Facilitating inactive awake states in preterm infants: a study of three interventions. Promotion of preterm infant nipple feeding with nonnutritive sucking. Nonnutritive sucking during tube feedings: effects on preterm neonates in an intensive care unit. The effect of nonnutritive sucking on heart rate in preterm infants. Effect of non-nutritive and nutritive suck on gastric emptying in premature infants. Non-nutritive sucking does not increase blood levels of gastrin, motilin, insulin and insulin-like growth factor 1 in premature infants receiving enteral feedings. Effects of non-nutritive sucking on nutritive sucking, breathing, and behavior during bottle feedings of preterm infants. Nonnutritive sucking in tube-fed preterm infants: effects on gastric motility and gastric contents of somatostatin. Nonnutritive sucking during gavage feeding enhances growth and maturation in premature infants. Behavioral and physiologic effects of nonnutritive sucking during gavage feeding in preterm infants. Nonnutritive sucking modulates behavioral state for preterm infants before feeding. The effect of nonnutritive sucking on bottle-feeding stress in preterm infants. Effects of nonnutritive sucking on behavioral organization and feeding performance in preterm infants. Nonnutritive sucking during tube feedings: effect on clinical course in premature infants. Evaluation of beneficial effects of nonnutritive sucking in preterm infants. Lack of improved growth outcome related to nonnutritive sucking in very low birth weight premature infants fed a controlled nutrient intake: a randomized prospective study. Effect of nonnutritive sucking on nutrient retention in preterm infants. Effects of sweet taste stimulation on growth and sucking in preterm infants. The effect of nonnutritive sucking on transcutaneous oxygen tension in noncrying, preterm neonates. Effect of nonnutritive sucking on behavioral state in preterm infants before feeding.
Inactive awake behavioral states have been associated with reduced heart rates and more successful feeding in preterm infants. The purpose of this study was to test the efficacy of three different interventions to facilitate these optimal feeding states. Twenty preterm infants (gestational ages 27-33 weeks, M = 31.6, SD = 1.7; birth weights 931-2,140 grams, M = 34, SD = 373) serving as their own controls were randomly administered nonnutritive sucking, nonnutritive sucking plus rocking, and stroking interventions; and a control condition. There were significantly more inactive awake states with the nonnutritive sucking and nonnutritive sucking plus rocking interventions than with the stroking intervention and the control conditions. The results suggest that there are interventions that can help preterm infants in the transition from gavage to oral feeding and potentially shorten their hospital stays. Transition of preterm infants from enteral to nipple feeding is a necessary milestone for hospital discharge. This study tested the efficacy of one potential intervention to facilitate the transition process. Ten minutes of nonnutritive sucking (NNS) and a control condition were administered randomly before first nipple feedings. The sample consisted of 20 preterm infants (gestational ages 27-33 weeks, M = 31.6, SD = 1.7; birth weights 931-2, 140 g, M = 1,649, SD = 373) who served as their own controls. NNS resulted in fewer behavioral state changes during feedings and produced quiet, awake states more frequently during feedings. Heart rates did not differ between feedings following NNS compared with those in the control condition. Preterm neonates (mean 32 weeks' gestation, 1,300 gm birth weight) were provided a pacifier for nonnutritive sucking during tube feedings in the intensive care nursery. Their clinical course, subsequent bottle feeding behavior, and performance on the Brazelton Neonatal Behavior Assessment scale were compared with those of control group infants. The infants provided with pacifiers averaged 27 fewer tube feedings, started bottle feeding three days earlier, averaged a greater weight gain per day, and were discharged eight days earlier for an average hospital cost savings of approximately $3,500. Formula intake was similar for the two groups, although nurses appeared to provide more feeding stimulation for the control infants. On the Brazelton scale, the infants provided with pacifiers showed weak reflexes more frequently. Increased restfulness and diminished activity level in these infants may have contributed to the appearance of weak reflexes. The consistency between these findings and those of previous investigators suggests that the provision of a pacifier for nonnutritive sucking during tube feedings may be a cost-effective form of intervention. A laboratory and a field experiment used within-subject designs to test the hypothesis that nonnutritive sucking (NNS) reduces heart rate (HR) in preterm infants. Infants in Experiment A were provided a standard pacifier nipple for 30 min under strictly controlled conditions. In the field Experiment B, nursing staff provided infants with a standard pacifier during alternate intervals in a sequence of four interfeed intervals spanning 12 hr. NNS significantly reduced average HR in each experiment. Given the strongly positive relationship between HR and energy expenditure, these results suggest that NNS reduces energy expenditure in preterm infants. Such an effect, in turn, could help to explain how the opportunity to engage in NNS enhances growth in preterms. Ten healthy preterm infants were studied to determine if non-nutritive and nutritive suck significantly altered gastric emptying patterns when compared with gavage feeding alone. We used a 10% dextrose meal with phenol red marker and a double sampling technique to determine gastric emptying at 10-min intervals over a 30-min test period. A crossover study design compared the effects of the three feeding methods in each infant. The gastric residual volumes expressed in milliliters per kilogram did not differ significantly when comparisons were made among groups at 10, 20, and 30 min following the test meal. Non-nutritive suck and nutritive suck and swallow of a liquid dextrose meal do not significantly improve gastric emptying in healthy preterm infants. The beneficial effects of non-nutritive and nutritive sucking on the nutritional status of preterm infants, demonstrated by others, are not related to improved gastric evacuation of feeds. Alternative explanations for these beneficial effects require further investigation. Non-nutritive sucking in premature infants accelerates weight gain for unclear reasons. The effects of non-nutritive sucking on enteral hormone secretion may augment digestion and/or absorption of nutrients. Blood concentrations of gastrin, motilin, insulin and insulin-like growth factor-1 were measured before and 72 h after the initiation of nasogastric feedings in 21 premature infants randomly assigned to either a non-nutritive suckling or control group. Gastrin and motilin concentrations increased significantly after feedings in all infants (mean +/- SEM) (gastrin, 41 +/- 4 to 73 +/- 9 pg/ml, p < 0.01; motilin, 141 +/- 5 to 181 +/- 3 pg/ml, p < 0.01) Pre- and post-feed insulin concentrations were greater in the non-nutritive sucking group receiving bolus feeds than in control infants who were bolus-fed (P < 0.01). Non-nutritive sucking in premature infants does not appear to alter blood concentrations of motilin, gastrin, insulin or insulin-like growth factor-1 three days after initiation of feedings. If changes in the secretion of these hormones are induced by non-nutritive sucking, they may be at a local paracrine level. The purpose of this study was to examine the effect of prefeeding non-nutritive sucking (NNS) on breathing, nutritive sucking (NS), and behavioral characteristics of bottle feeding.
                The convenience sample was composed of 10 preterm infants who were 33 to 40 weeks postconceptual age (PCA) at the time of the observation.
                Randomized, crossover; each infant was observed twice during the first 48 hours of bottle feeding.
                Ten preterm infants received NNS before 1 bottle feeding and served as their own control at a second bottle feeding. Sucking was measured using a chin strain gauge and breathing was measured with a nasal thermistor. Behavioral characteristics included behavior state, measured using the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) behavior state scale, and feeding efficiency.
                Characteristics of NS (number of suck bursts, sucks/burst, suck burst length) and breathing (number of breath bursts, breaths/burst, breath burst length), as well as behavior state during bottle feedings and feeding efficiency (percent of prescribed formula consumed, formula consumed/minute of feeding).
                NS waves were smoother and more regular than NNS waves. Time to onset and duration of the first non-nutritive suck burst were positively correlated with time to onset for the first nutritive suck burst. Prefeeding NNS had no statistically significant effect on characteristics of breathing or on any other characteristics of NS. Behavioral state during feedings and feeding efficiency were not affected by prefeeding NNS.
                In this sample, the use of prefeeding NNS did not affect NS, breathing during feeding, or select behavioral characteristics of feeding. The present study investigated the way that sucking of a pacifier influences gastric secretory and motor functions in connection with tube feeding. Experiments were performed on eight preterm infants who were tube fed twice--once with and once without sucking of a pacifier. The time for tube feeding was significantly decreased and gastric retention decreased in five of seven infants when sucking a pacifier. Maternal milk was found to contain gastrin-17, somatostatin-14, and a somatostatin-like peptide larger than somatostatin-28. Somatostatin levels were significantly reduced in connection with non-nutritive sucking. Gastrin levels were increased in six of ten experiments 2 h and/or 3 h after bolus feeding, suggesting that these peptides were not only supplied by the milk, but were also released from the gastric mucosa. The presence of gastrin and somatostatin in gastric aspirates was established by use of chromatographic methods. The results indicate that somatostatin and gastrin are released into the gastric lumen in preterm infants and that sucking of a pacifier, in connection with bolus feeding, stimulates the gastric motor functions and facilitates the digestion process, probably via activation of vagal mechanisms. The effects of nonnutritive sucking (NNS) by means of a pacifier during gavage feeding were studied in 30 premature infants whose birth weight was less than 1,500 g. The addition of NNS accelerated the maturation of the sucking reflex, facilitating a more rapid transition from gavage to oral feedings. Additionally, NNS decreased intestinal transit time and caused a more rapid weight gain despite comparable caloric intake resulting in a shortened hospital stay. Although the physiologic mechanisms resulting from this form of oral stimulation remain to be investigated, our data suggest that NNS may be an important factor to consider in the feeding of premature infants. Behavioral and physiologic responsivity to nasogastric gavage feeding was assessed in 36 preterm infants on 2 consecutive d. On one of these days, a pacifier was provided during and after the gavage segment of the standardized protocol. The protocol was divided into segments that included baseline, preparatory handling, pregavage, gavage, and postgavage periods. Patterns of cardiac (heart period and vagal tone), oxygen saturation, behavioral state, and defensive behavioral responses to gavage were quantified. These stable preterm infants responded to handling and gavage feeding with reduction in heart period, vagal tone, and oxygen saturation. These responses were not altered by provision of a pacifier, although there was a tendency for fewer episodes of bradycardia and oxygen desaturation. Conversely, behavioral state was affected significantly by nonnutritive sucking: when provided with a pacifier, infants exhibited less behavioral distress, spent less time in fussy and active awake states during and after feeding, and returned to a sleep state significantly faster. There is converging evidence to suggest that nonnutritive sucking lessens behavioral distress to iatrogenic stressors but does not alter physiologic responsiveness. Forty-two pre-term infants were studied to determine the effect of nonnutritive sucking pre-feeding on behavioral state. Infants were randomly assigned to pacifier or rest groups. Pacifiers or rest were given for 5 minutes following routine caregiving and before each of the first 16 bottle feedings. A 12-category scale was used to measure state immediately before the 5-minutes and after. Frequencies of states that precede optimal feedings changed for infants given pacifiers versus rest: alert inactivity (+6 vs. -2), quiet awake (+19 vs. -6), and active awake (-24 vs. +12); infants given pacifiers had more sleep and fewer restless states. Group differences were non-significant before nonnutritive sucking (p = 0.16) but significant after (p = 0.00001). When self-regulatory feeding policies based on early hunger cues are not allowed, nonnutritive sucking for 5 minutes pre-feeding is simple, brief, and appropriate for busy intensive care units. These findings confirm those from earlier less conclusive research and indicate that nonnutritive sucking modulates behavioral state. To examine the effects of nonnutritive sucking on the physiologic and behavioral stress reactions of preterm infants at early bottle feedings and to examine the effect of nonnutritive sucking on the feeding performance of preterm infants at early bottle feedings.
                Quasi-experimental with a matched sample.
                A level III neonatal intensive-care unit in a large medical center.
                Twenty preterm infants whose gestational ages at birth ranged from 26 to 34 weeks.
                Ten infants were provided nonnutritive sucking for 5 minutes before and 5 minutes after an early bottle feeding. Ten infants served as controls.
                Physiologic stress was measured by heart rate and oxygen saturation rate. Behavioral stress was measured by observation of behavioral state. Feeding performance was measured by duration, percentage of formula taken by bottle, and behavioral state after feeding.
                Infants who received nonnutritive sucking before and after bottle feedings were more likely to be in a quiescent behavior state 5 minutes after the feeding (p = .01) and had higher feeding performance scores (p = .01) than infants who did not receive nonnutritive sucking. The purpose of this study was to examine the effects of nonnutritive sucking (NNS) on behavioral organization and feeding performance in preterm infants. Thirteen preterm infants were observed at four bottle-feedings, two of which involved treatment with prefeeding NNS. NNS had a positive effect on oxygen saturation and behavior state, as well as on the initiation and duration of the first nutritive suck burst. Fifty-nine infants, 28--34 weeks' gestation, were assigned to treatment and control groups. Treatment infants were offered a pacifier during and following every tube feeding; control infants received routine care. The treatment began when an infant could tolerate room air and 10 cc of full-strength formula by tube; it ended when the infant was totally bottle fed. Treated infants showed readiness for bottle feeding 3.4 days earlier, i.e., with 27 fewer tube feedings each. Performance during the first bottle feeding was assessed with a feeding scale and was statistically similar for both groups. From study entry to first bottle feeding the treated infants gained 2.6 gm/day more and were discharged 4 days sooner. Complications differed between the two groups. The effects of nonnutritive sucking (NNS) were studied in 40 preterm infants weighing less than or equal to 1800 g and of less than or equal to 35 weeks gestation by using a pacifier. The provision of NNS accelerated the maturation of sucking resulting in a faster transition from gavage to oral feedings. Treated infants (20) were ready for bottle feeds 1.54 days earlier, took their bottle feeds 1.5 min/30 ml faster and were transferred out of the nursery on an average .5 days earlier than the control infants. No adverse effects due to NNS were observed throughout the period of study. This resulted in an earlier union with their mother, less maternal deprivation and decreased work load on the nursery staff. Used judiciously this simple and safe modality of providing a pacifier for NNS during tube feeding may be useful in the management of preterm infants. The effect of nonnutritive sucking during gavage feeding on nutritional outcome and gastrointestinal transit time was evaluated in 18 premature appropriate for gestational age infants whose birth weights were less than or equal to 1,400 g and gestational ages were less than or equal to 30 weeks. Infants were randomized to a treatment (nonnutritive sucking infants received a pacifier for 30 minutes with each feeding, 12 times per day until they reached a weight of 1,500 g, eight times per day thereafter) or control (no pacifier) group. The nine nonnutritive sucking (five girls, four boys) and nine control (five girls, four boys) infants were treated for 14 days. Infants were without medical complications and were fed a single premature formula by intermittent gastric gavage at exactly 120 kcal/kg/d throughout the study period. Weight gain, linear growth, subscapular and triceps skinfold, and arm circumference accretions were assessed weekly. Serum proteins (albumin, prealbumin, retinol-binding protein, and transferrin) were measured weekly. Gastrointestinal transit times were measured weekly using carmine red markers. In contrast to previous studies, these data indicate no apparent effect of nonnutritive sucking on growth outcome, serum proteins, or gastrointestinal transit time in growing, very low birth weight infants when nutrient intake was controlled. In a subgroup of eight boys (four nonnutritive sucking, four control), energy and fat excretions were determined from 72-hour fecal collections and energy expenditure was estimated from six-hour cumulative heart rate measurements. Neither excretion of fat and calories nor estimated energy expenditure was affected significantly by nonnutritive sucking in this subgroup of baby boys. Fat excretion correlated well (r = .987) with energy excretion. nan To evaluate the effect of sweet taste stimulation in augmenting the reported growth-enhancing effects of nonnutritive sucking in preterm infants who are gavage-fed.
                Random assignment of preterm infants to receive stimulation by one of three methods during each feeding until totally orally fed.
                Hospital intensive-care and infant transitional units.
                Eligibility criteria included body weight greater than or equal to 1,250 g, gestational age younger than 34 weeks, growth parameters appropriate for gestational age, tolerating at least 100 kcals/kg/day by gavage feeding with evidence of weight gain, and no clinical evidence of health complications. Data are presented for 42 infants who completed 14 days of treatment.
                Exposure to a sweet pacifier, a latex pacifier, or maternal heartbeat sounds during gavage feedings.
                Growth, time to total oral feeding, and sucking responses.
                No significant differences in sucking measures were noted among treatment groups. Differences in progression time to total oral feedings and weight gain favored the sweet-pacifier group but were not statistically significant.
                Oral stimulation of gavage-fed, preterm infants during a 2-week hospitalization was not sufficient to elicit a significant improvement in growth efficiency, progression to total oral feedings, or sucking maturation. Additional studies may show a beneficial effect of chemosensory stimulation in preterm infants. nan To describe the effect of nonnutritive sucking (NNS) on behavioral state (BSt) in preterm infants before feedings 24 preterm infants were randomly assigned and studied before each of their first 16 bottle feedings. Twelve received NNS by pacifier for 5 minutes; 12 did not receive a pacifier. BSt was measured with a 12-category scale for 30 seconds before the 5-minute period (BSt1) and for 30 seconds after (BSt2). Sleep states decreased for both groups. BSts considered more optimal for feeding increased more during NNS (86 vs. 46). Restless states were three times less frequent after NNS (23 vs. 68). Differences between groups were nonsignificant at BSt1, but were significant at BSt2, p less than .001. In the absence of self-regulatory feeding policies based on early hunger cues, NNS for 5 minutes prefeeding is simple, brief, and suitable for implementation in busy neonatal intensive care units. Nonnutritive sucking was an effective modulator of behavioral state for this sample.
This review found a significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state).
The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects.