Evaluation of beneficial effects of nonnutritive sucking in preterm infants. Promotion of preterm infant nipple feeding with nonnutritive sucking. Effects of non-nutritive sucking on nutritive sucking, breathing, and behavior during bottle feedings of preterm infants. Randomized controlled trial of slow vs rapid enteral feeding advancements on the clinical outcomes of preterm infants with birth weight 750-1250 g. The effects of a prefeeding stimulation program on preterm infants. The effect of nonnutritive sucking on heart rate in preterm infants. Effect of nonnutritive sucking on behavioral state in preterm infants before feeding. Transitioning preterm infants with nasogastric tube supplementation: increased likelihood of breastfeeding. Effects of nonnutritive sucking on behavioral organization and feeding performance in preterm infants. Individualized developmental care for the very low-birth-weight preterm infant. Medical and neurofunctional effects. Nonnutritive sucking during heelstick procedures decreases behavioral distress in the newborn infant. Cue-based feeding for preterm infants: a prospective trial. Facilitating inactive awake states in preterm infants: a study of three interventions. Randomized trial of donor human milk versus preterm formula as substitutes for mothers' own milk in the feeding of extremely premature infants. Randomized controlled trial of very early continuous distending pressure in the management of preterm infants. Nasoduodenal versus nasogastric feeding in the very low birthweight infant. The Provo multicenter early high-frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in respiratory distress syndrome. Individualized behavioral and environmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: neonatal intensive care unit and developmental outcome. Behavioral and physiologic effects of nonnutritive sucking during gavage feeding in preterm infants. A randomised controlled trial of glutamine-enriched neonatal parenteral nutrition in Malaysia.
The effects of nonnutritive sucking (NNS) were studied in 40 preterm infants weighing less than or equal to 1800 g and of less than or equal to 35 weeks gestation by using a pacifier. The provision of NNS accelerated the maturation of sucking resulting in a faster transition from gavage to oral feedings. Treated infants (20) were ready for bottle feeds 1.54 days earlier, took their bottle feeds 1.5 min/30 ml faster and were transferred out of the nursery on an average .5 days earlier than the control infants. No adverse effects due to NNS were observed throughout the period of study. This resulted in an earlier union with their mother, less maternal deprivation and decreased work load on the nursery staff. Used judiciously this simple and safe modality of providing a pacifier for NNS during tube feeding may be useful in the management of preterm infants. Transition of preterm infants from enteral to nipple feeding is a necessary milestone for hospital discharge. This study tested the efficacy of one potential intervention to facilitate the transition process. Ten minutes of nonnutritive sucking (NNS) and a control condition were administered randomly before first nipple feedings. The sample consisted of 20 preterm infants (gestational ages 27-33 weeks, M = 31.6, SD = 1.7; birth weights 931-2, 140 g, M = 1,649, SD = 373) who served as their own controls. NNS resulted in fewer behavioral state changes during feedings and produced quiet, awake states more frequently during feedings. Heart rates did not differ between feedings following NNS compared with those in the control condition. The purpose of this study was to examine the effect of prefeeding non-nutritive sucking (NNS) on breathing, nutritive sucking (NS), and behavioral characteristics of bottle feeding.
                The convenience sample was composed of 10 preterm infants who were 33 to 40 weeks postconceptual age (PCA) at the time of the observation.
                Randomized, crossover; each infant was observed twice during the first 48 hours of bottle feeding.
                Ten preterm infants received NNS before 1 bottle feeding and served as their own control at a second bottle feeding. Sucking was measured using a chin strain gauge and breathing was measured with a nasal thermistor. Behavioral characteristics included behavior state, measured using the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) behavior state scale, and feeding efficiency.
                Characteristics of NS (number of suck bursts, sucks/burst, suck burst length) and breathing (number of breath bursts, breaths/burst, breath burst length), as well as behavior state during bottle feedings and feeding efficiency (percent of prescribed formula consumed, formula consumed/minute of feeding).
