INVESTIGATION OF AN ALIMENTATION SYSTEM IN PREMATURE NEWBORNS FROM GUSTATORY STIMULATION

(1) Núcleo de Fonoaudiologia da Universidade Federal de Sergipe, São Cristóvão, SE, Brasil. (2) Núcleo de Fonoaudiologia da Universidade Federal de Sergipe, São Cristóvão, SE, Brasil. (3) Núcleo de Fonoaudiologia da Universidade Federal de Sergipe, São Cristóvão, SE, Brasil. (4) Núcleo de Fonoaudiologia da Universidade Federal de Sergipe, São Cristóvão, SE, Brasil. (5) Departamento de Estatística e Ciências Atuariais da Universidade Federal de Sergipe, São Cristóvão, SE, Brasil.


INTRODUCTION
For several years the theoretical assumptions that guided the research on development and human Some authors 25,26 describe premature birth as a risk factor for abnormal neurodevelopment and functional capabilities.In this sense, considering that the ability to supply is achieved concurrently with the development of the central nervous system (CNS) 27 , the changes that occur in preterm newborns could even disrupt the normal course of development of feeding.
The literature 28 indicates that the introduction of oral feeding in premature newborns may be performed from 34 weeks on the gestational age, when the sucking pattern matches with these babies of term.Thus, it is necessary to investigate whether there is a feeding system developed in such an early age already.
Thus, the aim of this study was to investigate the existence of the feeding system in preterm infants from the gustatory stimulation (sucrose for analysis -PA 12% or water).

METHODS
This is an experimental, analytical, double-blind study performed in a public hospital in Aracaju (SE) of 90 preterm infants of both sexes, hospitalized in rooming.The inclusion criteria for this study were: clinically stable at the time of the test, Corrected Gestational Age (CGA) of up to 36 weeks and one day old, with an average of 34.92 days (Standard Deviaton of 1.05 days) and intrauterine growth curve Suitable for Gestational Age (SGA).Subjects who used respiratory support, were excluded from this study, showed significant clinical history of neurological or cardiac complications and were suffering from syndromes and / or diagnosed malformations or still to be clarified.
Initially we had to select the RN and then the signing of the consent form.Each newborn was placed in carry-cot, in the supine position, with naked torso and upper limbs.The newborns were divided into two groups (water or sucrose for analysis 12%), being filmed in the crib by attached digital camera on a tripod, so the face and upper limbs stay framed in the video.
It is important to mention that this study followed the same methodological design conducted in the thesis of doctoral degree of Medeiros 2 with newborns terms, particularly in relation to the testing procedure as well as the characterization of behavioral states and specific behaviors studied.
One of the researchers was responsible for the double-blind procedure, randomly distributing the substances water or sucrose in vials, which were numbered.For female newborns were used even bottles and males, the odd vials.The administration of sucrose solution or water was taken by other has learning abilities and social interaction in an extremely early age.
From this perspective scholars 4 started to defend the specific behaviors evidenced in the newborn, are part of specific functional systems that make explicit certain skills and abilities of the human being, in a period of extremely early life.
These same authors 4 still consider that behaviors can be identified as 'actions' much more than 'answers' or mechanical 'reflexes', requiring a more complete understanding of the functional specificity of child behavior.These behaviors are seen as belonging to a group of 'action systems', which are defined by the hypothetical function as intended, fulfilling certain functions of survival for humans, such as food and protection 2 .
The system related to food action would be demonstrated by the ability to recognize the given taste stimulus given to the RN, put his hand to his mouth and still coordinate sucking movements and breathing, to suck it 2,5 .These behaviors, relating to "feeding system", in turn, are related to the development of speech structures and coordinate the functions of swallowing, sucking and breathing and can be influenced by internal and / or external 5 factors, such as the gustatory stimuli.
The gustatory stimulation has been used with newborns, since the assumption that the gustatory capacity already got their start in the early experiences of intrauterine life, since the development of taste buds occurs in early stages 6 , allowing that the fetus already has the ability to feel the taste of amniotic fluid.
In this sense, Medeiros 2 used sucrose as gustatory stimuli in newborn terms to discuss the existence of a feeding system from the moment of birth.
The knowledge on the supply system could increase the basis in speech therapy in breastfeeding promotion, from the differentiated interpretation of behaviors of readiness to breastfeed presented by RN.
The feeding system has already been evidenced in newborns terms by Medeiros 2 , as related to neurologic status and important in readiness for food.Therefore intend to investigate the feeding system in preterm infants, a population that often presents with feeding difficulties in the neonatal period.

Specific Behaviors 2
a. Right hand suction, right (RHS) and left (LHS): Contact one of the hands or both on oral region along with sucking movements; there may or may not tongue protrusion; frequent rhythmic movements in the oral region (cheeks) and the protrusion and retraction of the mandible.
b. Tong Protrusion (TP): not necessarily occluded lips; visualization of the apex of the tongue between the upper and lower lips; existence of movement of the tongue in the posterior-anterior direction.
c. Suction movements (SU): occluded or narrowed (rounded) lips; viewing retraction of the angle of the mouth, the region corresponding to the action of the muscle; rhythmic movements are often observed in the oral region (cheeks); there may or may not protrusion and retraction movements of the jaw.
It is understood by oral region 2 for the purpose of recording and analysis: lips, oral cavity, tongue, and floor of the mouth cavity.
Frequencies of behavioral states and specific behaviors were recorded in SPSS (version 18, 2008, Chicago, Illinois, USA) software.Counted up each behavioral state and each specific behavior, second by second, the exact time of occurrence, the total amount of times being calculated as these behaviors appeared.
For CGA fractions of the week were used to calculate the sundry days (1 week = 0.14 days).
The project in question was approved by the Ethics Committee on Human Research from the origin Institution under paragraph CAAE 0027.0.107.000-11.
Correlations in statistical treatment of all RNs were made, regardless of the stimulus administered, and in the two groups separately.Measures of central tendency (average), variability (standard deviation) and prevalence (absolute and relative) form used to characterize the population.To test the normality of the data was made the Shapiro-Wilk test.Due to lack of normality nonparametric Mann-Whitney test for comparison of average was used.The Spearman correlation test was used to verify the correlation between behavioral states and specific behaviors in each time of testing.Values between 0.1 and 0.3 was considered poor correlation; moderate between 0.4 and 0.6; strong above 0.7, and ideal when equal to 1,0 30 .The p values less than 5% (p <0.05) was considered significant.researchers who were unaware of the solution administered (double-blind procedure).The vials were randomly selected at the moment of the shooting.Randomization was performed in the draw of bottles for their newborns until all vials had been selected.
Besides the procedure (test itself) for data collection, the researchers studied the medical records of infants and mothers, recording on a specific protocol the following data: RN gender, Gestational Age at Birth (GAB), Corrected Gestational Age (CGA), birth weight, lifetime, Apgar scores (1 st and 5 th minutes), full name and age of mother, type of birth, date and time of the test.
It is noteworthy that there was previously a conduction of a pilot study so that the researchers would train the execution of the procedure, provided being the judges themselves would also analyze the videos (behavioral states and specific behaviors) reliably.Thus, the calibration procedure of the judges, which were analyzed together some videos of the pilot was conducted.
To analyze the videos of the 90 infants who participated in this research, each video was watched by three different and independent judges, establishing to themselves as a criterion of agreement between them, only the behaviors displayed by at least two judges.
The observation of the variables was based on the following classification: No newborn behavioral state was in deep sleep (1), then there is no correlation for this state.
When RNs were analyzed together, regardless of the given stimulus (water or sucrose), the specific behavior right hand suction (RHS) showed a strong correlation only in sleepy (3) and poor behavioral state in alertness (4) before stimulation in BL1.After stimulation, the BL2, this behavior showed a strong correlation in the behavioral states of light sleep (2) and agitated/irritated (5) and moderate correlation in sleepy states (3) and alertness (4).As for the specific behavior left hand suction (LHS), it was noted weaker correlation values in BL1 than BL2 (TABLE1).
Treating the groups separately, the specific behavior of suction right hand (SMD) in the water group showed only a weak correlation in the alert
The specific behaviors studied were observed in each behavioral state and in every moment of the test.
When the water and sucrose groups were analyzed separately for the TP behavior in sucrose correlation became stronger in B2 in most behavioral states.In the Water group this also occurred, with the exception of drowsy state (3) in BL2 had a lower correlation than in BL1.
Considering the total RNs, stimulated with water or sucrose, for the specific suction behavior (SU), the behavioral states of light sleep (2) sleepy (3) the correlation was changed from moderate to strong in the BL1to BL2 (TABLE 4).Water 1 0,000 0,000 contributes to these premature newborns reach and remain at more favorable behavioral states for the feeding situation, contributing to the success of the offer of oral diet, and especially breastfeeding.The fact of having been an increased suction specific behavior (SU), regardless of the taste stimulus received, points in the direction that the population of premature infants studied did not have the same ability to gustatory discrimination of healthy and term newborns researched by Medeiros 2 .
Furthermore, when analyzing the water and sucrose groups separately also increased correlation of sucking behavior was observed in behavioral states light sleep (2) sleepy (3) in both groups.This increase of correlation seems to show that the intraoral stimulation contributes effectively so that there was sucking movements, which are also considered important for the feeding situation of the newborn.
The same was observed in the research 2 performed with newborn terms, in which stimulation, both in water and in sucrose group, triggered the action of the buccinator muscles, and consequently suction then swallowing.Importantly, this synchrony of movements associated with breathing is essential for effective breastfeeding.
However, it is noteworthy that in the sucrose group in behavioral alertness (4), the behavior of SU reached higher value than in the water group, this response may be from the suction effect of sucrose on the behavioral state considered more effective in the presence related behavior and readiness to breastfeeding [7][8] .The same may have occurred in the reduction of moderate to strong correlation in irritated/agitated (5) behavioral state, since this state is not considered favorable, unlike the behavioral state of alertness 29 .
These data seem to indicate that sucrose in the specific behavior of suction provided soothing, as the effects of analgesic and calming obtained in non-pharmacological measurements in newborns undergoing painful procedures [7][8][9][10][11][12][13][14][15][16] .The use of sucrose, in turn, should also be discussed with more coverage in speech therapy field as a likely strategy for stimulating infants with feeding difficulties.
Sucrose was a stimulus capable of increasing the correlation of hand suction behaviors and sucking movements in alertness, which are considered ideal for the occurrence of readiness behavior to feeding 7,8 .Besides, in the specific behavior tongue protrusion independently from the RN have been stimulated with water or sucrose, gustatory stimulation favored the presence of the same, showing that the different taste stimuli used here in readiness for feeding contributed in this population.
By observing the results found in this study, from the administration of the taste stimulus, whether this be water or sucrose, it is perceived that there is clearly stronger correlations in BL2 for specific behaviors: right hand and left hand suction (RHS and LHS, respectively).This finding corroborates the literature 2 , which states that the taste stimulus in the oral region triggers the execution of sucking movements.
The correlations in specific behavior right hand suction (RHS) showed increasing when water and sucrose groups were considered separately.Thus, unlike the data presented in literature 2 with newborns terms, the population studied here (premature) water also significantly increased the correlation of this behavior, although not one taste stimulus considered as effective as sucrose.
For the behavior of suckling the mothers, the fact that there were no significant differences that occur between groups of stimuli (water and sucrose) in this population born with GA average of 34.10 weeks and tested with an CGA average of 34.91 weeks makes that the data do not corroborate with that studies 6 indicate that the intrauterine period the fetus already has gustatory discrimination and preference.
On the other hand, the correlations increased after gustatory stimulation in both groups, which may demonstrate that independent from stimuli, gustatory stimulation is an important conduit for readiness to activate the feeding behavior, such as suction movements, which are fundamental for the effectiveness of feeding, especially within the breastfeeding 31 .
Considering the behavior of hand suction as indicative of readiness to feed and related to a feeding system, the sucrose group, the correlation increased sucking behavior of the right hand in alertness and reduced in drowsy state, as well as increasing correlation of specific behavior of left hand suction, also in alertness, corroborates the literature 2,32,33 which states that the sucrose elicits specific behaviors of readiness for food, especially in behavioral state considered ideal (alert) to occurrence of behaviors readiness to breastfeeding 7,8 .
By analyzing the behavior of tongue protrusion (TP), independent of the administered stimulus (water or sucrose) was more evident in alertness (4) after stimulation, as occurred in the behavior of hand suction, actually evidenced that the conduct of readiness to breastfeeding 7,8 are more incidents in alertness.
Thus, one could envisage the importance of stimuli being held in readiness for favorable feeding behavioral states.On the other hand, the very embodiment of the oral gustatory stimulation likely and especially on the alert, they show that the use of gustatory stimuli in hospital routine preterm infants, could contribute to elicit behaviors of readiness to breastfeed collaborate in the activation of a feeding system, contributing to the baby can be fed orally earlier in life.
Thus, the main contribution of the present study was about the effect of gustatory stimuli evident in the age range studied (GAB average of 34,14 and 34,91 weeks of CGA) for specific behaviors of readiness to breastfeed, especially in behavioral alertness , pointing out that gustatory stimuli can be used in procedures to elicit behaviors of readiness to breastfeed in order to contribute to the nutrition of preterm infants and breastfeeding promotion at an early age.
Points up the need for further research that envisage effective conduits of gustatory stimulation, from speech therapy, allowing the activation of the feeding system, bringing benefits to newborns, especially in the situation of breastfeeding.
In summary, we found in preterm infants, increased correlation for the specific behaviors related to the feeding system after oral stimulation, which envisions the possibility of gustatory stimulation be used to interfere with the activation of a feeding system.

CONCLUSION
In this study about population of premature infants, there was evidence of the existence of specific behaviors related to the feeding system, as demonstrated by Medeiros 2 in newborns terms and healthy.However newborns in this study did not show the same ability to discriminate taste of terms NBs, not corroborating the literature 7 which states that capacity been developed further at 32 gestational weeks.

Baby, mother and the test Data Protocol BABY DATA
TEST DATA Date of test: ____/___/____ Time of test: Beginning _______ Finish __________ Consciousness State of the baby at the beginning of the test : Last Time of breastfeeding (according to the prompt-book): Last Time of breastfeeding (according to the mother): Caption: GA: Gestational Age; GA (P.E): Gestational Age at the physical exam; CGA: Corrected Gestational Age; AGA: Adequate to Gestational Age; SGA: Small to Gestational Age; LGA: Large to Gestational Age.Figure 1 -Baby, mother and the test Data Protocol behavior of the left hand suction (LHS) observed the group sucrose strong correlation in BL2 on 2, 3 and 4. Already in the water group, the correlations of these behavioral states dropped in BL2 (TABLES 2 and 3).stateBL1 (4) and strong correlation in BL2, the alert states (4) and agitated/irritated(5).In the sucrose group, there were strong correlation in BL1 in Sleepy (3) behavioral state and weak in the alert (4), but the BL2 moderate correlation in 3 and 4. The specific