor stimulation before feeding. The effectiveness of oromotor stimulation can be obtained by following the proper technique. The mother should be taught the technique of oromotor stimulation and made to practice in the hospital setting under supervision followed by which she can continue it at home.


  Conclusion Top


The present study concludes that home-based oromotor stimulation program is effective in improving sucking frequency, Latch scores, and duration of transition from spoon-feeding to breastfeeding in PTLBW infants, although no significant changes were seen in the rate of weight gain between the groups. Oromotor stimulation should be added along with routine NICU care for preterm low-birth-weight infants to improve breastfeeding performance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lemes EF, Silva TH, Run AD, Almeida EO, Luchesi KF. Oral and non-oral sensorimotor stimulation in preterm infants: Bibliographic review. Rev CEFAC 2015;17:945-55.  Back to cited text no. 1
    
2.
Park K. Park's textbook of preventive and social medicine. 22nd ed. Jabalpur: M/s BANARSIDAS BHANOT; 2013.  Back to cited text no. 2
    
3.
Bala P, Kaur R, Mukhopadhyay K, Kaur S. Oromotor stimulation for transition from gavage to full oral feeding in preterm neonates: A Randomized controlled trial. Indian Pediatr 2016;53:36-8.  Back to cited text no. 3
    
4.
Lau C, Smith EO, Schanler RJ. Coordination of suck-swallow and swallow respiration in preterm infants. Acta Paediatr 2003;92:721-7.  Back to cited text no. 4
    
5.
Fucile S, Gisel EG, McFarland DH, Lau C. Oral and non-oral sensorimotor interventions enhance oral feeding performance in preterm infants. Dev Med Child Neurol 2011;53:829-35.  Back to cited text no. 5
    
6.
Moher D, Schulz KF, Altman DG. The CONSORT statement: Revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001;357:1191-4.  Back to cited text no. 6
    
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Barlow SM, Finan DS, Lee J, Chu S. Synthetic orocutaneous stimulation entrains preterm infants with feeding difficulties to suck. J Perinatol 2008;28:541-8.  Back to cited text no. 7
    
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Gaebler CP, Hanzlik JR. The effects of a prefeeding stimulation program on preterm infants. Am J Occup Ther 1996;50:184-92.  Back to cited text no. 8
    
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Noel-Weiss J, Courant G, Woodend AK. Physiological weight loss in the breastfed neonate: A systematic review. Open Med 2008;2:e99-110.  Back to cited text no. 9
    
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Gathwala G, Singh B, Singh J. Effect of kangaroo mother care on physical growth, breastfeeding and its acceptability. Trop Doct 2010;40:199-202.  Back to cited text no. 10
    
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Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A, et al. Kangaroo mother care for low birthweight infants: A randomized controlled trial in different settings. Acta Paediatr 1998;87:976-85.  Back to cited text no. 11
    
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Ghavane S, Murki S, Subramanian S, Gaddam P, Kandraju H, Thumalla S, et al. Kangaroo mother care in kangaroo ward for improving the growth and breastfeeding outcomes when reaching term gestational age in very low birth weight infants. Acta Paediatr 2012;101:e545-9.  Back to cited text no. 12
    
13.
Crapnell TL, Rogers CE, Neil JJ, Inder TE, Woodward LJ, Pineda RG, et al. Factors associated with feeding difficulties in the very preterm infant. Acta Paediatr 2013;102:e539-45.  Back to cited text no. 13
    
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Hwang YS, Vergara E, Lin CH, Coster WJ, Bigsby R, Tsai WH, et al. Effects of prefeeding oral stimulation on feeding performance of preterm infants. Indian J Pediatr 2010;77:869-73.  Back to cited text no. 14
    
15.
Lessen BS. Effect of the premature infant oral motor intervention on feeding progression and length of stay in preterm infants. Adv Neonatal Care 2011;11:129-39.  Back to cited text no. 15
    
16.
Jensen D, Wallace S, Kelsay P. LATCH: A breastfeeding charting system and documentation tool. J Obstet Gynecol Neonatal Nurs 1994;23:27-32.  Back to cited text no. 16
    
17.
Pimenta HP, Moreira ME, Rocha AD, Gomes SC Jr. Pinto LW, Lucena SL, et al. Effects of non-nutritive sucking and oral stimulation on breastfeeding rates for preterm, low birth weight infants: A randomized clinical trial. J Pediatr (Rio J) 2008;84:423-7.  Back to cited text no. 17
    


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