                NS waves were smoother and more regular than NNS waves. Time to onset and duration of the first non-nutritive suck burst were positively correlated with time to onset for the first nutritive suck burst. Prefeeding NNS had no statistically significant effect on characteristics of breathing or on any other characteristics of NS. Behavioral state during feedings and feeding efficiency were not affected by prefeeding NNS.
                In this sample, the use of prefeeding NNS did not affect NS, breathing during feeding, or select behavioral characteristics of feeding. To evaluate the effect of slow vs rapid rates of advancement of enteral feed volumes on the clinical outcomes in preterm infants with 750-1250 g birth weight.
                A total of 92 stable neonates 750-1250 g and gestational age <32 weeks were randomly allocated to enteral feeding advancement of 20 mL/kg/d (n = 46) or 30 mL/kg/d (n = 46). The primary outcome was days to reach full enteral feeding, defined as 180 mL/kg/d. Secondary outcomes included rates of necrotizing enterocolitis (NEC) and culture-proven sepsis, days of parenteral nutrition (PN), length of hospital stay, and growth end points.
                Neonates in the rapid-feeding advancement group achieved full enteral volume of feedings earlier than the slower advancement group. They received significantly fewer days of PN, exhibited a shorter time to regain birth weight, and had a shorter duration of hospital stay. The incidence of NEC and the number of episodes of feeding intolerance were not significantly different between the groups, whereas the incidence of culture-proven late-onset sepsis was significantly less in infants receiving a rapid feeding advancement. Excluding infants who were small for gestational age at birth, the incidence of extrauterine growth restriction was significantly reduced in the rapid-advancement group at 28 days and at hospital discharge.
                Rapid enteral feeding advancements in 750-1250 g birth weight infants reduce the time to reach full enteral feeding and the use of PN administration. Rapid-advancement enteral feed also decreases extrauterine growth restriction with improved short-term outcomes for these high-risk infants. This study examined the effects of stroking and a perioral and intraoral prefeeding stimulation program on healthy, growing, preterm infants in a Level II special care nursery. Only infants without cardiac, gastrointestinal, or central nervous system problems were included in the study.
                Two groups of nine randomly assigned, medically stable preterm infants, born between 30 weeks and 34 weeks gestation, were selected for the study. All infants were introduced to nipple feeding at approximately 34 weeks postconceptual age. The infants in the control group received a 5-min stroking protocol before feeding; the infants in the experimental group received a 5-min stroking protocol in addition to a perioral and intraoral stimulation program.
                Compared with the control group, the experimental group had a decreased number of gavage feedings, greater weight gain, and fewer days of hospitalization. The experimental group also had higher scores on the Revised-Neonatal Oral Motor Assessment nutritive suck scale than the control group.
                On a preliminary basis, the findings from this study establish the efficacy of occupational therapy in a Level II special care nursery for healthy, growing, preterm infants. Further, the specific treatment strategies conducted with the infants receiving the experimental procedures have also been preliminary established as effective in enhancing the infants' feeding skills, resulting in weight gain and decreased hospital stays as compared with their counterparts in the control group. However, our findings cannot be generalized to preterm infant populations who are at greater medical risk than the infants in our study because of the potentially hazardous effects that could result. Implications of the results for intervention programs and future research are discussed. A laboratory and a field experiment used within-subject designs to test the hypothesis that nonnutritive sucking (NNS) reduces heart rate (HR) in preterm infants. Infants in Experiment A were provided a standard pacifier nipple for 30 min under strictly controlled conditions. In the field Experiment B, nursing staff provided infants with a standard pacifier during alternate intervals in a sequence of four interfeed intervals spanning 12 hr. NNS significantly reduced average HR in each experiment. Given the strongly positive relationship between HR and energy expenditure, these results suggest that NNS reduces energy expenditure in preterm infants. Such an effect, in turn, could help to explain how the opportunity to engage in NNS enhances growth in preterms. To describe the effect of nonnutritive sucking (NNS) on behavioral state (BSt) in preterm infants before feedings 24 preterm infants were randomly assigned and studied before each of their first 16 bottle feedings. Twelve received NNS by pacifier for 5 minutes; 12 did not receive a pacifier. BSt was measured with a 12-category scale for 30 seconds before the 5-minute period (BSt1) and for 30 seconds after (BSt2). Sleep states decreased for both groups. BSts considered more optimal for feeding increased more during NNS (86 vs. 46). Restless states were three times less frequent after NNS (23 vs. 68). Differences between groups were nonsignificant at BSt1, but were significant at BSt2, p less than .001. In the absence of self-regulatory feeding policies based on early hunger cues, NNS for 5 minutes prefeeding is simple, brief, and suitable for implementation in busy neonatal intensive care units. Nonnutritive sucking was an effective modulator of behavioral state for this sample. To compare nasogastric tube and bottle supplementation as two means of transitioning preterm infants to breastfeeding within an established breastfeeding support program.
