Neonatal Care has been transforming in recent year, mainly with respect to care humanization. The concern is to focus care not only on preterm infants’ survival, but also to a comprehensive, humanized and preventive care, within an individualized and developmental care perspective, with a view to these children’s quality of life . This care reveals a tendency to offer mother’s milk as early as possible, so as to meet infants’ nutritional needs, to encourage breastfeeding, to improve mother-baby relations and to include the mother in care during the stay at the Neonatal Unit, besides providing for the adequate development of oral functions. Despite all of these benefits, there is a need to train the Neonatal Care team in terms of breastfeeding-related issues
In clinical practice, professionals face difficulties to precisely determine the ideal moment to start the transition from gastric to oral feeding. In general, the criteria to start this transition are weight and gestational age. In this process, most health professionals have only looked at isolated data for the infants, without an assessment that takes into account aspects of their general conditions, neuro-psychomotor development and oral-motor ability.
The advances in perinatal and neonatal care have led to increased survival among children. However, these babies require careful follow-up, since they present greater vulnerability with regard to abnormalities of neuropsychomotor development.
It is observed that, at birth, some infants have abilities that correspond to their state of maturity. Their exposure to neonatal intensive care and an interactional history that is greatly brought forward require competencies that do not exist yet, thus overloading their process of full development. Therefore, professionals who follow up the evolution of these babies must be alert towards detecting abnormalities and undertaking early intervention. Assessment of overall motor development and oral sensorimotor development is an important part of this follow-up
The abnormalities most frequently found were the presence of primitive oral reflexes (rooting, suckling and phasic bite), absence of lip contact, absence of tongue activity in the frontal plane, absence of symmetrical activity of the buccinator muscles, larynx in the primitive elevated posture, absence of laryngeal elevation during deglutition, absence of symmetrical arm activity in the medial line, and also absence of gargling.
The theory of dynamics systems proposes that movement and changes in their patterns are generated by various systems in which the components interact and become organized. Within this context, many authors have emphasized that comprehensive assessment of orofacial motricity not only includes observation of oral motor control and sensory responses but also includes other factors such as body weight, muscle strength, weight support, attention, specific context of the environment and the complexity of the task offered
Although most children do not develop severe neurological abnormalities like cerebral palsy, mental deficiency or epilepsy, so-called minor developmental disorders are very prevalent in this population. Prominent among these are attention deficit, minor overall and oral motor abnormalities, delayed language development and behavioral disorders. It has been shown that minor deficits become more visible with increasing age, especially from the fifth month of life onwards. These signs are often not identified at an early stage, because of the lack of measurements that are sufficiently sensitive for detecting motor and behavioral problems within this age group
The assessment of nonnutritive sucking can be used as one sign of maturity for the transition to oral feeding, together with other aspects of the infant’s global behavior, such as gestational age, posture and global tonus and behavioral state
Most scales assess preterm feeding through descriptive observation, using the Neonatal Oral-Motor Assessment Scale (NOMAS). Sucking problems in preterm infants can be specified by means of visual observation. The Neonatal Oral-Motor Assessment Scale (NOMAS) is the visual observation method most commonly used to assess the non-nutritive sucking (NNS) and nutritive sucking (NS) skills of infants up to approximately 8 weeks postterm. During the first 2 min of a regular feeding the infant’s sucking skill is assessed, either immediately or on video. Although NOMAS has been used since 1993, little is known about the method’s reliability. This scale consists of 13 characteristics of jaw movement and 13 characteristics of tongue movement, which are divided into categories of normal, disorganized and dysfunctional. The assessment of nonnutritive sucking takes 2 minutes and nutritive sucking 5 minutes. An observation scale of premature infants’ feeding pattern was developed to verify tolerance to oral milk intake, specifically looking at feeding-related abilities, such as oral-motor organization; coordination between the sucking, swallowing and breathing functions and clinical stability. However, Brazilian literature does not offer any protocols to assess premature infants’ sucking which have been validated. This is a necessary aspect for a legitimate instrument.
Some premature infants require prolonged tube-feeding, beyond term equivalent gestational age. Tools that could prospectively identify such infants from among otherwise healthy patients are needed. Neonatal Oral Motor Assessment Scale (NOMAS) predicts premature infants’ transition from tube to oral feeding.
Assessment of oral sensorimotor development
This assessment was conducted by two authors (the speech therapists ACG and RRA). To test the research forms and standardize the assessment technique, a pilot study involving 10 infants was carried out.
The oral sensorimotor development was assessed by means of a protocol drawn up by the principal investigator (ACG) that was based on the evolution of normal development among infants from four to five months of age, in accordance with the Bobath neuroevolution concept and the Alexander, Boheme and Cupps assessment (1993). When the observed developmental item was what was expected (normal), it was coded as zero (0), and when it was not what was expected (sign of risk), it was coded as one (1). The sum of the signs of risk resulted in an assessment index for the oral sensorimotor system that could range from 0 to 15.
