www.jped.com.br
REVIEW
ARTICLE
Dietary
transition
difficulties
in
preterm
infants:
critical
literature
review
夽
Carla
Lucchi
Pagliaro
a,∗,
Karina
Elena
Bernardis
Bühler
b,
Silvia
Maria
Ibidi
c,
Suelly
Cecília
Olivan
Limongi
aaDepartmentofSpeechTherapyandAudiology,PhysicalTherapyandOccupationalTherapy,FaculdadedeMedicina,
UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
bSectorofSpeechTherapyandAudiology,HospitalUniversitário,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil cSectionofNeonatology,HospitalUniversitário,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
Received25May2015;accepted27May2015 Availableonline17October2015
KEYWORDS
Developmentof feedingskills; Infantfeeding; Feedingproblems; Infantsandpreterm infants
Abstract
Objective: Toanalyzethescientificliteratureondietarychangesinpretermchildrenduring
thefirstyearsoflife.
Datasource:The PubMeddatabase wasused forarticle selection.The texts wereanalyzed
according to their objectives, research design, and research group characteristics. The followingwereselectedtocomprisethecriteria:(1)publicationsintheperiodfrom1996to 2014;(2)participationofinfantsandchildrenfrombirthto10yearsofage;(3)development oforal motor skillsnecessary for feeding;(4) developmentofthe feedingprocess;and(5) feedingdifficultiesduringchildhood.
Summaryofthefindings: There were 282 studies identified, ofwhich 17 were used inthe
review,andfivemorearticleswereidentifiedthroughthereferencelistofselectedarticles, totaling22references.
Conclusion: Verylowbirthweightpretermnewbornsaremorelikelytohavefeedingproblems
inearlypostnatalstagesandduringchildhoodwhencomparedwithfull-terminfants. Monitor-ingthefeedingoftheseinfantsafterhospitaldischargeisstrictlyrecommendedinanearly interventionprogramaimingatbetterdevelopmentoffeedingskills.
©2015SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
夽
Pleasecitethisarticleas:PagliaroCL,BühlerKE,IbidiSM,LimongiSC.Dietarytransitiondifficultiesinpreterminfants:criticalliterature review.JPediatr(RioJ).2016;92:7---14.
∗Correspondingauthor.
E-mail:[email protected](C.L.Pagliaro). http://dx.doi.org/10.1016/j.jped.2015.05.004
PALAVRAS-CHAVE
Desenvolvimento dashabilidades alimentares;
Alimentac¸ãoinfantil; Problemasde alimentac¸ão; Bebêsecrianc¸as prematuras
Dificuldadesdetransic¸ãoalimentaremcrianc¸asprematuras:revisãocrítica deliteratura
Resumo
Objetivo: Analisaraliteraturacientíficasobrealterac¸õesalimentaresemcrianc¸asprematuras
duranteosprimeirosanosdevida.
Fontedosdados: AbasededadosdoPubmedfoiapercursoraparaaselec¸ãodosartigos.Os
tex-tosforamanalisadosquantoaosseusobjetivos;desenhosdapesquisa;característicasdogrupo pesquisaeforamselecionadososseguintestemasparacomporoscritérios:(1)publicac¸õesno períodode1996a2014;(2)participac¸ãodebebêsecrianc¸as,donascimentoatéos10anos deidade;(3)desenvolvimentodashabilidadesmotorasoraisnecessáriasparaaalimentac¸ão; (4) desenvolvimento do processo de alimentac¸ão e (5) dificuldades alimentares durante a infância.
Síntesedosdados: foramidentificados282estudos,destes17foramutilizadose5artigosforam
identificadospormeiodalistadereferênciabibliográficadosartigosselecionados,totalizando 22referênciasbibliográficas.
Conclusão: A revisão permitiu concluir que recém-nascidos pré-termo muito baixo peso
(RNPTMBP)sãomaispropensosaapresentaremproblemasdealimentac¸ãonosestágiosiniciais pós-nataleduranteainfânciaquandocomparadoscomcrianc¸asatermo.Omonitoramento da alimentac¸ão após a alta hospitalar é estritamente recomendado em um programa de intervenc¸ãoprecocecomvistasaomelhordesenvolvimentodashabilidadesalimentares. ©2015SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.