                Prospective, randomized controlled trial; mothers and health care providers, who were not blinded.
                Metropolitan private regional perinatal center; 40-bed intensive-care nursery.
                Eighty-four preterm breastfed infants whose birth weight was 1,000-2,500 g.
                Rates of exclusive and partial breastfeeding at discharge from the intensive-care nursery, and at 3 days, 3 months, and 6 months after discharge.
                Compared with infants receiving bottle supplements, infants receiving nasogastric tube supplements were more likely to be breastfeeding at discharge and at 3 days, 3 months and 6 months, after adjusting for confounding variables. Odds ratios (confidence intervals = 95%) showed that the group receiving nasogastric supplements was 4.5 times (1.4 to 15) more likely to be breastfed at discharge and 9.4 times more likely to be fully breastfed (3.1 to 28.4). There were significantly fewer apnea and bradycardia episodes in the group receiving nasogastric supplements, although they had more episodes that required stimulation for resolution. Groups were not different with respect to length of hospitalization and infant weight at discharge.
                Using nasogastric tube supplementation during transition to oral feedings increases the likelihood of breastfeeding at discharge, 3 days, 3 months, and 6 months. This intervention requires a program with skilled personnel and an environment that allows the mother and infant to be in close physical proximity. Further study should investigate differences in the effects on maternal confidence, imprinting, and suck mechanism when preterm infants are bottle fed and breastfed. The purpose of this study was to examine the effects of nonnutritive sucking (NNS) on behavioral organization and feeding performance in preterm infants. Thirteen preterm infants were observed at four bottle-feedings, two of which involved treatment with prefeeding NNS. NNS had a positive effect on oxygen saturation and behavior state, as well as on the initiation and duration of the first nutritive suck burst. To investigate the effectiveness of individualized developmental care in reducing medical and neurodevelopmental sequelae for very low-birth-weight infants.
                Randomized controlled trial.
                Newborn intensive care unit.
                Thirty-eight singleton preterm infants, free of known congenital abnormalities, weighing less than 1250 g, born before 30 weeks' gestation, mechanically ventilated within 3 hours of delivery and for more than 24 hours in the first 48 hours, randomly assigned to a control or an experimental group.
                Caregiving by nurses specifically trained in individualized developmental care; observation and documentation of the infants' behavior within 12 hours of admission, and subsequently every 10th day; developmental care recommendations and ongoing clinical support for the nurses and parents based on regular observation of the infant by developmental specialists; and the availability of special caregiving accessories.
                Medical outcome, including average daily weight gain; number of days the infant required mechanical ventilation, oxygen, gavage tube feeding, and hospitalization; severity of retinopathy of prematurity, bronchopulmonary dysplasia, pneumothorax, and intraventricular hemorrhage; pediatric complications; age at discharge; and hospital charges. Neurodevelopmental outcome, including Assessment of Preterm Infants' Behavior scale and quantified electroencephalography (2 weeks after due date); and Bayley Scales of Infant Development and Kangaroo Box Paradigm (9 months after due date).