The infants were examined in the prone and supine postures on a standard mat and when seated on the examiner’s lap. Manipulations were performed, consisting of touching the face and oral cavity (proprioceptive tactile stimulus), sometimes with the examiner’s hands and sometimes with a standardized toy made of very flexible rubber.
The protocol was composed of 15 items, subdivided into four groups:
- primitive oral reflexes
- oral motor structures
- oral emissions
- arm activity.
Primitive oral reflexes
- In this group, the infants were monitored for the presence of rooting, suckling, gagging and phasic bite reflexes. At the age studied, the presence of any of these reflexes was considered to be a risk factor.
- The rooting reflex was assessed by means of touching the cheeks and perioral region and was considered to be present when the infant turned its head and opened its mouth in the direction of the stimulus.
- The suckling reflex was assessed by introducing a gloved finger into the infant’s oral cavity, between the tongue and the hard palate, and observing whether grasping occurred and rhythmic suction started.
- The gagging reflex was tested by touching the gloved index finger on the anterior medial and posterior regions of the tongue and following towards the uvula, posterior wall of the pharynx and soft palate. The reflex was present when, at the time the mouth was open, the head was pulled back and the infant scowled.
- The phasic bite reflex was assessed by stimulating the lateral region of the lower gums, and it was considered present when the infant made sequenced chewing movements without contracting the buccinator muscles on the side of the stimulus, as seen by the contraction of the cheek on this side.
Oral motor structures
This group was assessed by observing the oral structures (lips, tongue, cheeks, mandible and larynx) in activity and at rest, while the infant was exploring a very flexible rubber toy. Absence of the activities or postures described in the following was considered to be a risk factor at this age:
- To assess the lips, the infant’s activity on the mat in the prone position was observed. The expected posture was that the infant would support its weight on its forearms, with contraction and stretching of the upper lip and lip closure.
- To assess the tongue, the infant’s position was not standardized. When the rubber toy was introduced into the infant’s oral cavity, the examiners assessed the activity of the tongue in the frontal movement plane, as observed by the presence of contraction of the tongue in the lateral region.
- The activity of the cheeks was investigated according to symmetrical contraction of the buccinator muscles, unilateral contraction and symmetrical smile. With the infant on the examiner’s lap, a rubber toy was introduced into the oral cavity above the tongue. This maneuver was expected to trigger symmetrical contraction of the buccinator muscle. To assess the lateral contraction of this muscle, the toy was positioned laterally in the oral cavity, with an expected response of contraction of the buccinator muscle on the side of the stimulus. The presence of a symmetrical smile was assessed during interaction with the examiner, mother and/or caregiver.
- Synergic contraction of the levator and depressor muscles was observed for assessing the activity of the mandible, with the infant on the investigator’s lap, while exploring the intra-oral region with the toy. The mandible was expected to be aligned with the maxilla, with sufficient excursion of its condyles to enable opening and closing.
- The posture of the larynx was assessed with the infant in the prone position on the mat. For the laryngeal posture to be considered adequate (start of its descent), the investigator observed that when looking at the toy that was on the mat, the infant kept its neck stretched and supported the weight of its upper trunk on its forearms.
- The presence of normal laryngeal elevation movement during deglutition was assessed with the infant on the investigator’s lap, exploring the rubber toy in the oral cavity, thereby stimulating the production of saliva that was then swallowed.
- The levels of oral emissions were assessed by means of interaction between the infant and the examiner, with toys, and/or with the infant’s mother/caregiver. Absence of guttural sounds (gargles) and vocalization during the assessment was considered to be a risk factor.
- Symmetrical activity of the arms
- With the infant seated on the examiner’s lap or in the supine position on the mat, it was observed whether the infant had the capacity to bring the toy to its mouth with the arms acting symmetrically. Absence of this activity was considered to be a risk factor.
Assessment of overall motor development
- Overall motor development was assessed by using the Alberta Infant Motor Scale (AIMS), which consists of a test that observes the quality of the movement components, such as the infant’s ability to transfer its weight, posture adopted in motor tasks and control over muscles that work against gravity. The scale is composed of 58 items divided into four subscales: 21 items in the prone posture; 9 in the supine posture; 12 in the seated posture and 16 in a standing posture. This scale is applicable from birth to 18 months of age.
- The result from the assessment consisted of a dichotomized choice for each item, which had to be assessed as “observed” or “not observed”. Each item observed in the infant’s motor skill repertoire received a score of one, and each item not observed received a score of zero. The observed items on each of the subscales were summed, thus resulting in four subtotals for the subscales of prone, supine, seated and standing. The total score for the test was given by the sum of the subtotals, and could be converted into a motor performance percentage that was established on the basis of the normative sample for the test
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