Comparison of Feeding Behaviours in Term Infants and Preterm Infants ( 30 To 34 Weeks ) at Six Months Corrected

Feeding is explained as the placement, manipulation and mastication of food in the oral cavity prior to initiation of the swallow. In infants, feeding is considered as innate behaviour. Literature provides evidences connecting successful feeding as a predictor for normal communication. This study aimed at comparing the feeding behaviours of term and preterm infants (30 to 34 weeks) at six months corrected age. A questionnaire was developed based on milestones on feeding development. This consisted information on mode of feeding, difficulties in feeding and feeding behaviour. The questionnaire was administered on parents of 50 infants (25 term and 25 preterm infants). Significant difference in feeding behaviour was observed between the term and preterm infants at six months of age. This long term feeding difficulty may be pronounced during the transitional feeding. Hence the need for Speech Language Pathologist to evaluate feeding behaviour at transitional period for preterm infants becomes necessary.


Introduction
T he feeding and swallowing is a complex process controlled neuro-physiologically 1 .For normal feeding skills development, the coordina on of the motor and sensory func ons are essen al. Prerequisites for successful feeding include oro-motor skills, oral sensi vity, refl exes related to swallowing and Coordina on of sucking, swallowing and breathing.Preterm infants are stated as, those infants born below 37 weeks of gesta on 2 .These skills may be aff ected in preterm infants.The neurological, feeding, respiratory abnormali es may be predicted by coordina on of suck-swallow pa erns and swallow-respira on 2 .In preterm infants, feeding disorders are extremely common due to disorganized or weak oral movements, hypotonia, lack of arousal and irritability, behavioural disorganiza on, presence of assis ve ven la on devices or poor endurance 3 .Oral diffi cul es are frequent in preterm infants due to their underdeveloped cardiorespiratory system, central nervous system and oral musculature 4 .The preterm infants who are born before three weeks than term should be weaned between four and seven months or at six months of age 5 .It is also reported that feeding problems are common in preterm infants at fi rst year of life 6 .During the phase of feeding development infants are fed with foods with various consistency using diff erent modes.Evidences provide that feeding and pre-speech vocaliza ons have been assumed to be manifesta on of neurological manifesta on of the infant.Early vocaliza on that is speech has thought to be infl uenced by the infant's feeding pa ern 7 .The speech and normal feeding depends on several factors such as; liptone, rhythm, Breath control, fi nely coordinated tongue movements, well developed sensory feedback systems and speed of the muscle movements.These evidences deliver the connec on between successful feeding as a predictor for normal communica on 8 .These studies provide us knowledge that Speech Language Pathologist has a remarkable role in assessing these skills among children.
Hence the present study aimed to compare feeding behaviour in term and preterm infants (30 to 34 weeks of GA) at six months of age to understand the presence of feeding diffi cul es around transi onal feeding.

Materials and Methods
Parents of 25 pre-term and 25 term infants par cipated in this study.The par cipants were included based on following inclusion and exclusion criteria: Inclusion criteria for preterm infants 1. Preterm infants at 30-34 weeks of gesta onal age.

Inclusion criteria for term infants
1. Infants without craniofacial abnormality 2. Normal birth weight

Nil co-exis ng neurological, cardiology or any vital organ issues
The study was carried in two phases:-During the fi rst phase a ques onnaire was devised in English based on the literature.The paediatrician verifi ed the ques ons and its applicability to assess the development and growth of the child.The nutri onist reviewed the ques onnaire with respect to the texture and nutri onal aspect in Indian context.Two speech language pathologists viewed the ques onnaire to ensure the appropriateness of feeding behaviour of these infants.The ques onnaire consisted of demographic details, feeding history, current feeding status of the infants and 14 closed ended ques ons under following domain viz.age at which puree feeding was ini ated, current feeding behaviour, feeding diffi cul es in infants and dura on of feeding.
In the second phase, the ques onnaire was administered on parents of 25 term and 25 preterm infants a er obtaining an informed consent.These individuals were iden fi ed with help of the previous hospital records.The examiner selected those infants who had met the inclusion and the exclusion criteria.Followed by the examiner contacted the parents/ guardians of these infants.For the study the examiner used percentage analysis and Pearson chi-square (χ 2 ) analysis.
This study adhered to the guidelines of Indian Council of Medical Research (ICMR) and was approved by the Internal Ethics commi ee and the Publica on oversight commi ee (POC) of the University.