                The infants in the experimental group had a significantly shorter duration of mechanical ventilation and supplemental oxygen support; earlier oral feeding; reduced incidence of intraventricular hemorrhage, pneumothorax, and severe bronchopulmonary dysplasia; improved daily weight gain; shorter hospital stays; younger ages at hospital discharge; and reduced hospital charges compared with the infants in the control group. At 2 weeks after their due dates, these infants also showed improved autonomic regulation, motor system functioning, self-regulatory abilities, and visual evoked potential measures; and at 9 months, they had improved Bayley Mental and Psychomotor Developmental Index scores, as well as Kangaroo Box Paradigm scores.
                Very low-birth-weight preterm infants may benefit from individualized developmental care in the neonatal intensive care unit in terms of medical and neurodevelopmental outcome. We investigated if nonnutritive sucking (NNS) during heelstick procedures alleviates behavioral distress in neonates. In our NICU, 26 neonates without severe complications (mean Minde score 0.8, range 0-3), undergoing heelstick procedures at least twice a day, in the first 2 weeks of life, were enrolled in the trial (mean gestational age 33.9 weeks, range 26-39 weeks, mean birth weight 1, 988.5 g, range 1,200-4,010 g, mean Apgar score at the first minute 6. 7, range 4-10, at the fifth minute 8.5, range 6-10). Two heelpricks were performed in each neonate with NNS randomly assigned. Behavioral states, transcutaneous oxygen tension (TcPO(2)), heart rate, and respiratory rate were monitored before, during and after the heelstick procedures. Heelstick procedures lasted for a mean of 109 s (range 50-230 s) with NNS, and a mean of 128.8 s (range 20-420 s) without NNS. Compared with baseline, heart rate and behavioral distress increased and respiratory rate decreased during heelstick and after heelstick. Oxygen tension did not change. Nonnutritive sucking had no effect on respiratory rate or transcutaneous oxygen tension, but reduced the time of crying and the heart rate increase during the procedure. In conclusion, NNS can be recommended to reduce distress in newborns undergoing invasive routine procedures. Further studies are needed to evaluate the effects of NNS on respiratory rate and blood gas levels.
                Copyright 2000 S. Karger AG, Basel We set out to test whether premature infants were able to be fed orally on feeding cues and be discharged home earlier than infants fed by traditional feeding regimens. Attainment of adequate growth, adverse events, and nursing time to provide care were also assessed. After screening, the recruited premature infants (< 36 wks post-conceptual age [PCA]) were divided into two feeding regimens. A control group of 40 infants was fed using an initial combination of scheduled gavage and bottle feeding and then graduating to demand feeds. The intervention group comprised 39 neonates who had gavage feeds discontinued at study entrance and fed orally on cues. Outcomes measured were: weight gain in grams/kg/day, length of stay (in days) after enrollment, PCA on entrance and at discharge, adverse events during feeding, number of cues per feed in the intervention group, and resource utilization using nurse/patient ratios. Differences between groups were evaluated using Mann-Whitney U test, Fisher's exact test, and regression analysis. Two-tailed P values of < 0.05 were considered significant. There was no difference between groups in the mean weight gain; in the control group mean weight gain was 12.5 gm/kg/day and in the intervention group 12.1 gm/kg/day ( P = 0.83). The average length of stay in the control group of 14.5 days was significantly longer than the 10.0 days in the intervention group ( P = 0.009). This difference remained significant after adjusting for gestational age at birth in regression analysis. The average total number of adverse events in the control group (12.5 events) was significantly greater than in the intervention group (3.5 events; P = 0.007). The mean PCA on study entry was 34.4 wks in both groups and on exit 36.5 wks in the control group and 35.8 wks in the intervention group, a significant difference ( P = 0.02), The intervention group elicited 2.8 cues/feed. The nurse to patient ratios was equal in both groups throughout the study period. Cue-based feeding was possible for premature infants with similar weight gain as traditional feeding without affecting workload. Hospitalization and adverse events were decreased. Inactive awake behavioral states have been associated with reduced heart rates and more successful feeding in preterm infants. The purpose of this study was to test the efficacy of three different interventions to facilitate these optimal feeding states. Twenty preterm infants (gestational ages 27-33 weeks, M = 31.6, SD = 1.7; birth weights 931-2,140 grams, M = 34, SD = 373) serving as their own controls were randomly administered nonnutritive sucking, nonnutritive sucking plus rocking, and stroking interventions; and a control condition. There were significantly more inactive awake states with the nonnutritive sucking and nonnutritive sucking plus rocking interventions than with the stroking intervention and the control conditions. The results suggest that there are interventions that can help preterm infants in the transition from gavage to oral feeding and potentially shorten their hospital stays. Compared with preterm formula (PF), mother's milk (MM) is associated with lower rates of late-onset sepsis (LOS) and necrotizing enterocolitis (NEC) among premature infants. Because not all mothers of premature infants produce sufficient milk to supply their infants throughout hospitalization, we reasoned that pasteurized donor human milk (DM) would be a suitable alternative.