Introduction
Prematurityisconsideredariskfactor,becausetheinfant’s anatomicaland physiological immaturity predisposes toa numberofadaptationandevolutiondifficultiesinpost-natal life.1 The reduction of neonatal morbidity and mortality
and, consequently, the significant increase in survival of
verylowbirthweight(VLBW)pretermnewborns,i.e.,those
withgestationalage(GA)<37weeksandbirthweight(BW)
<1500g,2---5 hasled many authorstoidentify thisgroup of
childrenaspronetodevelopimportantdietary-related
prob-lems.
The initialdifficultieswithsuckingandswallowing
pat-ternsinVLBWpretermnewbornsduringthehospitalization
periodaredescribedin theliterature6---9 asimmature oral
reflexes,reducedsuckingeffort,smallnumberofsucksdue
topauses,incoordinationofsucking,swallowingand
breath-ing, choking, and difficulty accepting full volume by oral
route(OR).10 Themorbiditiesassociatedwithprematurity,
suchaslowerGAatbirth,presenceofclinicalinstabilityof
thebreathingpattern,prolongedintubationtime,and
gas-trointestinalsystemimmaturity11maketheseinfantsunable
toinitiallyreceiveoralfeedingexclusively.Thus,theuseof
alternative feeding routes, through a nasogastric (NG) or
orogastrictube,becomesstrictlynecessary.12,13
Studieshaveindicatedthatfeedingproblemscanpersist
in these children after hospital discharge, and this can
have consequences in the long term.12---16 Understanding
thedevelopmentofthefeedingprocessinthispopulation,
aswell as identifying the factors that may contribute to
the onset of eating disorders in childhood are essential
to determine, in this group of children, which would be
more likely to develop problems, and to identify which
stages of feeding development can be altered.17,18 This
literaturereviewaimedtoassessinternationalandBrazilian
articles on feeding development of preterm children and
feedingproblemsduringthefirstyearsoflife.
Methods
Datasource
ArticleswereselectedfromthePubMeddatabaseusingthe following descriptors: feeding problems, development of feedingskills,andpreterminfants,intheperiodfrom1996 to2014.
Articleselection
Thestudytitlesandabstractswereidentifiedbytwo inde-pendentresearchers,anddisagreementswereresolvedby consensus-baseddiscussion.Allpotentiallyrelevantstudies andthosewhoseabstractsdidnotprovidesufficient infor-mation for inclusion or exclusion were recovered as full articles.Aftertheliteraturereviewandselectionofarticles accordingtotheirobjectives,ananalysisofpotentially rele-vantfulltextswascarriedoutbasedonthepre-established criteria,characterizingitasnotsingle-blinded.
Articleswhose full textswere notaccessible [obtained fromtheCAPES(Coordenac¸ãodeAperfeic¸oamentode Pes-soaldeNívelSuperior)JournalPortal]wereexcludedfrom theselection,aswellasthoserelatedtocasestudies, let-terstotheeditor,andstudiespublishedinlanguagesother thanEnglish,Spanish,andPortuguese.Articleswhosetopics werenotrelatedtothefocusofthisreview,suchasmaternal diseases,children’ssevereillnesses, nutritionalaspectsof breastmilkorartificialformula,specificassessmentsoftime ofdietarytransitionfromgavagetooralfeeding,and spe-cificresultsofthetreatmentofnon-nutritivesuckingwere alsoexcluded.
Results
A total of 282 references were retrieved in the litera-turesearch.Of these,177 studieswereexcluded,asthey addressedmaternaldiseases(35),children’ssevereillnesses (47),nutritionalaspectsofbreastmilkorartificialformula (43), specific breastfeeding assessments (47), and dental problems (two). Two other reasons were also cause for exclusion: twostudies published in other languages, such asFrenchandChinese,andonecasestudy.
Of the remaining 105 studies,after they wereread as fulltexts,88wereexcluded,astheyaddressedtopicsthat were not relevant for the main purpose of the research, namely: (18)reviewsonsucking in preterminfants in the neonatalintensivecare unitenvironment,(46) onspecific assessmentsoftimeofdietarytransitionfromgavagetooral feeding,and(24)onspecificinterventionsinnon-nutritive sucking of infants during hospitalization. Five literature review articles were identified throughthe reference list of the selected articles,and were included because they addressedtopicsthatwererelevantforthisresearch.Thus, 22articleswereincludedinthisreview.Theflowchart rep-resentingarticle search andselection method is shownin Fig.1.