Modes of feeding
History of feeding in these infants was recorded.There were three modes through which the preterm and term infants were fed.These were nasogastric tube feeding, paladai feeding and direct breast feeding.The study revealed that, none of the term infants had history of NG tube feeding whereas 17 preterm infants were fed through NG tube feeding.Two mothers reported to have diffi culty in lacta on through breast feeding.Hence these infants were fed through paladai mode followed by direct breast feeding.It was observed that direct breast feeding was ini ated for 23 term infants and only 8 preterm infants.

Duration of practice
The dura on of prac ce of feeding modes include; history of nasogastric tube feeding, paladai feeding and direct feeding.On analysing the data it was noted that there were signifi cant diff erence between term and preterm infants at six months of age on following behaviours.

Discussion
The study aimed to study compare feeding behaviours in term infants and preterm infants (30 to 34 weeks) at six months corrected age.Based on the above results we have discussed our fi ndings under following domains.

History of modes of feeding:
The infants were fed through diff erent modes.Nasogastric tube feeding are required for preterm infants since these may have poor suck swallow coordina on, it s then prac ced un l the suck swallow coordina on is achieved 2 .Literature does also reveal that nasogastric tube feeding is ini ated for preterm infants born between 30 and 34 weeks of gesta onal age 9 .
Paladai feeding is also considered as a form of cup feeding.In India paladai feeding is used to feed premature infants.Paladai feeding is ini ated on following reasons 10 : 1.When the infant is unable to latch on the breast for any reason 2. When the mother is unavailable during the neonatal period 3.When breast feeding is not possible for any reason.
In the present study two term infants were fed through paladai mode because the mothers had diffi culty during breast feeding.
The study aimed to study compare feeding behaviours in term infants and preterm infants (30 to 34 weeks) at six months corrected age.Based on the above results we have discussed our fi ndings under following domains.
Cough while giving puree: Change in the texture of food during the transi onal feeding may contribute to the cough during feeding.The infant may not suck and swallow as the way they used to perform before.This may lead to cough, splu er or spit the food.This behaviour could be a ributed to the infants who are s ll learning to use the lingual and buccal muscles 11 .
The present study shows that preterm infants have more occurrence of cough during pureed feeding than term infants than the term infants Vomi ng during/ while puree feeding: By around 6 to 12 months children with sensory food aversions becomes more symptoma c and these sensory aversions include spi ng, vomi ng and gagging 12 .It is also described that during breast feeding the infants, mothers should "kick out" the swallowed air.This release of the swallowed air is characterized by burping.Any failure in this act may lead to regurgita on, vomi ng and abdominal pain.Similar fi ndings are documented where vomi ng is contributed to GERD found in infants born prematurely and infants or children with concomitant medical disorders 13 .
Spi ng during puree feeding: When the food is introduced to infants at early stages of transi onal feeding, they may splu er, spit out food, cough 13 and/ or turn away or bat it away with the hands due to changes in sensa on 14 .It is also reported that sensory food aversion is one of the most common feeding disorders during the fi rst three years of life 14 .
Frequency of feeding: Term infants indicate hunger and have suppor ve feeding refl exes.But for the preterm infant, the central nervous system doesn't indicate hunger.This might lead the mothers of the term infant to feed infants more frequently 15 .

Conclusion
In conclusion, preterm infants when compared to the term infants had certain issues in feeding.This could be a ributed to long term NG tube feeding and co-exis ng medical condi ons.This long term feeding diffi culty may be more pronounced during the transi onal feeding.Hence it is necessary for a Speech Language Pathologist to evaluate feeding behaviour at transi onal period for preterm infants.

Table 1 :
History of mode of feeding in term and preterm infants

Table 2 :
Percentage analysis, chi-square (χ 2 ) value and signifi cance (p) value on the prac ce of nasogastric tube feeding for above 1 week and less than 1 week in term and preterm infants Signifi cant * at p < 0.05, signifi cant ** at p <0.01

Table 3 :
Percentage analysis, chi-square (χ2) value and signifi cance (p) value on the prac ce of paladai feeding for above 1 week and less than 1 week in term and preterm infants

Table 4 :
Percentage analysis, chi-square (χ2) value and signifi cance (p) value for direct breast feeding in terms and preterm infants.

Table 5 :
Percentage analysis, chi-square (χ 2 ) value and signifi cance (p) value on ques ons like cough while giving puree, vomi ng during/ while puree feeding, spi ng during feeding and frequency of feeding among preterm preterm infants.