                Extremely premature infants (<30 weeks of gestation) whose mothers intended to breastfeed were assigned randomly to receive either pasteurized DM or PF if the supply of their own MM became insufficient during the study (birth to 90 days of age or hospital discharge). Infection-related events (LOS, NEC, meningitis, presumed sepsis, or urinary tract infection) that occurred after the attainment of a milk intake of 50 mL/kg, dietary intake, growth, skin-to-skin contact, and duration of hospital stay were compared. The primary analysis compared groups DM and PF on an intent-to-treat basis. If no differences were noted, then these groups were combined and compared with the reference group, group MM. If differences were noted, then the subsequent analyses compared each group with group MM.
                Of 243 infants, 70 (29%) received only MM; group DM included 81 infants and group PF included 92 infants. Because of poor weight gain, 17 infants (21%), all in group DM, were switched to PF. There were no differences in birth weight, gestational age, multiple births, and age at attainment of feeding of 50 mL/kg among groups. There were no differences between group DM and group PF in LOS and/or NEC, other infection-related events, hospital stay, or number of deaths. Group DM received a greater intake of milk and more nutritional supplements but had a slower rate of weight gain, compared with group PF. Compared with groups DM and PF, group MM had fewer episodes of LOS and/or NEC and total infection-related events and a shorter duration of hospital stay. Group MM also had fewer Gram-negative organisms isolated from blood cultures than did the other groups.
                In this randomized, blinded trial of feeding of extremely premature infants, we found that, as a substitute for MM, DM offered little observed short-term advantage over PF for feeding extremely premature infants. Advantages to an exclusive diet of MM were observed in terms of fewer infection-related events and shorter hospital stays. Application of continuous distending pressure at birth (very early CDP) should stabilize the immature airways and reduce the severity of respiratory distress syndrome (RDS) in preterm infants. Eighty-two preterm infants of less than 32 weeks gestation were randomly assigned at birth to early treatment group (TG), in which CDP of 6 cm water pressure was applied at birth by the nasopharyngeal route (NP-CDP), or to control group (CG), in which CDP was applied when indicated for established criteria (pO2 less than 50 mmHg in FiO2 greater than 0.5). Characteristics of the infants in the two groups were comparable. No statistically significant difference between the two groups was found in the incidence of RDS. The course of RDS, and oxygen and ventilatory requirements also did not appear to be changed. In blood gas parameters of most of the time frames, no significant difference was found between the two groups when the results were analyzed according to the assigned group. When the results were analyzed separately for the infants who developed RDS, infants in TG appear to have fared worse from the therapy in terms of oxygenation, as indicated by significantly higher FiO2 (P less than 0.01) and lower a/A (P less than 0.01) values on the third day of the course of RDS, as compared to infants in CG. The incidence of complications was comparable in the two groups. Four infants from TG (9.3%) and one from CG (2.6%) died (P = NS). We conclude that VECDP by nasopharyngeal route does not reduce the incidence of RDS and