Startoftheinitialfeedingdifficulties
Frequent exposures to harmful sensory stimuli to which VLBW preterm infants are submitted as a result of
prematurity---suchasintubation,upperairwayaspiration, anduseoffeedingtubes---resultinanegativeexperience, andconsequently,aversiontooralstimulicanbeobserved inthatpopulation.19,20Theinitialexperienceofthefeeding
processusingtheNGtubeatbirthcanbeaprecursorto
dif-ficultiesin thisprocess,suchaschangesinfacialandoral
sensitivity,mainlyinpreterminfantsthathaveuseditfora
periodlongerthanthreeweeks.21
However, the necessary OMS for feeding continue to
develop,andtheliteraturehasemphasizedthateating
dis-ordersinpretermnewbornsmaypersistevenafterhospital
discharge.19,22
Jonssonetal.,16inacohortstudy,appliedaquestionnaire
toparentsconcerningthedevelopmentoffeedingskills
dur-ingthefirstthreeyearsoflifeof27preterminfants(born
withGAbetween 28and 32weeks, meanBW 1698g)and
29 children in the control group (CG). Children were
excluded if they had congenital abnormalities or chronic
diseases. The questionnaire was initially applied in the
neonatalperiodafterhospitaldischarge,atthetimewhen
solidfoodswereintroduced,andat36monthsofage.The
authorsfoundthat48%ofpretermchildrenhadfeeding
dif-ficultiessoonafterhospitaldischarge,followedbyextended
feedingtime(25%),vomiting(22%),poorweightgain(19%),
andfoodrefusal(15%).
Feedingdifficultiesininfancy
Thedescriptionofthefeedingdifficultiesinpreterminfants inthefirstyearoflifeisknownintheliteratureandismade notableby thepresenceof oralmotor dysfunction(OMD), vomiting, gastroesophageal reflux (GER), choking, aspira-tion,preferencefor only onefood consistency,significant leakingoffood,foodrefusal,reducedfeedingtimedueto lack of attention/involvement with the feedingsituation, difficultyduring the foodconsistency transition according totheagerange,difficultychewingsolidfood,poorweight gain,andlowvolumeoffoodintake.4,5,17,18,23---39
Norris et al.,21 through an observational study,
inter-viewedtheparentsof253preterminfantsupto12months
of corrected age (CA) on feeding practices. The authors
foundthatthemeanageforintroductionofcomplementary
282 references were retrieved in databases
177 were excluded as they addressed Maternal diseases (35)
Severe children diseases (47)
Nutritional aspects of breast milk and/or artificial formula (43) Specific breastfeeding assessments (47)
Dental problems (2)
Studies published in other languages, such as French or Chinese (2) Case study (1)
88 articles were excluded:
Assessment of sucking reflex in preterm infants (18) Specific assessments of the time of dietary transition from gavage to oral feeding (46)
Specific intervention in non-nutritive sucking (24)
105 articles were selected
17 articles were included
22 articles in total 5 articles were selected
foods was 17 weeks of postnatal GA for 50% of preterm infants;however,whenadjustingforthechronologicalage, these infants started receiving complementary foods at 11.5weeks.DifficultiesimplementingthenecessaryOMSto swallowthis newfood consistency were reported by par-ents.Onestudyfoundthatfoodintroductionoccurredearly in preterm infants born between 28 and 32 weeks, with meanCAof3.2and4.5monthswhencomparedtotheCG.16
Anotherstudy foundthat theintroduction of
complemen-tary foods wasinitiated at 3.5 monthsin preterm infants
withGA<32weeksandat4monthsofageinchildrenborn
atterm.22
Törölä et al.23 performed a longitudinal follow-up of
preterm infants with CA of 1.5 to 4 months of age born
withGAof27weeksandBW<1000g,toevaluatethe
devel-opment of feeding skills in these infants when compared
tofull-terminfants.Theauthorsobservedthatthesucking
reflexwaspresentwiththeuseofaspoonwhenintroducing
complementaryfeeding inmost preterm infants. Children
exhibiting this alteration had significant leaking of food,
makingthe feedingprocess longand exhausting, both for
thechildrenandtheircaregivers.Preterminfantsneededsix
weekstolearnhowtodealwiththisnewfoodconsistency,
whilefull-terminfantslearnedinstantly.
Castroetal.,24inanexploratorystudy,observedthe
asso-ciationbetweenGAandglobalmotordevelopmentandthe
presence ofearly signs of alterations in the development
oftheorofacialmyofunctionalsystem(OMFS)in55preterm
infantsat4and5monthsofCA,with29---34weeksGA,and
BWof1500---2000g.Childrenwithahistoryofneurological
alterations,genetic syndromes,and congenital
malforma-tionswereexcluded.Theauthorsfoundanassociationwith
lowerGAatbirth(<34weeks)andalterationsintheOMFS
assessment,whencomparedwiththegroupofinfantsthat
had a higher GA, between 35 and 36 weeks. The most
frequent alterations were the presence of primitive oral
reflexes(rooting,sucking,andphasicbite),absenceoflip
closure, absence of tongue activity in the frontal plane,
andabsenceofsymmetricalactivityofthebuccinator
mus-cles.Theauthorsconcludedthatthedifficultiesfoundinthe
globalmotordevelopmentofpreterminfantswere
impor-tantfactorsforthedeficitsofOMFSdevelopmentgaindue
tolack of stretching,symmetry, and synergy of the
mus-clesthatconstitutethetrunk,shouldergirdle,andcervical
region.
Ruedelletal.,25 throughalongitudinalandprospective
study, investigated the OMS of preterm infants with GA
between29and35weeksandmeanBWof1556g,at4and
6monthsofCA.Thepresenceofgeneticsyndromes,major
congenitalmalformations,andchildrensubmittedtospeech
therapywereexcluded. At4monthsold,suckingthe
bot-tlewasthemost affectedOMS in14preterm children.At
6months, 57.1% of thesechildren did not adequatelysip
liquidfromthecup.
Hawdonetal.4prospectivelyevaluatedtheincidenceof
feeding-relatedproblemsin35preterminfants(meanGAof
34weeks)intheNICUenvironmentanddescribedthe
char-acteristicsof thesechildren diagnosedwithfeeding
prob-lemsat6and12monthsofage.Childrenwhoremained
hos-pitalizedforaperiodoflessthanfivedayswereexcluded.
Theauthorsfoundthat40%ofpretermbabieswhoremained
hospitalized in the NICU for three months had feeding
disorders,withnineofthemshowingimportantalterations,
suchasneurologicaldisorders(cerebralpalsyand
neuromus-culardisorder).At6monthsofage,parentsreportedthat
episodesofchokingandvomitingwerecommonduringthe
feedingroutineoftheseinfants;at12monthsofagethese
childrenalsohadfeedingdifficulties,andrefusaltoeatwas
oneofthemaincausesofstressforthefamily.
Mathisen et al.,26 in a cross-sectional study using
video analysis, assessed the OMS and eating behaviors in
20 preterm infants, GA of 27 weeks and VLBW (<1000g),
at6monthsofCA.Childrendiagnosedwithintraventricular
hemorrhage,bronchopulmonarydysplasia,orchromosomal
abnormalitieswereexcluded.Theauthorsfoundthat80%of
childrenhadimmaturityoftheoralmotorfunctions,suchas
incoordinationbetweensucking,swallowing,andbreathing,
lackofheadorientationinthepresenceoffood,lipclosure
afterswallowing,difficultyswallowingliquids,andleakage
ofsalivaandfood.
Inaprospectivestudy,Kamita etal.27 investigatedthe
parental experience of the feeding behavior problems in
40 preterm infants up to12 months of CA. Childrenwith
syndromes and congenital malformations and those born
toadolescent parents wereexcluded. A smallpercentage
of children (22.7%) born with GA<29 weeks were
identi-fiedwithfeedingproblems,suchasleakageofsaliva,poor
weight gain, ingestion of small food volume, difficulties
ingestingnewconsistencies,anddifficultieswith
indepen-dentfeeding.Theauthorsfoundthatfooddifficultieswere
significantlyassociated withcomplications of prematurity,
aswellasgastrointestinalandpulmonaryproblems.
Pridham et al.28 assessed the performance of feeding
skillsin45preterminfantswithBW<1250ginalongitudinal
descriptivestudyduring thefirstyearof life.The authors
found that,at 8 and12 monthsof age,regarding feeding
skills,theminorityofpreterminfantsshoweddelayandlack
ofopportunitytoingestnewfoodconsistencies,suchassolid
foodsanddrinkingfromacup.
BoerandSchipper29carriedoutadirectanalysisof
feed-ingskillsin47preterminfantsbornwithmeanGA<30weeks
and BW<1286g, at 9 months of CA and CG. The authors
found the occurrence of significant feeding difficulties in
preterminfants whencomparedwiththeCGinfants,such
asepisodesofasphyxia(45%),choking(55%),andaccepting
crustybread(71%).
DeMauroetal.,30 inacohortstudy,analyzed the
feed-ingskills inthefirstyearoflifein319 extremelypreterm
infants(bornwithGAof25---33weeks)and571latepreterm
infants(bornat34---36weeksofGA)throughaspecific
ques-tionnaire applied to parents. Children with chromosomal
orcongenitalanomalieswereexcluded.Theauthorsfound
thattheextremelypretermchildrenhadmorefeeding
dif-ficulties,characterizedbyOMD,whencomparedwithlate
preterminfantsat3months.Difficultiessuchaschokingand
foodrefusalresolvedat6monthsofageinbothgroups.At
12 months, OMDand discomfort during feedingwere still
evidentinpreterminfants.
Buswell et al.31 evaluated the OMS through the
anal-ysis of videos in a small group of 15 preterm infants at
10monthsofGAduringfeedingwithdifferentfood
consis-tencies.Childrenthathadbirthdefects, heartdisease,or
gastrointestinalabnormalities,intraventricularhemorrhage
the present study, a small proportion of 20% of preterm
childrenwithOMDwasobserved.Therewasnoassociation
betweenOMDandneonatalhistoryvariables,suchasGAat
birth,numberofdayswithoxygensupport,andnumberof
daysfrombirthtofeedingstabilizationthroughOR.
Dodril et al.18 prospectively assessed the differences
between oral sensitivity in preterm infants, born after
32 weeksof GAand CG inthe NICU environmentand the
developmentoffeeding,from11to17monthsofCA.
Chil-drenwereexcludediftheyhadahistoryofstructurallesions
thataffectedtheswallowingmechanismandheart,
respira-tory,gastrointestinal,orneurologicaldiseases.Theauthors
foundthatpretermchildrenshowedimmaturityinboththe
incapacitytoingestliquidsfromacup,aswellastoeatfrom
aspoon,whencomparedwithchildrenfromtheCG.Preterm
childrenconsumedlessfoodduringthemeal;thedurationof
thefeedingwaslonger;lipactivitywhenremovingthefood
fromthe spoonwaslower.When compared tochildrenin
theCG,theyshowedhighertongueprotrusion,foodlossfor
semi-solidswallowing,andreducedsuckingwhen
swallow-ingliquids.Theauthorsalsofoundthatthepretermchildren
whousedNGfeedingforaperiodlongerthanthreeweeks
tendedtobeweaker,havingimmature movementsof jaw
when chewing andbitinginto solidfoods when compared
withchildrenthatusedNGfeedingforashorterperiodof
time.
DouglasandBryon20carriedoutadescriptiveanalysisin
201childrenyoungerthanseventoinvestigatetherisk
fac-tors thatcould beassociated withsevere chronic feeding
difficulties.Theauthorsverifiedthat22%ofpreterminfants
(GAbetween30and36weeks)showedahighincidenceof
nutritionalproblems,from0to3monthsandthedifficulties
persistedbetween3and6monthsofage,followedby
behav-iorssuchasfoodspitting whenurgedtofeedthemselves,
aswellaschoking,suffocation,GER,vomiting,andrefusal
toeat.The authorsfound thatthe riskfactors associated
with severe feeding problems in the pediatric population
wereunderweight,stuntedglobaldevelopment,early-onset
eatingdisordersinthefirstmonths,andfrequentvomiting
history.Itwaspointedoutthat90%oftheparentsreported
thattheirchildren’sfoodproblemsconstitutedoneoftheir
mainstressors.
Cerro et al.22 investigated the perception of parents,
throughapre-establishedquestionnaireinrelationto
feed-ing behavior in 95 preterm children (GA<32 weeks and
BW<1.5kg), aged1.5---3.5 years, whowere followedat a
neonatalfollow-upprogramandaCG.Childrenwithsevere
neurological problems were excluded. The authors found
significantdatainrelationtotherateoffeedingproblems,
correspondingto73%ofpreterminfantswhencomparedto
theCG.Themost commonproblems werevomiting(73%),
GER(33%),andfailuretothrive(32%).
Crapnelletal.,32inalongitudinalstudyof127preterm
infants,GA<30weeks,investigatedtheassociationbetween
neonatal clinical factors and feeding problems at age
2yearsthroughaquestionnaireappliedtoparents.Children
withcongenitalcomplicationswereexcluded.The authors
observed that 23% of children had feeding problems, 44
(55%)didnotfeedadequately,24(30%)didnotacceptthe
foodimmediately,22(28%)wereselectiveforfood,18(23%)
spatoutfood,12(15%) refusedtoeatsome typeof food,
nine(11%)refusedfood,eight(10%)accumulatedthefood
betweenthecheeks,seven(9%)refusedfoodthatrequired
chewing,five(6%)choked.Onechildwasidentifiedas
hav-ing a gastrostomy and 22% had sensory alterations. The
presence of these eatingdisorders at 2 yearsof age was
associatedwithgeneralhypotonia inthe childrenandlow
socio-economicstatusoftheparents.
Sweet et al.33 prospectively analyzed the survival
and neurological development of preterm infants with
BW≤600g, after 2 years of CA. A total of 104 children
wereidentified, of which 23% survived after hospital
dis-charge. The authors found that the diagnosis of cerebral
palsywaspresentin16(76%),whilethreechildrenhad
hemi-plegia, eight children had diplegia,and five children had
quadriplegia.The diagnosisofeatingdisorderswas
identi-fiedin62%(13)ofchildren,and28%(six)werefedthrougha
gastrostomy.Thegrowthofthesechildrenwassignificantly
impaired,and55%ofthemhadscoresbelowthe10th
per-centilefortheweight,height,andheadcircumference.
Woodetal.34prospectivelystudied283preterminfants
with GA<25 weeks to verify the associations between
growth and feeding problems at 30 months of CA. The
authors found that 33% of the parents of these children
reportedfeedingdifficulties,and34childrenhad
swallow-ingproblems, 66childrenhadfoodrefusal; bothproblems
wereobservedin19 ofthem.The differencesin standard
deviationforweightshowedworseresultsinchildrenwith
swallowingdifficultiesthaninthosewhorefusedfood.
Samaraetal.35conductedadescriptivestudyonfeeding
behaviorsin223extremelypretermchildren,at6yearsof
age,withGA<24weeksandmeanBWof749gandinaCG,
throughaquestionnaire appliedtoparents. The presence
ofbehavioralproblems,OMD,refusaltoeat,and
hypersen-sitivityshowedsignificant associations inpreterm infants,
in both genders, when compared with children from the
CG.Theproblems reportedwere:leakage ofliquids while
swallowingand difficulty biting intosolid foods, found in
49(23%)boys and23(10.6%) girls;hypersensitivity, found
in35 (16.4%)boys and15 (7.04%)girls. Feeding problems
weresignificantlyassociatedwithaninadequategrowth
pat-terninthesechildren,assessedat6yearsold,inadditionto
predictivefactorssuchasGA,BW,andfeedingdifficulties
intheearlystagesoflife.
Rommel etal.5 characterized theetiologies of feeding
difficultiesin 700preterminfants(GA<34 weeks)younger
than10years.Theauthorsshowedthatfeedingproblemsin
thesechildrenshowedsignificantassociationswithlowbirth
weightandGER,correspondingto53%ofchildren.
Discussion
This literature review included publications that inves-tigated feeding difficulties in preterm infants during the first years of life. Nine publications described the occurrence of feeding disorders through interviews with parents4,16,21,22,27,30,32,34,35;eightpublicationsincludeddirect
feeding assessments18,23---26,28,29,31; two studies performed
descriptiveanalysestocharacterizethechildren’sfeeding
problems5,20; and one article included the assessment of
neuropsychomotordevelopment,butthediagnosesof
feed-ingdisorderswerealsoevidenced.33 Tenarticlesanalyzed
theassociationsofthevariablesmotordevelopmentdelay,
at birth, prolonged oxygen use, use of NG feeding,
pres-enceofhypotoniainthechildren,andlowsocio-economic
statusofparentsaspredictorsfortheoccurrenceof
feed-ingdisordersin childrenduringinfancy.4,5,21,23,26,28,31,34,36,38
Of these ten articles, seven analyzed these associations
through structured interviews with parents,4,23,26,31,34,36,38
and three5,21,28 made objective assessments of feeding
dynamics.Thelongitudinalfollow-upofthesechildrenwas
observed in 12 articles,4,16,21,25---29,31,32,34,36 and in seven of
them4,16,25,26,31,34,36datawereobtainedbyrelyingonthe
par-ents’perceptionsoftheirchildren’sfeeding.However,few
studieshave been performed tomonitorfeeding
develop-ment,comprisingthestepsofdietarytransitionaccording
totheagerangeofthesechildren.Thedifficultiesin
con-ducting longitudinal studies, which depict the reality of
children’sfeedingpatternsperformedthroughdirect
assess-ments of feeding skills by specialized professionals and
comprisingasmallsamplenumber,canconfirm thisissue.
These qualitative analyses of feeding carried out through
interviewswithparentsandretrospectivelycollecteddata
may not represent an accurate assessment of these
chil-dren’sstatus.
Feeding difficulties in preterm infants have been
esti-mated to range between 25% and 45%; for children with
developmentaldelay, the mean increases to 33% to 80%.
Theproportionmayincreaseduetothesurvivalofextreme
preterminfantsandthosediagnosedwithneurological
prob-lems,suchascerebralpalsy.33,36
Theassociationbetweenfeedingdifficultiesandgrowth
deficitshas been reportedwith significant associations in
preterminfants’development.Failuretothriveduringthe
firstyearoflifehasshownseverelong-termproblemsand
implications,as nutritionand growth canhave an impact
onthemotor,cognitive,andpsychologicaldevelopmentof
thesechildren. Feeding difficulties predispose children to
recurrentrespiratoryinfections,gastrointestinaldisorders,
andbehavioralandlanguageproblems.5,22,33,36---43
Another group of factors that can influence the
performance of preterm infants’ feeding are medical
complicationsassociatedwithprematurity.Gastrointestinal
problems,suchasGER,areamajorfactorrelatedto
feed-ingdifficulties in childhood. The incidenceof GER is also
increased by reduced respiratory capacity and the
pres-enceof feedingtubes.36,39 Evidentsigns,suchasfrequent
episodes of crying, irritability, body stretching, nausea,
vomiting, and refusal to eat are often reported by
par-entsandhaveanegativeimpactonthechildren’sfeeding,
appetite,andgrowth.5,20,22,26GER isfrequentlyassociated
withOMDandoralhypersensitivity,factorsthatcontribute
toepisodesofpulmonaryaspirationandpulmonarychronic
diseases, considered one of the main reasons for the
increase in hospital length of stay.39 The constant acid
irritationintheesophagusmakeschildrenlosethedesireto
eatandassociatefoodwithsomethingthatcauses
displea-sureandpain.Somechildrenwhohaveoralhypersensitivity
usuallyreactexcessivelytochangesinfoodflavorand
con-sistency,withepisodesof nausea.This factor mayexplain
difficultieschildrenhavewhendealingwithsolidfoodsthat
requirechewing and,consequently,episodesof refusal to
eatcertainfoodsarecommonduringthefeedingroutine.40
Diseases that affect the respiratory pattern, such as
bronchopulmonarydysplasia,alsocausefeedingdifficulties.
Thelackofcoordinationbetweensucking,swallowing,and
breathing,aswellaslongapneaperiods,resultin
disturb-anceofthelipandjawmovementsduringfeeding.2,41Dueto
thisfactor,thesechildrencannotachievecomplete
recov-eryduringrespiratorypausesofsucking,becomingfatigued
andtiredbeforetheendoffeeding,andarethusunableto
ingest theentire foodvolume.The respiratory effortalso
results in high energy expenditure, which often leads to
growthdeficits,whenaggravatedbythedecrease indaily
energyconsumption.36
The understanding that successful feeding of VLBW
pretermnewbornsshouldoccurduringhospitalizationonly
toattainhospitaldischargeisamistake,aschildren’s
feed-ing skills continues to develop concomitantly with other
development milestones, suchas motor developmentand
communicationskills.12,19
The acquisition of the necessary OMS for each food
consistency is closely related to the children’s motor
development.36Pretermchildrenwhohaveadelayinglobal
motordevelopmentwhenconsideringtheCAmayalsohave
delaysinOMS,whencomparedwithnormalchildren.
Unfa-vorable feeding results in the short- and long-term are
attributed notonly to preterm infants’ development
fail-ures,butalsotothefacttheyareforcedtofeedatanearly
stage,whennotalloftheOMShavebeenreached.13
The studies included in this review showed that early
introductionofcomplementaryfeeding,at3and4monthsof
CA,contributedtotheoccurrenceofmajorproblems,such
as irritability, stress, choking, nausea, and vomiting. The
preterm children’sneurologicalimmaturityprevents them
from using all necessary OMS to deal with this new food
consistencyandthespoonutensil.12,27
Duetotheseinitial difficulties,parents,astheydonot
havetheknowledgeandstrategiesneededtohelptheir
chil-dren acquire better skills and involvement in the feeding
process, choose tofurther facilitate thelatter. Situations
such asinadequatepositioningof thesechildren (inclined
position)in ordertoavoid leakageof foodandhelp
swal-lowingwiththeaidofgravity,aswellasofferingpreferably
semi-solidfoodsforbetteracceptance,resultinthelackof
developmentofadequatefeedingskills.20Theseaspectscan
resultinsignificantalterationsinoralmotordevelopment,36
makingthemmorepronetoswallowingdisorderswithfoods
of different textures and consistencies and, as a result,
making them more prone to difficulties with solid food
mastication.30
Theintroductionofcomplementaryfoodsat6monthsof
CAcanincreasethechancesofachievingsuccessfulfeeding,
astheseinfantsareneurologicallymoreorganizedandhave
moresensoryexperience,whichareessentialforbetterfood
acceptance.Givingthesechildrenopportunitiestoplaywith
andorallyexploreobjectsofdifferenttextureswillprepare
themforabetterfeedingperformancewiththespoonand,
consequently,leadtopleasureinthisnewfeedingphase.40
Problemswiththestartoftheprocessofchewing
differ-entfoodtexturesarealsodemonstratedinpreterminfants,
such as vomiting, refusal to eat, and choking.19
Concur-rentlywithsuchdifficulties,theparentsdonotperformthe
adequatefoodconsistencyprogressionaccordingtotheage
group,andofferalimitednumberofconsistencies.4,5,15,27---31
This has been explained,in part, due to the initial
withprolongeduseofNGfeeding,mechanical ventilation,
aspiration of upper and lower respiratory tract,and
gas-trointestinalproblems, suchas occurrenceof GER. These
factors can contribute to an increase in oral sensitivity,
whichresultsinaversiontonewfoodtextures.5,18,20,22,27,40
Immaturity and neurological disorganization may also
explainthisissue,duetothelackofcontrolandorganization
oftheoralmuscles,necessaryforchewing.40
Offering opportunities for preterm children to acquire
theappropriatelearningexperiencesintheearlystagesof
feeding actuallycontributestopreventfeeding disorders.
Children who are more stimulated with the environment
andabletointeractwiththeirparentscanmoreeasilyfit
thedevelopmentalchangesinskillsrequiredforsuccessful
feeding.42,43
Thefollow-upofpreterminfantsaimingatmonitoringall
stagesofdietarytransition,withobjectiveanddirect
assess-mentsoffeedingskillscarriedoutbyaqualifiedaudiologist,
isstrictlyrecommended.Suchconductleadstoappropriate
guidancetomothers,regardingappropriateeatingutensils
andconsistenciesaccording tothechild’sage,inorderto
favorthe correctwaytoofferfood,makingthem ableto
useallnecessaryOMSwhenfeeding.Consequently,thechild
willreceivelearningexperiences,whichwillcontributeto
thesuccessfulandadequatedevelopmentofOMFSandthe
mother---childbond.Theearlierthechild’seatingdisorders
arediagnosed,thebetterthechancestoperformsuccessful
interventions.12,13,19,21,40,42,43
Conclusion
Basedonthe articlesassessed inthis literaturereview,it canbeaffirmedthatpreterminfants,especiallythoseborn withVLBW,aremorepronetofeedingproblemsintheearly stages of life and during childhood, when comparedwith children born atterm. The monitoring of thesechildren’s nutritionalstatusisstrictlyrecommendedinanearly inter-vention program withspecialized professionals,aiming to promote adequate nutritional development,as well asto ensureadequategrowth.
Funding
This research received funding subsidized by FAPESP 2013/13734-2.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgement
WethankFundac¸ãodeAmparoàPesquisadoEstadodeSão Paulo(FAPESP),forfundingthisresearch.
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