Evaluation of orofacial characteristics and breastfeeding in preterm newborns before hospital discharge

Purpose: to evaluate the oral characteristics and breastfeeding premature newborns before hospital discharge and verify the relationship between the oral sensory system motor and breastfeeding. Methods: this was a cross-sectional, quantitative and descriptive study. Data collection was conducted from June to October 2014 was carried out in three stages research: Data search in medical records, clinical assessment of oral sensory motor system and the evaluation of breastfeeding. Obtained a convenience sample in an intensive care unit of a teaching hospital in Porto Alegre. The inclusion criteria were: prematurity; receiving speech therapy, being in the hospital discharge process; be indicated for exclusive breastfeeding; have signed the informed consent and informed by the head of prematurity. Results: the sample consisted of 26 subjects, then 6 individuals were excluded. Most of the oral sensory motor system features of premature was adequate and most of the categories evaluated in breastfeeding was close to the maximum score. It was found that premature infants with state of consciousness alert showed better position mother / newborn during breastfeeding (p = 0.043). It was observed that the higher the corrected gestational age better the final score of the infant in evaluation of oral sensory motor system (rs = 0.512, p = 0.021). Conclusions: elucidated up information oral sensory motor system and breast-feeding premature. As well, relationships were found between the oral sensory system motor and breastfeeding premature.


INTRODUCTION
According to the World Health Organization, premature is defined as any live newborn (NB) with a gestational period less than 37 completed weeks, counted from the first day of the last menstrualperiod 1 .Premature newborn babies (PN) have an increased risk of morbidity due to the anatomical and functional immaturity of their systems, which are not yet ready to support life in an extra uterine environment 2.3 .The brain immaturity of a preterm infant may as a result cause limitations during feeding such as: difficulty maintaining alertness, predominant PN was obtained.In the second stage, there was clinical assessment to characterize the orofacial sensori-motor system of the PN, using the premature readiness protocol for oral administration 7 .Finally, in the third stage, the evaluation protocol was applied for Breastfeeding preterm infants 6 .
The premature infant readiness protocol for oral administration is divided into the following categories: corrected age, state of behavioral organization, oral posture, reflexes and oral non-nutritive sucking.Each category consists of items with performance variations between scores of 0 (zero) and 2 (two), with the total score of 0 to 36.Infant alertness, state of behavioral organization regarding global posture and overall tone were observed, while oral posture (lip and tongue posture) and oral reflexes (rooting reflex, sucking reflex, biting reflex and the gag reflex) were tested.To conclude, non-nutritive sucking was evaluated for one minute using a gloved little finger.This evaluation assessed tongue and jaw movement, tongue cupping, sucking strength, number of sucks per pause, sucking rhythm and ability to maintain alertness.During testing of non-nutritive sucking, the presence or absence of the following signs of stress was noted: accumulation of saliva, beating of nasal wings, change in skin color, apnea, tone variation, posture change, labored breathing, tongue or jaw tremors, hiccups or crying 8.15 .After the application of the Protocol, the total score was calculated.
After the evaluation or during the first feeding after evaluation, the protocol for assessment of preterm infant Breastfeeding was applied 6 .The evaluation consisted of the following categories: I. aspects related to breasts (anatomy, ejection signals, engorgement, trauma and pain); II.Baby rooting reflex; III Signs of mother/ newborn dyad (signs of autonomy, state of consciousness, handling of the newborn, attention to newborn facial expressions, mother's physical touch of the newborn); IV. mother / newborn position during breastfeeding (mother's level of comfort, handling of the breast, distance between the hand and the areola, pressure in the milk ducts, the position of the newborn, head / neck of the newborn, nose of the newborn); V. nipple gripping (the newborn's chin, mouth, lip seal, the marking of the areola); VI. ability to breastfeed (jaw movement, cheeks, sucking rhythm, pattern of sucking / swallowing / breathing) and VII Final phase of feeding: (technique of removing nipple from newborn´s mouth, nipple conditions, breast conditions, newborn behavior at the end of breastfeeding).Each answer from each category was given the following scores: 2 -seen as appropriate, 1-intermediate conditions and 0-inadequate conditions.appropriate development 9 .Thus, Breastfeeding (BF) is a natural, physiological and safe form of nutrition for infants.Moreover, BF adequately stimulates orofacial sensory and motor systems, because the sucking involved in milk extraction requires muscle force, which increases muscle tone, stimulating speech, breathing, swallowing and development of oral structures 10 .
However, for the PN to adequately breastfeed, it is necessary that orofacial sensorimotor system characteristics are suitable.While these are not fully developed the PN requires other nutritional pathways.This process requires that the professional have knowledge of both BF as well as alternative feeding techniques (parenteral, catheters, gastrostomy).In addition, he/she must know how to evaluate and diagnose changes in the orofacial motor function to promote proper nutrition conditions, as soon as clinically possible [11][12][13][14] .
This research aims to evaluate orofacial characteristics and breastfeeding in preterm infants before hospital discharge and verify possible relations between the newborn orofacial sensorimotor system and breastfeeding.

METHODS
The research conducted was designed as a cross-sectional, quantitative and descriptive study.Data collection was conducted from June 2014 to October 2014.Parents or legal guardians were required to sign a Patient Consent form for research on human beings -(Resolution No. 466/2012 -National Council of health -CNS).This study was approved by the Ethics Committee of Irmandade Santa Casa de Misericordia Hospital ISCMPA, protocol number CAAE: 26956814.5.0000.5335.
The sample was selected by the non-accidental probabilistic sampling method or by convenience in the intensive care unit of a university hospital in Porto Alegre.The inclusion criteria were: prematurity (gestational age <37 weeks); to have received speech therapy, in the process of hospital discharge; recommendation of exclusive breastfeeding; have a free and informed consent form signed by a legal guardian.Exclusion criteria: peri-intraventricular hemorrhage grade I, II, III and IV; Apgar score less than 7 at 5 minutes; genetic syndromes; congenital malformations of the head, neck or central nervous system, heart disease or meningitis (alteration in the cerebrospinal fluid examination).
The research consisted of three steps, with all three being conducted by the same examiner, in the first stage: hospital records were evaluated when the PN was between 24h-48h of discharge and the informed consent by the legal guardian of the (70%), with nutritional assessment presented below the 3rd percentile (65%) and delivery by C-section (100%); while in relation to the mothers most were in their first pregnancy (70%) had not previously breastfed (70%), made donations in the milk bank (90%), donated milk at least once a day (50%), received prenatal care (100%) received information on breastfeeding in hospital (100%) and intended to continue breastfeeding (100%).
The characteristics evaluated in the oral feeding readiness protocol for preterm infants are shown in Table 2.The assessment of breastfeeding characteristics was accomplished through the comparison of score averages with the total score of each category (x ± SD): in aspects related to breast, an average of 7.9 (±1.4) out of 10 points was observed; in baby rooting reflex, there was an average of 1.9 (±0.4) out of 2 points; in signs of mother-child dyad an average of 8.8 (±0.9) points of 10 was obtained; mother/ newborn position during breastfeeding, an average of 13 (±2.8)points of 16 was seen; nipple gripping, was observed at 7.4 (±1.1) out of 8 points; for ability to breastfeed, an average score of 7.4 (±0.6) out of 8 points was obtained; and in the final phase of breastfeeding an average of 6.6 (±1.4) of 8 points was observed.
The research was analyzed using a quantitative and descriptive approach.The data collected from medical records and the application of research protocols was compiled in a database and formatted into an Excel spreadsheet (Microsoft), the variables were then analyzed using SPSS 22 software.To facilitate sample characterization, data was presented for categorical or ordinal variables in frequency or percentage and continuous variables were presented with mean and standard deviation or median and interquartile range, depending on the normality of the variables verified by the Shapiro-Wilk test.The Mann-Whitney test was performed to analyze comparisons while the Spearman correlation test was used for correlating variables.A significance level of 5% (p-value <0.05) was adopted for this study.

RESULTS
Total study sample consisted of 26 preterm infants.Six (6) were excluded after medical records review, due to neurological impairments.The data of the characterization of the 20 PN is shown in Table 1.
Other global characteristics were verified by absolute frequency.Most newborns were male By analyzing the variables of the premature readiness protocol for oral administration 6 together with the categories of the Breastfeeding evaluation protocol for preterm infants 10 it was noted that the PN with alert states of consciousness had higher scores in the mother /newborn position during breastfeeding evaluation than PNs in a mild sleepy state (p = 0.043).Premature newborns with the features: tongue in planar rest position (p = 0.054), strong sucking (p = 0.055), adequate tongue movement (p = 0.055), were seen to have higher average scores in the ability to breastfeed category.However, a larger sample size is needed to confirm the findings (Table 3).
The corrected gestational age (in days) correlated with the final score of the PN in the oral administration readiness protocol and it was observed that the higher corrected gestational age the better the final performance score (rs = 0.512 ; p = 0.021) (Figure 1).Additionally the corrected age (in days) was shown to have a positive correlation with the categorical score of preterm infants in the breastfeeding assessment protocol; however this relationship was not statistically significant.

DISCUSSION
The success of breastfeeding (BF) depends on several factors related to preterm infants, postpartum and the routine of the mother /newborn.It is important that mother in the days after childbirth receive support and guidance on BF, in order to feel secure and capable of breastfeeding their baby who in their view is still very fragile [16][17][18][19][20] .
To facilitate this early support, the Ministry of Health recommends at least six prenatal consultations, since it is during this period that pregnant women should be made aware of the importance of BF 21 .In this study, the average number of visits was 6.45 ± 2.04, and moreover all mothers were instructed to breastfeeding during their child´s hospitalization and all intended to continue breastfeeding after hospital discharge.This outcome can be related to the "Baby Friendly Hospital" policy, implemented in the unit where the study was conducted, where all professionals are trained to encourage breastfeeding 22 .These findings are similar to a study conducted in the same neonatal intensive care unit, which found an average of 6.4 ± 2.4 prenatal consultations and also most of the mothers were oriented and encouraged by professionals to BF (96.2%) 23 .
In addition, in this study, all preterm infants received speech therapy during hospitalization with an average 10.0 (±4.17) daily visits.Studies have shown that speech therapy can detect the initial    administration, showing that the more premature the newborn, the longer the time needed for the transition from alternative means of nutrition to oral feeding 4 .These findings are in agreement with the present study that observed the best scores in the evaluation of the orofacial sensory motor system in newborns with higher corrected gestational ages.Close attention should be paid to the population of the extremely premature since this group will present more difficulties with the transition from alternative means of nutrition to oral feeding, principally difficulties related to the orofacial motor system [32][33][34][35] .

CONCLUSION
In summary after the presentation and analysis of the results we can concluded that this study demonstrated that the majority of the characteristics of the orofacial sensori-motor system in preterm infants were adequate and most of the categories assessed during breastfeeding received close to a maximum score, except the aspects related mother/newborn positioning during breastfeeding.In addition, it was found that premature newborns with an alert state of consciousness showed better positioning during breastfeeding than PN in a mild somnolent state.The best scores in the evaluation of the orofacial sensory motor system were associated with higher corrected gestational ages.Additionally, the sample showed a tendency to have better BF conditions when the tongue posture was at rest and when tongue movement and suction force in non-nutritive sucking were appropriate.
Therefore it can be said that this study has elucidated some of the practical implications of breastfeeding, however it should be noted that the study had some limiting factors such as reduced sample size and possible selection bias, due to the convenience sample used.Speech therapists must be inserted into the multiprofessional teams, due to their expertise in the evaluation of the orofacial sensori-motor system and breastfeeding.Moreover, they can greatly contribute to this team, pointing out the specific challenges of preterm infants, favoring the transition to oral administration and encouraging early breastfeeding.
difficulties that threaten the feeding process and may alter the course of these problems 10. 24.Thus, the participation of speech therapists in a multidisciplinary team may aid in the prevention of orofacial motor dysfunction and therefore contribute to safe feeding practices.
Speech therapy possibly had a positive influence on the performance of PN in this study 25,26 .In the evaluation of the orofacial sensori-motor system it was observed that preterm infants presented the majority of the characteristics adequately, similarly breastfeeding assessment found that the averages observed in each of the categories were close to the maximum score, except in the aspects related to mother/newborn position during breastfeeding.
Proper mother / infant positioning during breastfeeding is an essential factor for grip conditions, RN suction and BF duration to ensure that the baby has access to milk from the posterior regions of the breast (high in fat and energy) 24 .This study identified that a PN in a state of alert awareness had higher a median score in the mother / newborn position during feeding category than a PN with mild sleep (p = 0.043).Studies indicate that newborns in improper position can expend energy excessively and consequently tire and fall asleep faster 24.27-29 .Thus, proper positioning is critical to maintaining alertness during BF.
Another key to the success of BF is the handling of the breast by the newborn.It is important to assess oral reflexes, tongue movement during suction, jaw movement, coordination and rhythm of swallowing and breathing as well as the absence of participation of the buccinator muscle 24 .This study showed a tendency toward better milking conditions when the tongue posture at rest was planar, tongue movement was adequate and the suction force was appropriate.

Figure 1 -
Figure 1 -Correlation between the final score of the readiness protocol for oral administration in preterm infants and corrected gestational age.