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Introduction The purpose of this study was to describe symptoms of problematic feeding in infants with tongue-tie, evaluate changes in non-nutritive suck measures before and after frenotomy, and examine tongue-tie severity with changes in non-nutritive suck patterning. Method Parents completed the Neonatal Eating Assessment Tool about infant feeding before frenotomy. Non-nutritive suck data were collected for 5 min before and after frenotomy. We used paired t-tests to compare non-nutritive suck measures pre- and post-frenotomy and linear regression evaluated the effect of tongue-tie severity and infant behavioral state on change in non-nutritive suck mechanics. Results Twenty-one infants had scores that met criteria for problematic feeding. The infant's non-nutritive suck amplitude (cmH2O) (p = .02) and non-nutritive burst duration (sec) (p = .03) decreased post-frenotomy. Discussion This study supports the need for additional research to better understand feeding problems and changes in non-nutritive suck amplitude and duration in infants with tongue-tie.

Aims To compare flow rates for Australian bottle/teat systems marketed as ‘slow’ or ‘extra-slow’ flow, and to examine flow consistency within each teat type. Methods Established assessment methods were used to test 27 types of teats. Fifteen teats of each type were tested by measuring the amount of infant formula extracted in 1-min by a breast pump system. Teats were compared within ‘slow’ and ‘extra-slow’ categories, a coefficient of variation was calculated for each teat type, and a cluster analysis was performed to group teats with similar flow. Results There was significant variability observed between teats in the same 'slow' and 'extra-slow' categories, and sometimes between teat brands. Cluster analysis revealed 5 clusters. Many teats were considered to have moderate to high variability in flow rate. Conclusions This study provides information regarding Australian bottle/teat systems. This is of relevance to those who support the neonatal bottle-feeding journey, particularly with premature or medically complex neonates.

Introduction: The Pediatric Eating Assessment Tool (PediEAT) is a parent-report tool to assess feeding problems in children aged six months to seven years. This study aims to translate and adapt the PediEAT tool to Persian and determine its psychometric properties. Methods: The PediEAT was translated and culturally adapted following guidelines for health-related instruments. Face and content validity was assessed using an expert panel. To evaluate Psychometric properties using a sample of 160 children without feeding problems and 43 children with diagnosed feeding problems. Using known-groups validation to compare PediEAT scores between children with and without feeding problems. In criterion validity, using pediatricians’ opinions as a criterion. To calculate Internal consistency using Cronbach's alpha. After two weeks, temporal stability was assessed with 40 parents who repeated the PediEAT tool. Results: Face and content validity showed that all tool items had CVI and kappa coefficients higher than 0.8. Known group validity showed that the total and subscale scores significantly differed between children with and without feeding problems (p .74). Test-retest reliability was acceptable (ICC = 0.987, p

Feeding difficulties are common in infants hospitalized in the NICU and can be a challenge to manage. The purpose of this article is to explain how and why the flow rate from the bottle nipple affects physiologic stability in infants and to describe the current evidence available on the flow rates of nipples used in the hospital and after discharge. Study results have indicated that flow rate varies widely among different types of nipples. Within the same type of nipple, there can be significant variability in flow from one nipple to another. Other factors, such as type of infant formula and thickening, also affect flow. Altering the flow rate of the bottle nipple is a relatively simple intervention that may support safe oral feeding.

Background Difficulties related to eating are often reported in children born preterm. The objective of this study was to quantitatively synthesize available data on the prevalence of problematic feeding in children under 4 years of age who were born preterm. Methods Literature was identified from PubMed, CINAHL, and PsycInfo. The search was limited to English language and publication years 2000–2020. To be included in the meta-analysis, the article had to report the prevalence of problematic oral feeding within a population of children born prematurely ( Results There were 22 studies that met inclusion criteria. Overall prevalence of problematic feeding (N = 4381) was 42% (95% CI 33–51%). Prevalence was neither significantly different across categories of gestational age nor by child age at the time of study. Few studies used psychometrically-sound assessments of feeding. Conclusion Problematic feeding is highly prevalent in prematurely-born children in the first 4 years of life regardless of degree of prematurity. Healthcare providers of children born preterm should consider screening for problematic feeding throughout early childhood as a potential complication of preterm birth. Systematic review registration number Not applicable.

Objective To compare the flow rates of formula of various thicknesses through bottle nipples. Design Multiple crossover design. Setting Laboratory experiment. Participants No human subjects. Methods We used established methods to test the flow rates of UltraPreemie; Preemie; Newborn; and Levels 1, 2, 3, and 4 nipples with three thicknesses of formula: thin, slightly thick, and mildly thick. We used descriptive statistics to calculate mean flow rates (milliliters per minute) and standard deviation, from which we calculated the coefficient of variation. We used cluster analysis to identify nipple types and thicknesses with comparable flow rates. Results Flow rates ranged from less than 1 ml/min for the Preemie nipple with mildly thick formula to 82.29 ml/min for the Level 4 nipple with thin formula. As expected, within each nipple type, increased thickness of formula resulted in decreased flow. Increased thickness of formula also resulted in an increased variability in flow rate. For nearly all nipple types, mildly thick consistency resulted in the greatest amount of variability in flow. We identified seven clusters of nipple types and formula thicknesses with comparable flow rates. Conclusion These data provide clinicians with information to guide decision making about nipple choice when thickened feedings are needed. Thickening increases the variability in flow rates, which is an important consideration for infants who are still learning to safely and effectively feed by mouth.

To adapt the Neonatal Eating Assessment Tool-Breastfeeding (NeoEAT-Breastfeeding) into Tamil, a language spoken in several South Asian countries, to identify the tool's factor structure, and to assess its psychometric properties.Cross-sectional.Tertiary care hospital in South India.A cohort of 323 mothers of infants ages 1 week to 7 months, including infants with and without feeding difficulties.To adapt the English tool to Tamil, we followed standard procedures specified by the tool developers and international guidelines for tool translation and adaptation, including pilot testing and personal interviews with participants who had infants younger than 7 months. Participants completed the NeoEAT-Breastfeeding (Tamil) after assessment of breastfeeding by professionals. The 62-item tool involves rating each item on a 6-point scale, and higher scores indicate increased feeding difficulties.After exploratory factor analysis, we divided the tool into five subscales in the Tamil version compared to the seven subscales in the original English version. The Tamil version demonstrated high internal consistency reliability (Cronbach's α = 0.97) and test-retest reliability (intraclass correlation = 0.99) for the total scores. Infants with feeding concerns demonstrated significantly higher total and subscale scores on the NeoEAT-Breastfeeding (Tamil) than infants without feeding concerns (p = .000; construct validity).The NeoEAT-Breastfeeding (Tamil) holds promise as a culturally appropriate, clinically useful parent-report tool with evidence for initial reliability and validity for identifying feeding-related concerns among infants younger than 7 months in the Tamil-speaking population.

Aim The aims of this systematic review were to first identify and summarise original research that compared symptoms of problematic feeding in infants with tongue tie before and after frenotomy and then evaluate the quality of measures used to assess problematic feeding. Methods CINAHL and PubMed were searched for ((tongue-tie) or (ankyloglossia)) and ((feeding) or (breastfeeding) or (bottle-feeding)) and ((frenotomy) or (frenectomy) or (frenulectomy) or (frenulotomy)). Original research reporting on feeding before and after frenotomy in infants under 1 year old was included. Results Maternal nipple pain, breastfeeding self-efficacy and LATCH scores improved after frenotomy. Few data are available on the effect of frenotomy on infant feeding. The measures used to assess infant feeding were not comprehensive and did not possess strong psychometric properties. Conclusion Literature suggests that maternal nipple pain, self-efficacy and LATCH scores improve in breastfeeding mother-infant dyads after frenotomy. However, current literature does not provide adequate data regarding the effect of frenotomy on the infant's ability to feed or which infants benefit from the procedure. Future research should utilise comprehensive, psychometrically sound measures to assess infants for tongue tie and to evaluate infant feeding to provide stronger evidence for the effect of frenotomy on feeding in infants with tongue tie.

The purpose of this study was to describe the development of the Gastrointestinal and Gastroesophageal Reflux (GIGER) Scale for Infants and Toddlers, and determine its factor structure and psychometric properties. Items were developed to comprehensively assess gastrointestinal (GI) and gastroesophageal reflux (GER) symptoms observable by a parent. Exploratory factor analysis on 391 responses from parents of children under 2 years old resulted in a 36-item scale with 3 subscales. Internal consistency reliability was acceptable (α = .78-.94). The GIGER total score and all 3 subscales were correlated with the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) ( P

Infant massage is an ancient therapeutic technique used around the world. For infants who experience painful procedures, are exposed to the stressful NICU environment, and are separated from their parents, infant massage has been promoted as a method to reduce stress and promote bonding. In this article, we review the current literature on infant massage in the NICU. There is evidence that infant massage has beneficial effects on preterm infants in the NICU, including shorter length of stay; reduced pain; and improved weight gain, feeding tolerance, and neurodevelopment. Parents who performed massage with their infants in the NICU reported experiencing less stress, anxiety, and depression. Neonatal nurses can obtain education and certification in infant massage and can teach parents infant massage techniques, thereby promoting the health and well-being of parent–infant dyads.

This article describes the development and content validation of the Child Oral and Motor Proficiency Scale (ChOMPS), a parent-report assessment of eating, drinking, and related skills in children 6 months to 7 years of age. Initially, 69 items for the ChOMPS were generated from literature review. Nineteen professionals evaluated the ChOMPS using content validity indices (CVI). Significant revisions were made to items and directions based on professional feedback. CVI were acceptable for both the relevance and clarity of items. Cognitive interviews were then conducted with 19 parents to explore parent understanding of items. Additional revisions were made based on parent feedback. The reading grade level of the resulting ChOMPS was less than sixth grade. The 70-item ChOMPS has evidence of content validity, indicating the items are relevant and clear to professionals, and parents understand the directions and items as intended.

The purpose of this study was to identify the factor structure of the Child Oral and Motor Proficiency Scale (ChOMPS) and to evaluate the psychometric properties, including internal consistency reliability, test–retest reliability, and construct validity as measured by convergent and known-groups validity. Principal component analysis with varimax rotation conducted on responses from 364 parents of children between 6 months and 7 years of age identified four subscales: complex movement patterns, basic movement patterns, oral-motor coordination, and fundamental oral-motor skills. Acceptable internal consistency reliability (Cronbach’s α = .97) and test–retest reliability ( r = .98) were found. Convergent and known-groups validity were supported by significant associations between the ChOMPS and validation measures, as well as significant differences in the ChOMPS scores between children with and without feeding problems. The ChOMPS is a 63-item parent-report measure of eating, drinking, and related motor skills in children aged 6 months to 7 years with evidence of reliability and validity.

The Neonatal Eating Assessment Tool (NeoEAT)-Bottle-feeding is a parent-report assessment of bottle-feeding behavior in infants less than 7 months old with evidence of validity and reliability. The purpose of this study was to establish norm-reference values to guide score interpretation and clinical decision making. Parents of 478 healthy, typically developing infants completed the NeoEAT-Bottle-feeding. Descriptive statistics were calculated for the following age groups: 0 to 2, 2 to 4, 4 to 6, and 6 to 7 months. NeoEAT-Bottle-feeding total scores decreased with increasing infant age. The Infant Regulation subscale contributed the most to the total score and remained high across the first 6 months of life, then decreased dramatically in the 6- to 7-month age group. The 90th and 95th percentile values for the total score and subscale scores can be used to identify infants with problematic feeding, guide referral, tailor treatment, and assess response to treatment.

Describe symptoms of feeding problems in children born very preterm (32 weeks gestation) and moderate to late preterm (32-37 weeks gestation) compared to children born full-term; explore the contribution of medical risk factors to problematic feeding symptoms.The sample included 57 very preterm, 199 moderate to late preterm, and 979 full-term born children ages 6 months to 7 years. Symptoms of feeding problems were assessed using the Pediatric Eating Assessment Tool and compared between groups after accounting for the child's age and/or sex. With the sample of preterm children, we further analyzed 11 medical factors as potential risk factors affecting a child's feeding symptoms: feeding problems in early infancy and conditions of oxygen requirement past 40 weeks of postmenstrual age, congenital heart disease, structural anomaly, genetic disorder, cerebral palsy, developmental delay, speech-language delay, sensory processing disorder, vision impairment, or symptoms of gastroesophageal reflux.Compared to children born full-term, both very preterm and moderate to late preterm born children had significantly higher scores on the Pediatric Eating Assessment Tool total scale and all 4 subscales. More severe symptoms were noted in very preterm children, particularly in the areas of Physiologic Symptoms and Selective/Restrictive Eating. Among preterm children, all 11 medical factors were found to be associated significantly with increased symptoms of feeding problems.Compared to children born full-term, preterm born children demonstrated greater symptoms of feeding problems regardless of their current age, suggesting children born preterm may require more careful monitoring of feeding throughout childhood.

Children with CHD often experience difficulty with oral feeding, which contributes to growth faltering in this population. Few studies have explored symptoms of problematic feeding in children with CHD using valid and reliable measures of oral feeding. The purpose of this study was to describe symptoms of problematic feeding in children with CHD compared to healthy children without medical conditions, taking into account variables that may contribute to symptoms of problematic feeding. Oral feeding was measured by the Pediatric Eating Assessment Tool, a parent report assessment of feeding with evidence of validity and reliability. This secondary analysis used data collected from web-based surveys completed by parents of 1093 children between 6 months and 7 years of age who were eating solid foods by mouth. General linear models were used to evaluate the differences between 94 children with CHD and 999 children without medical conditions based on the Pediatric Eating Assessment Tool total score and four subscale scores. Covariates tested in the models included breathing tube duration, type of CHD, gastroesophageal reflux, genetic disorder, difficulty with breast- or bottle-feeding during infancy, cardiac surgery, and current child age. Children with CHD had significantly more symptoms of problematic feeding than healthy children on the Pediatric Eating Assessment Tool total score, more physiologic symptoms, problematic mealtime behaviours, selective/restrictive eating, and oral processing dysfunction (p

Objectives: Reflux is common in infancy; however, persistent signs and symptoms of gastrointestinal distress are often attributed to gastroesophageal reflux disease (GERD). In this pilot study, we aimed to characterize associations between signs and symptoms of suspected GERD and noninvasive markers of intestinal inflammation in preterm infants. Methods: We reviewed Electronic Medical Record (EMR) data to identify clinical signs and symptoms among case patients (n = 16). Controls (n = 16) were matched on gestational age. Univariate and multivariate regression analyses were used to compare fecal calprotectin and urinary intestinal fatty acid binding protein (I-FABP) levels between cases and controls. Results: We found no differences in baseline characteristics between cases and controls. In the multivariate regression analysis controlling for the proportion of mother’s milk, cases had higher fecal calprotectin levels than controls, with no differences in I-FABP levels between cases and controls. Conclusion: Our findings suggest that preterm infants with signs and symptoms of GERD have higher levels of intestinal inflammation as indicated by fecal calprotectin compared to their controls. Further studies are needed to evaluate the role of intestinal inflammation in signs and symptoms of gastrointestinal distress and whether fecal calprotectin might have predictive value in diagnosing GERD.

Purpose The purpose of this study was to evaluate the effect of infant formula type and preparation (i.e., ready-to-feed vs. powder) on International Dysphagia Diet Standardisation Initiative (IDDSI) thickness level and milk flow rates from bottle teats/nipples. Method The ready-to-feed and powder formulations of the following products were tested for IDDSI thickness level, using IDDSI guidelines, and for milk flow rate, using established flow testing methods: Similac Advance, Similac For Spit-Up, Enfamil Infant, and Enfamil A.R. Analysis of variance was used to compare flow rates among formula types/preparations. Results Enfamil A.R. ready-to-feed was classified as IDDSI “slightly thick.” All other formula types/preparations were found to be IDDSI “thin” liquids. The standard infant formulas (Similac Advance and Enfamil Infant) had comparable flow rates to each other, regardless of preparation (ready-to-feed and powder). The gastroesophageal reflux–specific formulas (Similac For Spit-Up and Enfamil A.R.) had slower flow rates than the standard formulas; within this category, there were significant differences in flow rates between ready-to-feed and powder. Enfamil A.R. powder had the slowest flow rate, but was the most variable. Conclusion For infants with difficulty coordinating sucking, swallowing, and breathing, clinicians and parents should consider the impact that changes to infant formula type and preparation may have on the infant's ability to safely feed.

Introduction: Feeding problems are often reported in infants after cardiac surgery. To date, no studies have followed the development of feeding after cardiac surgery using valid and reliable measures. Purpose: To describe feeding problems and the relationship between feeding and gastrointestinal tract symptoms in infants over the first 6 months (mos) after neonatal cardiac surgery. Methods: Parents of neonates requiring cardiac surgery were invited to complete surveys when their infant was 2, 4, and 6 mos old. The survey included the Neonatal Eating Assessment Tool (NeoEAT), Infant Gastroesophageal Reflux Questionnaire – Revised (I-GERQ-R), and Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Scores on the NeoEAT subscales ( Infant Regulation, Energy & Physiologic Stability, Gastrointestinal Tract Function, Sensory Responsiveness , and Compelling Symptoms of Problematic Feeding) were categorized as problematic (≥ 90 th percentile) or not problematic (< 90 th percentile) based on reference data. Percent of the sample with problematic feeding at each time point was determined. Bivariate correlations were calculated between the NeoEAT, IGSQ, and I-GERQ-R. Results: 27 parents completed the surveys, reporting on 6 infants with single ventricle and 21 with two ventricle conditions. Problematic feeding scores were common at all times and in both cardiac conditions. Problematic scores were reported on Compelling Symptoms of Problematic Feeding for 52% of the sample at 2 mos, 36% at 4 mos, and 22% at 6 mos. Problematic scores occurred in Gastrointestinal Tract Function for 22% at 2 mos, 10% at 4 mos, and 39% at 6 mos. Problems occurred in Sensory Responsiveness in 17% at 2 mos, 24% at 4 mos, and 33% at 6 mos. Energy & Physiologic Stability problems occurred in 13%, 10%, and 22%, respectively. None reported problems in Infant Regulation . Symptoms of gastroesophageal reflux (I-GERQ-R) were significantly correlated with the NeoEAT ( p < .05), but gastrointestinal symptoms (IGSQ) were not. Conclusions: Problematic feeding is common in the first 6 mos after neonatal cardiac surgery and is related to gastroesophageal reflux symptoms. Some areas of feeding improved over time, while others worsened, likely related to developmental and disease-related changes.

BACKGROUND The Neonatal Eating Assessment Tool-Mixed Breastfeeding and Bottle-feeding (NeoEAT-Mixed Feeding) is a parent-report assessment of symptoms of problematic feeding in infants who are feeding by both breast and bottle. PURPOSE To establish reference values for the NeoEAT-Mixed Feeding and evaluate factors that contribute to symptoms of problematic feeding in healthy, full-term infants. METHODS Parents of 409 infants less than 7 months old completed an online survey. Median and percentile scores are presented for infants aged 0-2, 2-4, 4-6, and 6-7 months old. RESULTS Neonatal Eating Assessment Tool-Mixed Feeding total score and scores for the Gastrointestinal Tract Function and Energy & Physiologic Stability subscales decreased with increasing infant age. Infant Regulation and Feeding Flexibility subscale scores remained stable over time, whereas Sensory Responsiveness subscale scores increased with increasing infant age. Infants with more gastrointestinal symptoms had higher NeoEAT-Mixed Feeding total scores. IMPLICATIONS FOR PRACTICE The reported reference values may be used to identify infants in need of further assessment, referral, and intervention. In healthy, full-term infants with concurrent gastrointestinal symptoms and problematic feeding, interventions targeted at gastrointestinal symptoms may help to improve symptoms of problematic feeding as well.

Many infants in the NICU experience difficulties with oral feeding, which contribute to prolonged length of stay. Oral feeding is a complex task involving sensorimotor functioning of the face, mouth, and larynx, as well as coordination of sucking, swallowing, and breathing. The care provided in the NICU starting at birth sets the stage for future oral feeding. The purpose of this article is to describe strategies that will establish a positive foundation to support optimal oral feeding. Nurses can use these strategies to protect newborns from noxious stimuli and promote positive auditory, tactile, gustatory, and olfactory experiences to optimize neurodevelopment for the complex task of feeding.

The purpose of this study was to identify the factor structure of the Neonatal Eating Assessment Tool-Breastfeeding (NeoEAT-Breastfeeding) and to assess its psychometric properties, including internal consistency reliability, test-retest reliability, and construct validity as measured by concurrent and known-groups validity. Exploratory factor analysis conducted on responses from 402 parents of breastfeeding infants younger than 7 months old showed a 62-item measure with seven subscales and acceptable internal consistency reliability (Cronbach's α = .92). Test-retest reliability was also acceptable (r = .91). The NeoEAT-Breastfeeding has evidence of concurrent validity with the Infant Gastroesophageal Reflux Questionnaire (r = .69) and Infant Gastrointestinal Symptoms Questionnaire (r = .62). The NeoEAT-Breastfeeding total score and all subscale scores were higher in infants with feeding problems than in typically feeding infants (p .001, known-groups validity). The NeoEAT-Breastfeeding is a parent-report assessment of breastfeeding in infants from birth to 7 months old with good initial evidence of reliability and validity.

Background Evidence supports the superiority of mother's own milk (MOM) in reducing the comorbidities common to prematurity and very low birth weight. In situations where an insufficient amount of MOM is available or maternal contraindications prevent its use, pasteurized donor human milk (DHM) is a viable substitution. When DHM is deemed best, a common practice in many neonatal intensive care units (NICUs) is for parents to provide their consent. However, no universal mandate for informed consent exists. Often, healthcare providers present and obtain the consent for DHM use prior to delivery or shortly after birth and this consent may be "bundled" along with other standardized NICU treatment consents. This approach is likely less than ideal since it provides insufficient time for decision making and often precedes the mother's ability to initiate the expression of her own milk. Purpose To review the history of DHM use and the ethics surrounding the consenting process including the ethical principles involved in infant feeding decision making. We argue for the standardization and consistent use of informed consent for DHM in the NICU and offer clinical practice implications. Findings/results/implications for practice and research Providers face several challenges in the consenting process for the use of DHM in the NICU setting. These include limited time to support parents and educate them appropriately during the decision-making process. Standardized and consistent use of informed consent is essential to address the ethical concerns surrounding the use of DHM in the NICU setting.

To describe symptoms of gastrointestinal distress experienced by healthy, full-term infants in the first 7 months of life and test the psychometric properties of the Infant Gastrointestinal Symptoms Questionnaire (IGSQ).Parents of infants7 months (n = 320) completed the IGSQ, the Infant Gastroesophageal Reflux Questionnaire - Revised (I-GERQ-R), and the Neonatal Eating Assessment Tool (NeoEAT) - Breastfeeding and/or Bottle-feeding. Median and percentile scores were calculated for the IGSQ scores for each age group: 0-2, 2-4, 4-6, and 6-7 months. Change in IGSQ scores with age were evaluated using the Kruskal-Wallis test with Mann-Whitney U tests for post-hoc comparisons. Internal consistency reliability was assessed using Cronbach's alpha. Concurrent validity was tested using Spearman's rho between the IGSQ and the I-GERQ-R and NeoEAT.IGSQ scores decreased significantly with increased infant age, from a median of 28 at 0-2 months to 23 at 6-7 months old. The IGSQ had acceptable internal consistency reliability (Cronbach's alpha = 0.74). IGSQ total score was significantly correlated with I-GERQ-R total score (Spearman's rho (rGastrointestinal symptoms decrease with increasing age in the first 7 months of life. The IGSQ has evidence of acceptable internal consistency reliability and concurrent validity.These data can be used to guide IGSQ score interpretation.

Objective To describe the range of symptoms of gastroesophageal reflux in healthy, full-term infants in the first 7 months of life. Design Cross-sectional, descriptive study. Median and percentile scores for the Infant Gastroesophageal Reflux Questionnaire–Revised (I-GERQ-R) were calculated for each of the following age groups of infants: 0 to 2, 2 to 4, 4 to 6, and 6 to 7 months. Psychometric properties, including internal consistency reliability and concurrent validity of the I-GERQ-R, were also tested. Setting Online. Participants Primary caregivers of 559 healthy, full-term (≥37 weeks gestational age) infants younger than 7 months. Measurements Participants were asked to answer questions about themselves, their family, and their infant and to complete the I-GERQ-R, the Infant Gastrointestinal Symptoms Questionnaire, and the Neonatal Eating Assessment Tool. Results Symptoms of gastroesophageal reflux decreased over the first 7 months of life. Scores in the 95th percentile decreased from 19 in infants 0 to 2 months old to 16.7 in infants 6 to 7 months old. Internal consistency reliability of the I-GERQ-R was acceptable (Cronbach’s α = .71). The I-GERQ-R had evidence of concurrent validity with the Infant Gastrointestinal Symptoms Questionnaire (rs = .69, p Conclusions Authors of prior studies used a cutoff score of 16 for the diagnosis of gastroesophageal reflux disease in infants younger than 18 months. Our results indicate that symptoms of reflux change with age over the first 7 months of life and that using more age-specific reference values may be more appropriate. Health care providers can use these age-specific percentile scores, together with clinical assessment, to identify significant symptomatology related to gastroesophageal reflux disease.

Gastroesophageal reflux is common in young infants, particularly those born prematurely or with a history of medical complexity. The most recent clinical practice guidelines recommend the use of nonpharmacologic management strategies because of concerns about the safety of acid-reducing medications and a lack of evidence of their effectiveness. Our purpose in this article is to holistically review the pathophysiology of gastroesophageal reflux disease, identify symptom management targets, and describe nonpharmacologic strategies that nurses can implement and/or teach to parents to manage symptoms of gastroesophageal reflux. Strategies targeting stress, dysbiosis, food intolerances, feeding difficulties, and positioning are discussed. Nurses can work with families to identify factors contributing to gastroesophageal reflux disease and determine individualized strategies that can be used in lieu of, or in addition to, medication.

Background The Neonatal Eating Assessment Tool—Breastfeeding is a valid and reliable 62-item parent-report assessment of symptoms of problematic breastfeeding behavior intended for infants less than 7 months old. Research aim The aim of this study was to describe the Neonatal Eating Assessment Tool—Breastfeeding total score and subscale scores within a sample of full-term, healthy, typically-developing infants under 7 months old. Methods Parents of healthy, full-term breastfeeding infants ( N = 475) less than 7 months old completed the Neonatal Eating Assessment Tool – Breastfeeding through an online survey. Descriptive statistics were calculated for the total score and seven subscale scores within each age group: 0–2, 2–4, 4–6, and 6–7 months. Results Neonatal Eating Assessment Tool—Breastfeeding total scores were highest (i.e., more problematic symptoms) at 0–2 months and decreased in older infant age groups. All subscale scores also had a downward trajectory in symptoms of problematic breastfeeding except the subscale Compelling Symptoms of Problematic Feeding, which was very low across age groups. Conclusion The Neonatal Eating Assessment Tool—Breastfeeding now has reference values to facilitate interpretation of scores and guide decision-making, personalization of interventions, and assessment of response to interventions. For research, the Neonatal Eating Assessment Tool—Breastfeeding can be used to follow longitudinal development of breastfeeding as well as to test efficacy of breastfeeding interventions.

Objective To explore parents' descriptions of and concerns about their infants' feeding in the first 6 months of life. Design Descriptive study. Setting Online survey. Participants We recruited 29 parents of infants younger than 7 months old from a variety of online local, regional, and international communities to complete a survey about their infants' feeding. Measurements The survey included a combination of selection and open-text entry questions. Qualitative data from open-text questions were analyzed with directed content analysis to identify factors that influenced infant feeding. Two coders coded all data. Results Concerns about feeding were common, and many parents made changes to facilitate feeding. Parents described characteristics of the infant (e.g., temperament), the task of feeding (e.g., milk flow), and factors external to the infant (e.g., breast anatomy) that affected feeding. Although some parents described feeling happy, calm, and bonded during feeding, others described feeling terrified, anxious, and worried. Health care providers played a significant role in helping parents navigate feeding, but they sometimes provided conflicting and even unsafe advice. Conclusion Understanding the experience of feeding from the parent perspective may help to identify targets for intervention to support parents and infants when feeding is difficult.

Background Infants in the neonatal intensive care unit (NICU) are exposed to many stressors. There is growing evidence that chronic stress early in life has long-term neurodevelopmental implications. Skin-to-skin care (SSC) is an intervention used to reduce stress in the NICU. Clinical question In premature infants in the NICU, what is the available evidence that SSC improves short-term physiologic stress outcomes compared with incubator care? Search strategy PubMed and CINAHL were searched for terms related to SSC, stress, physiology, and premature infants. Of 1280 unique articles, 19 were identified that reported on research studies comparing SSC with incubator care in the NICU and reported stress-related physiologic outcome measures. Results Although there have been some mixed findings, the research supports that SSC improves short-term cardiorespiratory stress outcomes compared with incubator care. The evidence is clearer for studies reporting stress hormone outcomes, with strong evidence that SSC reduces cortisol and increases oxytocin levels in preterm infants. Implications for practice and research SSC is safe and has stress-reducing benefits. SSC should be considered an essential component to providing optimal care in the NICU. More research is needed to determine the timing of initiation, duration, and frequency of SSC to optimize the stress-reducing benefits. Future research should include the most fragile infants, who are most likely to benefit from SSC, utilize power analyses to ensure adequate sample sizes, and use sophisticated data collection and analysis techniques to more accurately evaluate the effect of SSC on infants in the NICU.

Aim The aim of this study was to report an analysis of the concept of pediatric feeding problems. Background Reviews of the literature on pediatric feeding problems and disorders repeatedly reference the lack of a shared conceptualization of feeding problems. It is difficult to track aetiology, prevalence and incidence of a phenomenon when available definitions and diagnoses lack practical utility. Design An evolutionary concept analysis. Data sources A search was conducted in October 2014 of Google Scholar, CINAHL, PubMed and Web of Science databases, with MeSH terms and key words including: failure to thrive, feeding disorder/difficulty/problems, infantile anorexia, oral aversion, mealtime behaviour and dysphagia. Inclusion criteria were: subject of feeding problems, index children 0-10 years of age, English language and full text. Methods The articles (n = 266) were sorted into disciplines of authorship, including Psychology, Medicine, Nursing, Nutrition, Occupational Therapy, Speech Language Pathology or Other. The sample was divided into a historical sample (n = 42) for pre-2000 articles and current for those published post-2000. The current sample was later reduced to 100 and coded for surrogate terms, related concepts, attributes, antecedents and consequences. Results The historical view of pediatric feeding problems shows a tradition of mother blame or parental culpability, both direct and indirect. Currently, there exist many different definitions and typologies, but none have sound validity or generalizability. Areas of attribute consensus across disciplines are problematic feeding behaviours and selective or restrictive intake. Conclusion A spectrum conceptualization of feeding problems is suggested for further development, with attributes that would be critical to have a feeding problem.

Purpose: Feeding difficulties in early childhood are common, affecting approximately 25% of typically developing children and up to 80% of children with developmental disabilities. There is no interdisciplinary consensus on the definition of a feeding problem and there is no input from families in the conceptualization. Lack of common language is a barrier to effective communication between clinicians, researchers, and caregivers, and inhibits collaboration. The purpose of this study was to examine the conceptualization of pediatric feeding problems by family caregivers (parents). Study Design and Methods: This study reports an empirical phase of a concept analysis. Data from interviews with 12 parents of children with feeding problems were coded for related concepts, attributes, antecedents, and consequences of feeding problems, and then analyzed for themes within conceptual categories. Results: Conceptual elements across interviews are presented with an emphasis on shared perspectives. Parents related pediatric feeding problems to be a process or journey on which they found themselves for an unknown duration. Common themes of attributes were problematic feeding behaviors of the child, restrictive or selective intake, and child weight or growth concerns. Clinical Implications: Parents conceptualize feeding problems as a condition with symptoms experienced by the child and family that need to be incorporated into family life. In contrast, prior literature coming from providers' point of view presents this problem to be of the child. Nurses can improve care of families with children who have feeding problems by coordinating interdisciplinary, family-centered care.

Infants with hypoplastic left heart syndrome often experience difficulty with oral feeding, which contributes to growth failure, morbidity, and mortality. In response to feeding difficulty, clinicians often change the bottle nipple, and thus milk flow rate. Slow-flow nipples have been found to reduce the stress of feeding in other fragile infants, but no research has evaluated the responses of infants with hypoplastic left heart syndrome to alterations in milk flow. The purpose of this study was to evaluate the physiological and behavioural responses of an infant with hypoplastic left heart syndrome to bottle feeding with either a slow-flow (Dr. Brown’s Preemie) or a standard-flow (Dr. Brown’s Level 2) nipple. A single infant was studied for three feedings: two slow-flow and one standard-flow. Oral feeding, whether with a slow-flow or a standard-flow nipple, was distressing for this infant. During slow-flow feeding, she experienced more coughing events, whereas during standard-flow she experienced more gagging. Disengagement and compelling disorganisation were most common during feeding 3, that is slow-flow, which occurred 2 days after surgical placement of a gastrostomy tube. Clinically significant changes in heart rate, oxygen saturation, and respiratory rate were seen during all feedings. Heart rate was higher during standard-flow and respiratory rate was higher during slow-flow. Further research is needed to examine the responses of infants with hypoplastic left heart syndrome to oral feeding and to identify strategies that will support these fragile infants as they learn to feed. Future research should evaluate an even slower-flow nipple along with additional supportive feeding strategies.

PurposeThis study tested the milk flow rates and variability in flow of currently available nipples used for bottle-feeding infants who are hospitalized.MethodClinicians in 3 countries were surveyed regarding nipples available to them for feeding infants who are hospitalized. Twenty-nine nipple types were identified, and 10 nipples of each type were tested by measuring the amount of infant formula expressed in 1 min using a breast pump. Mean milk flow rate (mL/min) and coefficient of variation were used to compare nipples within brand and within category (i.e., Slow, Standard, Premature).ResultsFlow rates varied widely between nipples, ranging from 2.10 mL/min for the Enfamil Cross-Cut to 85.34 mL/min for the Dr. Brown's Y-Cut Standard Neck. Variability of flow rates among nipples of the same type ranged from a coefficient of variation of 0.05 for Dr. Brown's Level 1 Standard- and Wide-Neck to 0.42 for the Enfamil Cross-Cut. Mean coefficient of variation by brand ranged from 0.08 for Dr. Brown's to 0.36 for Bionix.ConclusionsMilk flow is an easily manipulated variable that may contribute to the degree of physiologic instability experienced by infants who are medically fragile during oral feeding. This study provides clinicians with information to guide appropriate selection of bottle nipples for feeding infants who are hospitalized.

Preterm infants frequently experience oral feeding challenges while in the neonatal intensive care unit, with research focusing on infant feeding during this hospital stay. There is little data on symptoms of problematic feeding in preterm-born infants in the months after discharge. The purpose of this study was to describe symptoms of problematic bottle-feeding in the first 7 months of life in infants born preterm, compared to full-term infants. Parents of infants less than 7 months old completed an online survey that included the Neonatal Eating Assessment Tool—Bottle-feeding and questions about the infant’s medical and feeding history. General linear models were used to evaluate differences in NeoEAT—Bottle-feeding total score and subscale scores by preterm category, considering other significant factors. Very preterm infants had more symptoms of problematic bottle-feeding than other infants. Current age, presence of gastroesophageal reflux, and anomalies of the face/mouth were associated with problematic bottle-feeding.

Supporting infants as they develop feeding skills is an essential component of neonatal and pediatric care. Selecting appropriate and supportive interventions begins with a thorough assessment of the infant's skills. The Early Feeding Skills (EFS) tool is a clinician-reported instrument developed to assess the emergence of early feeding skills and identify domains in need of intervention.The purpose of this study was to identify the factor structure of the EFS and test its psychometric properties, including internal consistency reliability and construct validity.EFS-trained interprofessional clinicians in 3 settings scored 142 feeding observations of infants 33 to 50 weeks' postmenstrual age. Redundant and rarely endorsed items were removed. Factor analysis methods clustered items into subscales. Construct validity was examined through the association of the EFS with (1) concurrently scored Infant-Driven Feeding Scale-Quality (IDFS-Q), (2) infant birth risk (gestational age), and (3) maturity (postmenstrual age).Principal components analysis with varimax rotation supported a 5-factor structure. The total EFS demonstrated good internal consistency reliability (Cronbach α= 0.81). The total EFS score had construct validity with the IDFS-Q (r =-0.73; P.01), and with gestational age of a subsample of premature infants (r = 0.22; P.05).As a valid and reliable tool, the EFS can assist the interprofessional feeding team to organize feeding assessment and plan care.The strong psychometric properties of the EFS support its use in future research.

Milk flow rate may play an important role in an infant's ability to safely and efficiently coordinate sucking, swallowing, and breathing during feeding.To test milk flow rates from bottle nipples used in the hospital and after discharge.Bottle nipples used in hospitals (10 unique types) and available nationwide at major retailers (15 unique types) were identified. For each of the 25 nipple types, 15 nipples of that type were tested by measuring the amount of infant formula extracted in 1 minute by a breast pump. Mean milk flow rate (mL/min) and coefficient of variation (CV) were calculated for each nipple type. Comparisons between nipple types were made within brand and within category (eg, Slow, Standard). A cluster analysis was conducted to identify nipples of comparable flow.A total of 375 individual nipples were tested. Milk flow rates varied widely, from 0.86 to 37.61 mL/min. There was also a wide range of CVs, from 0.03 to 0.35. Packing information did not accurately reflect the flow rates of bottle nipples. The cluster analysis revealed 5 clusters of nipples, with flow rates from Extra Slow to Very Fast.These data can be used to guide decisions regarding nipples to use for feeding infants with medical complexity in the hospital and after discharge.Research on infant feeding should consider the flow rate and variability of nipples used, as these factors may impact findings.

Advances in neonatal care have allowed for the increasing survival of critically ill infants. These infants experience significant stress related to painful procedures and physical separation from their parents. The purpose of this article is to describe the physiologic stress mechanisms that contribute to mortality and morbidity in infants in the NICU and the physiologic mechanisms by which skin-to-skin care (SSC) acts on the stress response system. Findings from current literature supporting the use of SSC and barriers and facilitators to implementation are reviewed. SSC is a safe and effective intervention to reduce stress for infants and their parents. Nurses play a key role in facilitating SSC to optimize outcomes of care in the NICU.

Feeding difficulties are common in infancy. There are currently no valid and reliable parent-report measures to assess bottle-feeding in infants younger than 7 months. The Neonatal Eating Assessment Tool (NeoEAT)-Bottle-feeding has been developed and content validated.To determine the factor structure and psychometric properties of the NeoEAT-Bottle-feeding.Parents of bottle-feeding infants younger than 7 months were invited to participate. Exploratory factor analysis was used to determine factor structure. Internal consistency reliability was tested using Cronbach α. Test-retest reliability was tested between scores on the NeoEAT-Bottle-feeding completed 2 weeks apart. Construct validity was tested using correlations between the NeoEAT-Bottle-feeding, the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R), and the Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Known-groups validation was tested by comparing scores between healthy infants and infants with feeding problems.A total of 441 parents participated. Exploratory factor analysis revealed a 64-item scale with 5 factors. Internal consistency reliability (α= .92) and test-retest reliability (r = 0.90; P.001) were both excellent. The NeoEAT-Bottle-feeding had construct validity with the I-GERQ-R (r = 0.74; P.001) and IGSQ (r = 0.64; P.001). Healthy infants scored lower on the NeoEAT-Bottle-feeding than infants with feeding problems (P.001), supporting known-groups validity.The NeoEAT-Bottle-feeding is an available assessment tool for clinical practice.The NeoEAT-Bottle-feeding is a valid and reliable measure that can now be used in feeding research.Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Differentiating problematic feeding from variations of typical behavior is a challenge for pediatric providers. The Pediatric Eating Assessment Tool (PediEAT) is a parent-report measure of symptoms of problematic feeding in children 6 months to 7 years old with evidence of reliability and validity. This study aimed to determine age-based, norm-referenced values for the PediEAT. Parents of children between 6 months and 7 years old (n = 1110) completed the PediEAT. Descriptive statistics were calculated for subscale and total scores of the PediEAT within 11 age groups. The PediEAT total scores followed a general downward trajectory with increasing age. Physiologic Symptoms were relatively steady from 6 to 15 months, and then rapidly declined in 15–18 month olds and continued to decline thereafter. Problematic Mealtime Behaviors increased from 6 to 9 months to a peak in 24–30 month olds and then declined with increasing age. Selective/Restrictive Eating increased from 6 to 9 months to a peak at 12–15 months and then decreased over time thereafter. Symptoms of difficulty with Oral Processing were highest in 6–9 month olds and decreased with age. The PediEAT now has age-based norm-reference values to guide score interpretation and clinical decision-making.

Aim To determine reference values for the Child Oral and Motor Proficiency Scale (ChOMPS) based on healthy, typically developing and typically eating children between six months and seven years old. Methods Parents of children six months to seven years old (n = 1057) completed the 63-item ChOMPS. Median, range, 5th and 10th percentiles were calculated for scores on the four subscales of the ChOMPS as well as the total score in each of 11 age groups. Results Age-based norm-reference values are reported. By 24 months, 95% of children could perform all skills in the Basic Movement Patterns subscale. By four years, more than 95% of children could perform all of the skills in the Fundamental Oral-Motor Skills subscale. The Oral-Motor Coordination and Complex Movement Patterns skills developed later. By five years, 90% of children could perform all Oral-Motor Coordination skills. In six to seven year olds, 95% received a score of 44 of 46 on the Complex Movement Patterns subscale, indicating that some typical children had not established all of these complex skills by seven years. Conclusion The ChOMPS is the first valid and reliable parent-report measure of eating, drinking and related skills that has age-based norm-reference values for use in clinical practice and research.

Purpose: To develop and content validate the Neonatal Eating Assessment Tool (NeoEAT), a parent-report measure of infant feeding.Design: The NeoEAT was developed in three phases. Phase 1: Items were generated from a literature review, available assessment tools, and parents’ descriptions of problematic feeding in infants. Phase 2: Professionals rated items for relevance and clarity. Content validity indices were calculated. Phase 3: Parent understanding was explored through cognitive interviews.Sample: Phase 1: Descriptions of infant feeding were obtained from 12 parents of children with diagnosed feeding problems and 29 parents of infants younger than seven months. Phase 2: Nine professionals rated items. Phase 3: Sixteen parents of infants younger than seven months completed the cognitive interview.Main Outcome Variable: Content validity of the NeoEAT.Results: Three versions were developed: NeoEAT Breastfeeding (72 items), NeoEAT Bottle Feeding (74 items), and NeoEAT Breastfeeding and Bottle Feeding (89 items).

Pediatric feeding problems occur in 25% of the general pediatric population and up to 80% of those who have developmental delays. When feeding problems place the child at nutritional risk, families are typically encouraged to increase their child's intake. Family mealtime can become a battle, which further reinforces problematic feeding behaviors from the child and intensifies well-intentioned but unguided parental mealtime efforts. Family has an essential influence on feeding; however, studies to date neglect to address the family context of feeding difficulty. In this study we describe, in the context of everyday life, family management of feeding when a child had a significant feeding problem. Parents of children with feeding problems were interviewed with the Family Management Style Framework components as a guide. Twelve parents participated, representing nine families of children with feeding disorder. Description of family management of feeding provides a foundation for development of family feeding interventions.

The Pediatric Eating Assessment Tool (PediEAT) is a parent-report instrument developed to assess symptoms of feeding problems in children aged 6 months to 7 years. The purpose of this study was to identify the factor structure of the PediEAT and test its psychometric properties, including internal consistency reliability, temporal stability, and construct validity.Participants included 567 parents of children aged 6 months to 7 years. Fifty-four percent of the sample had parent report of a diagnosed feeding problem or feeding concerns. Exploratory factor-analysis techniques were used to remove redundant or non-endorsed items and identify the factor structure of the instrument. Construct validity was examined with 466 parents completing the Mealtime Behavior Questionnaire as a criterion standard. Known-groups validation was used to compare PediEAT scores between children with and without diagnosed feeding problems. Temporal stability of the PediEAT was examined with 97 parents repeating the PediEAT after 2 weeks.Principal components factor analysis with varimax rotation supported a 4-factor model accounting for 39.4% of the total variance. The 4 subscales (Physiologic Symptoms, Problematic Mealtime Behaviors, Selective/Restrictive Eating, Oral Processing) demonstrated acceptable internal consistencies (coefficient alphas: 0.92, 0.91, 0.83, 0.83; respectively). Construct validity was supported in 2 ways. The PediEAT correlated with the Mealtime Behavior Questionnaire (r = 0.77, P 0.001) and total score and subscale scores were significantly different between children with and without diagnosed feeding problem (P 0.001). Temporal stability was demonstrated through test-retest reliability (r = 0.95, P 0.001).Strong psychometric properties support the use of the PediEAT in research and clinical practice.

Background Feeding interventions for preterm infants aim to reduce the physiologic stress of feeding to promote growth. Heart rate variability (HRV) is a potential noninvasive measure of physiologic stress that may be useful for evaluating efficacy of feeding interventions. Purpose To evaluate whether HRV is a sensitive measure of physiologic stress compared with standard physiologic outcomes in the context of a feeding intervention study. Methods This was a secondary analysis of a within-subjects, cross-over design study comparing usual care feeding with a gentle, coregulated (CoReg) feeding approach in 14 infants born less than 35 weeks' postmenstrual age. HRV indices were calculated from electrocardiogram data and compared with standard physiologic outcomes, including oxygen saturation (Spo2), respiratory rate (RR), apnea, heart rate (HR), and bradycardia. Data were analyzed using linear mixed modeling. Results Infants fed using the CoReg approach had fewer apneic events and higher RR, suggesting they were able to breathe more during feeding. No statistically significant differences were found in SpO2, HR, bradycardia, or high frequency power (the most commonly reported measure of HRV). Infants fed using the usual care approach had significantly higher SD12, a measure of HRV indicating randomness in the HR, which is a potential indicator of elevated stress. Implications for practice SD12 was more sensitive to stress than SpO2, HR, and bradycardia. The utility of HRV as a measure of feeding outcomes in clinical practice needs further exploration. Implications for research Further exploration of HRV as an intervention outcome measure is needed, particularly evaluating nonlinear indices, such as SD12.

Background Feeding difficulty is common in infants younger than 6 months. Identification of infants in need of specialized treatment is critical to ensure appropriate nutrition and feeding skill development. Valid and reliable assessment tools help clinicians objectively evaluate feeding. Purpose To identify and evaluate assessment tools available for clinical assessment of bottle- and breastfeeding in infants younger than 6 months. Methods/search strategy CINAHL, HaPI, PubMed, and Web of Science were searched for "infant feeding" and "assessment tool." The literature (n = 237) was reviewed for relevant assessment tools. A secondary search was conducted in CINAHL and PubMed for additional literature on identified tools. Findings/results Eighteen assessment tools met inclusion criteria. Of these, 7 were excluded because of limited available literature or because they were intended for use with a specific diagnosis or in research only. There are 11 assessment tools available for clinical practice. Only 2 of these were intended for bottle-feeding. All 11 indicated that they were appropriate for use with breastfeeding. None of the available tools have adequate psychometric development and testing. Implications for practice All of the tools should be used with caution. The Early Feeding Skills Assessment and Bristol Breastfeeding Assessment Tool had the most supportive psychometric development and testing. Implications for research Feeding assessment tools need to be developed and tested to guide optimal clinical care of infants from birth through 6 months. A tool that assesses both bottle- and breastfeeding would allow for consistent assessment across feeding methods.

PURPOSE To test the milk flow rates and variability in flow rates of bottle nipples used after hospital discharge. STUDY DESIGN AND METHODS Twenty-six nipple types that represented 15 common brands as well as variety in price per nipple and store location sold (e.g., Babies R' Us, Walmart, Dollar Store) were chosen for testing. Ten of each nipple type (n = 260 total) were tested by measuring the amount of infant formula expressed in 1 minute using a breast pump. Mean milk flow rate (mL/min) and coefficient of variation (CV) were calculated. Flow rates of nipples within brand were compared statistically. RESULTS Milk flow rates varied from 1.68 mL/min for the Avent Natural Newborn Flow to 85.34 mL/min for the Dr. Brown's Standard Y-cut. Variability between nipple types also varied widely, from .03 for the Dr. Brown's Standard Level 3 to .37 for MAM Nipple 1 Slow Flow. CLINICAL IMPLICATIONS The extreme range of milk flow rates found may be significant for medically fragile infants being discharged home who are continuing to develop oral feeding skills. The name of the nipple does not provide clear information about the flow rate to guide parents in decision making. Variability in flow rates within nipples of the same type may complicate oral feeding for the medically fragile infant who may not be able to adapt easily to change in flow rates. Both flow rate and variability should be considered when guiding parents to a nipple choice.