does not appear to improve the outcome and may worsen the severity of RDS when compared to application of CDP for established criteria. The practicality, effectiveness, and safety of feeding very low birthweight infants (less than 1,300 gm) by continuous nasoduodenal infusion was assessed by comparison with continuous nasogastric feeding. The nasoduodenal group appeared to have a clear advantage over the nasogastric group for the overall period in terms of caloric intake (131 cal/kg/day vs. 106 cal/kg/day), average weight gain (16 gm/day vs. 10 gm/day), and safety. This advantage was even more striking in the first two weeks of life. A caloric intake of 120 cal/kg/day could be reached within 48 to 72 hours after tube placement in the nasoduodenal group but only after a week in the nasogastric group. Nasoduodenal feeding resulted in faster weight gain than comparable published data on conventional feeding, peripheral intravenous alimentation, and parenteral alimentation. There were no cases of aspiration associated with tubes placed in the duodenum whereas two cases of aspiration pneumonia were associated with tubes placed in the stomach. With the tip of the catheter in the duodenum, none of the complications reported with nasojejunal tubes (intussusception, perforation, or necrotizing enterocolitis) were seen, either in the initial pilot study reported here or in 50 additional infants. To compare the hospital course and clinical outcome of preterm infants with respiratory distress syndrome treated with surfactant and managed with high-frequency oscillatory ventilation (HFOV) or conventional mechanical ventilation (CV) as their primary mode of ventilator support.
                A prospective randomized clinical trial.
                Three community-based level III neonatal intensive care units.
                A total of 125 neonates who were 35 weeks or less estimated gestation requiring intubation and assisted ventilation for respiratory distress syndrome with arterial to alveolar oxygen ratio less than .50.
                Patients were randomized to continue CV (61 patients) or be changed to HFOV (64 patients) after exogenous surfactant administration (100 mg/kg). HFOV was used in a strategy to promote lung recruitment and maintain lung volume. Protocol respiratory care guidelines were followed; otherwise routine care was provided by each neonatal intensive care unit.
                No differences were noted in demographic features between the two study groups. The study population birth weight was 1.51 +/- .47 kg (mean +/- SD), gestational age was 30.9 +/- 2.5 weeks, and study entry age was 2 to 3 hours. Patients randomized to HFOV demonstrated the following significant findings compared with CV-treated patients: vasopressor support was less intensive; surfactant redosing was not as frequent; oxygenation improved more rapidly and remained higher during the first 7 days; fewer infants required prolonged supplemental oxygen or ventilator support; treatment failure was reduced; more patients survived without chronic lung disease at 30 days; need for continuous supplemental oxygen at discharge was less; frequency of necrotizing enterocolitis illness was lower; there were fewer abnormal hearing tests; and hospital costs were decreased. No differences were seen between the two study groups in the frequency or severity of patent ductus arteriosus, air leak, retinopathy of prematurity, or intraventricular hemorrhage. Length of hospital stay and survival to discharge were similar for HFOV- and CV-treated infants.
                When used early with a lung recruitment strategy, HFOV after surfactant replacement resulted in clinical outcomes consistent with a reduction in both acute and chronic lung injury. Benefit was evident for preterm infants both less than or equal to 1 kg and more than 1 kg. In addition, early HFOV treatment may have had a more global effect on patient health throughout the hospitalization, resulting in reduced morbidity and decreased health care cost. We hypothesize that the respiratory and functional states of the very low birth weight infant with bronchopulmonary dysplasia can be improved in the neonatal intensive care unit by prevention of inappropriate sensory input. To test this hypothesis, we developed for preterm newborns a behavior observation method that catalogues specific reaction patterns according to putative stress and relaxation behaviors. We then collected behavioral information and heart rate, respiratory rate, and transcutaneous PO2 readings before, during, and after routine care-giving interventions. Eight control and eight experimental infants were selected for study based on the following criteria: birth weight less than 1,250 g, gestational age less than 28 weeks, on the respirator greater than 24 hours in first 48 hours of life at greater than or equal to 0.60 FiO2 for more than two hours during first 48 hours of life. Additionally, the two groups were comparable on other medical and demographic variables, including severity of respiratory status for the first ten days and incidence of intraventricular hemorrhage, patent ductus arteriosus, and socioeconomic status. Systematic observations were conducted on days 10, 20, and 30 after birth and at 36 and 40 weeks postconception. For the intervention infants, our observations were discussed with the infants' primary nurses, and individualized modifications for each infant's care plan were implemented based on these observations. Experimental infants showed significantly briefer stays on the respirator (P less than .01) and in increased FiO2 (P less than .05). Their feeding behavior was normalized significantly earlier (P less than .01). Experimental infants also showed significantly better behavioral regulation scores at 1 month after their mothers' estimated dates of confinement (post-EDC), as measured with the Assessment of Preterm Infants' Behavior, significantly better Mental and Psychomotor Developmental Indices at 3, 6, and 9 months post-EDC, as measured with the Bayley Scales of Infant Development, and significantly better behavioral regulation scores at 9 months post-EDC, as measured in a videotaped play observation. Measurements of weight, height, and head circumference at 3, 6, and 9 months post-EDC showed no differences. All assessments were performed by one of two trained testers not familiar with the goals of the study or the group status of the infant. These results support the hypothesis that very low birth weight preterm babies profit significantly both medically and developmentally from individualized behavioral care in the neonatal intensive care unit. Behavioral and physiologic responsivity to nasogastric gavage feeding was assessed in 36 preterm infants on 2 consecutive d. On one of these days, a pacifier was provided during and after the gavage segment of the standardized protocol. The protocol was divided into segments that included baseline, preparatory handling, pregavage, gavage, and postgavage periods. Patterns of cardiac (heart period and vagal tone), oxygen saturation, behavioral state, and defensive behavioral responses to gavage were quantified. These stable preterm infants responded to handling and gavage feeding with reduction in heart period, vagal tone, and oxygen saturation. These responses were not altered by provision of a pacifier, although there was a tendency for fewer episodes of bradycardia and oxygen desaturation. Conversely, behavioral state was affected significantly by nonnutritive sucking: when provided with a pacifier, infants exhibited less behavioral distress, spent less time in fussy and active awake states during and after feeding, and returned to a sleep state significantly faster. There is converging evidence to suggest that nonnutritive sucking lessens behavioral distress to iatrogenic stressors but does not alter physiologic responsiveness. The addition of glutamine to parenteral nutrition (PN) in neonates has not shown significant benefits as compared to adults thus far. This study aimed to determine the potential benefits of the addition of glutamine to neonatal PN in a tertiary hospital in a middle-income country.
                This was a double-blinded randomised controlled trial. Babies who were admitted to the neonatal intensive care unit (NICU) and who required PN were eligible for inclusion in the study. The subjects were randomised to receive either glutamine-added PN (intervention) or standard PN (control). The most important outcomes included time to full enteral nutrition, incidence of sepsis and necrotising enterocolitis (NEC), clinical or culture-proven sepsis.
                Out of 270 subjects, 132 were randomised to the intervention group and 138, to the control group. Baseline data were comparable in both groups. The median time taken to reach full enteral nutrition was similar for both intervention and control groups (six days in each group, p-value is 0.52). The incidences of NEC, clinical sepsis and culture-proven sepsis did not differ significantly in the intervention and control groups (5.8 vs. 7.1 percent, p-value is 0.68; 15.7 percent vs. 10.2 percent, p-value is 0.21 and 16.5 percent vs. 15.7 percent, p-value is 0.38, respectively). Other outcomes such as duration of ventilation, duration of NICU stay and a subgroup analysis for preterm and term babies also showed no statistically significant differences.
                Addition of glutamine to neonatal PN was not shown to improve outcome.
This review found a significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state).
The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects.