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Read the article: “Coker-Bolt, P., Jarrard, C.,Woodard, F., & Merrill, P. (2013). The effects of oral motor stimulation on feeding behaviors of infants born with univentricle anatomy. Journal of Pediatric Nursing, 28(1), 64-71.” After reviewing the article, please answer the following questions (see below).

Coker-Bolt, P., Jarrard, C.,Woodard, F., & Merrill, P. (2013). The effects of oral motor stimulation on feeding behaviors of infants born with univentricle anatomy. Journal of Pediatric Nursing, 28(1), 64-71.

1. The Problem/Question:

Was there a clear statement of the question, objectives and aims of the research?
Is the problem practically important?
What is the hypothesis?
2. Background

Are the cited sources pertinent to the study?
Is the review too broad or too narrow?
Are the references recent?
Was a theoretical perspective identified?
3. Design and procedures

What research methodology was used?
What are the variables? What is the dependent variable and independent variable?
How was sampling performed?
4. Conclusions and Implications

Were the implications discussed?
What recommendations were made at the conclusion?
Is it possible to implement these recommendations in practice?
Journal of Pediatric Nursing (2013) 28, 64–71

The Effects of Oral Motor Stimulation on Feeding Behaviors of Infants Born With Univentricle Anatomy Patty Coker-Bolt PhD, OTR/La,⁎, Courtney Jarrard OTR/L, C/NDTa, Francis Woodard CPNPb, Paige Merrill OTR/La

aDivision of Occupation Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC bDepartment of Pediatric Cardiology, Medical University Hospital, Medical University of South Carolina, SC

0 h

Key words: Cardiac infants; Oral motor stimulation; Feeding; Nutrition

The purpose of this pilot study was to determine the effects of oral motor stimulation on infants born with complex univentricle anatomy who required surgery shortly after birth. A quasi-experimental group design was used to compare 18 infants receiving an oral motor stimulation program with 10 infants who did not receive any oral motor intervention. Infants in the treatment group received the oral motor treatment prior to cardiac surgery and immediately following surgery, one time a day, 6 days a week. Outcomes data were collected for length of time to reach full bottle-feeds and length of hospital stay. A statistically significant difference was seen in the overall length of hospital stay between the two groups (p = .04). Infants in the experimental group were hospitalized for a mean of 28.6 days and infants in the comparison group for a mean of 35.3 days. Infants in the treatment group achieved full bottle- feeds 2 days earlier than infants in the comparison group, although this was not statistically significant. There is positive support for the use of oral motor stimulation for infants born with univentricle anatomy, but further study is needed to determine the long-lasting effects of this intervention. Published by Elsevier Inc.

Background

OVER THE LAST decade, infants born with complex univentricle anatomy have improved life expectancy due to advances in prenatal diagnosis, staged palliative surgical approaches, and pre- and postoperative management (Atallah et al., 2008; Golbus, Wojcik, Charpie, & Hirsch, 2011; Semera, Cook, Shirali, & McQuinn, 2005). As a result, nutrition has become a major focus for infants born with a single ventricle anatomy especially in issues related to failure to thrive, feeding intolerance, and oral motor incoordination (Golbus et al., 2011; Medoff-Cooper & Irving, 2009; Medoff-Cooper et al., 2011). Failure to thrive can result from the anatomy and physiology of the defect itself and the

⁎ Corresponding author: Patty Coker-Bolt, PhD, OTR/L. E-mail address: cokerpc@musc.edu (P. Coker-Bolt).

882-5963/$ – see front matter. Published by Elsevier Inc. ttp://dx.doi.org/10.1016/j.pedn.2012.03.024

effects of surgery and postoperative complications or sequelae (Maurer et al., 2011; Owens & Musa, 2009). Feeding intolerance intertwines with failure to thrive but can also be because of persistent mesenteric ischemia, chronic reflux, and other gastrointestinal issues seen in infants with univentricle anatomy (Golbus et al., 2011).

In cardiac infants, oral motor incoordination can originate from prolonged intubation, generalized hypotonia, and vocal cord injury from surgical approach (Maurer et al., 2011; Imms, 2002). During the preoperative period, concern for necrotizing entercolitis from systemic hypofusion and concern for initiation of enteral feeds while administrating prostaglandins can further delay the development of oral motor skills (Imms, 2002; Owens & Musa, 2009; Semera et al., 2005; St. Pierre et al., 2010). Maurer et al. reported that a significant factor related to poor oral feeding in infants with univentricle anatomy is length of respiratory support after surgery. The first stage of cardiac surgery for these infants involves placing a surgical shunt to palliate blood flow to the

mailto:cokerpc@musc.edu
http://dx.doi.org/10.1016/j.pedn.2012.03.024
65Oral Stimulation and Infants With Univentricle Anatomy

pulmonary and systemic circulation. It is a balanced circulation, but because the pulmonary vascular resistance is lower than the systemic vasculature, there is more blood to the lungs than to the body resulting in tachypnea. Poorly developed oral motor skills, combined with an uncoordinated swallowing mechanism, tachypnea from a shunted circula- tion resulting in pulmonary overcirculation, and fatigue can increase the risk of aspiration in infants with univentricle anatomy during the postoperative period (Davis et al., 2008; Jadcherla, Vijayapal, & Leuthner, 2009; Skinner et al., 2005). Approximately 80% of infants with univentricle anatomy demonstrate potential signs of aspiration due to vocal cord injury resulting from recurrent laryngeal nerve manipulation during surgery (Skinner et al., 2005).

In addition, Maurer et al. (2011) reported that at 2 years of age, two significant factors in the single-ventricle popula- tion’s long-term feeding problems include intracardiac mixing resulting in cyanosis and volume overload requiring diuretics. Delay in initiation of oral feeding and repeated postoperative procedures such as cardiac catheterization or magnetic resonance imaging, which interrupt normal feeding schedules, can further accentuate problem feeding behaviors (Arvedson & Brodsky, 2002; Golbus et al., 2011; Ross & Browne, 2002; Wolf & Glass, 2002). Studies on infants born with univentricle anatomy reported poor oral feeding behaviors including weak oral motor skills and poor suck, milk leakage from the mouth, severe gastroesophageal reflux, tachypnea, and overall difficulty achieving full oral feedings (Davis et al., 2008; Golbus et al., 2011; Jadcherla et al., 2009; St. Pierre et al., 2010). In addition, many infants with single- ventricle anatomy are placed on prolonged nasogastric tube feeds to improve overall nutrition, but this can further delay initiation of oral feeds. Although nasogastric tube feeding may improve nutritional status, major side effects of prolonged nasogastric tube feeding include delayed oral motor development, increase in gastroesophageal reflux, and swallowing abnormalities (Doddrill et al., 2003; Mason, Harris, & Blissett, 2005). Although the feeding difficulties experienced by infants with univentricle anatomy are well documented, there are no published studies on interventions to improve the oral feeding behaviors of these infants (Golbus et al., 2011).

Oral Motor Stimulation

Recent research on therapy to improve infant feeding behaviors has focused on feeding interventions for premature infants who are born before they are medically stable to begin oral feeding (Boiron, DaNobrega, Roux, Henrot, & Saliba, 2007; Pinelli & Symington, 2005; Rocha, Moreira, Pimenta, Ramos, & Lucena, 2007). Premature infants share many of the feeding problems seen in infants with single ventricle anatomy. Many premature infants and infants with univentricle anatomy must wait weeks before attempting bottle- or breast-feeding. Extremely premature infants do not begin orally feeding until they are at least 31 weeks

gestational age and may not begin breast- or bottle-feeds until they are medically stable as seen with patients with single ventricles. Both groups demonstrate feeding deficits related to poor feeding endurance and fatigue after breast- or bottle-feedings are initiated (Boiron et al., 2007; Doddrill et al., 2003; Fucile, Gisel, & Lau, 2002, 2005; Hafstrom & Kjellmer, 2001).

Current infant feeding studies have shown that oral motor stimulation programs, including facilitation of nonnutritive sucking, significantly decreases the length of hospital stay of preterm infants by improving oral motor coordination and nonnutritive sucking (Boiron et al., 2007; Fucile et al., 2002, 2005). Providing oral motor stimulation prior to oral feeds has significant benefits on the development of feeding skills in preterm infants, improving the expression component of sucking, increasing the rate of milk transfer, enhancing the transition to full oral feedings, decreasing length of hospitalization, and possibly accelerating the maturation of oral feeding skills (Fucile et al., 2002, 2005; Mason et al., 2005). Theoretically, studies have shown that oral motor stimulation can be beneficial for improving an infant’s later performance in nutritive sucking, and sensory–motor–oral stimulation associated with nonnutritive sucking may increase the maturation of neural structures, improving the performance in the coordination of sucking–swallowing– breathing (Fucile et al., 2005; Rocha et al., 2007). Learned experiences may influence the maturation of these functions and increase the prevalence of successful transition to bottle- feeding while decreasing both length of stay and therefore hospital and social costs (Rocha et al., 2007).

Although infants born with univentricle anatomy demon- strate many of the same feeding behaviors as premature infants with feeding difficulties (fatigue, oral motor incoor- dination, and poor feeding endurance), there are no studies on the effects of oral motor stimulation to improve feeding behaviors in this population (Golbus et al., 2011; Jadcherla et al., 2009). Failure to thrive and feeding intolerance are an ongoing dilemma for the multidisciplinary teams taking care of infants with univentricle anatomy and have led cardiac specialty centers to form postoperative feeding guidelines to alleviate the feeding problems commonly seen in these infants (St. Pierre et al, 2010). These guidelines include a feeding and nutrition checklist that can be used to assess an infant’s weight changes, GI issues, physiological status, vocal cord integrity, and behavior during feeding (i.e., maturity of sucking, coughing, or choking). The increased risk of ongoing malnutrition and poor feeding compromises the outcome of cardiac surgery, lengthens hospital stay, and increases morbidity (Gillespie et al., 2006; Golbus et al., 2011; Jadcherla et al., 2009). A recent systematic review of feeding complications in infants with univentricle anatomy suggests that non-nutritive sucking and attention to early oral feeding behaviors could improve postoperative out- comes (Golbus et al., 2011). Therefore, the aim of this pilot study was to determine the effects of an oral motor stimulation program on infants born with single ventricles

Table 1 Participant Demographics

Treatment Group (n = 18)

Comparison Group (n = 10)

Male (%) 73 90 Female (%) 27 10

66 P. Coker-Bolt et al.

with regard to attainment of oral feeding and impact on length of hospitalization. This study will specifically provide an oral motor stimulation program for infants born with univentricle anatomy who require surgery shortly after birth, thus experiencing delays in the initiation of oral feeding.

Methods

Study Design and Setting

This pilot study employed a quasi-experimental approach with a nonequivalent group design. The study was approved by the institutional review board (IRB) at the Medical University of South Carolina (MUSC), and informed consent was obtained from the families of all infants involved in this study. Information for the comparison group of subjects was taken from the MUSC Division of Pediatric Cardiology archived patient database for infants with univentricle anatomy born between 2005 and 2006. This time frame was selected because infants born with univentricle anatomy before 2006 did not consistently receive occupational therapy services or an oral motor stimulation program. The historical comparison group allowed for further comparison of the new clinical oral motor stimulation treatment with a group that had not received the intervention. Infants in the treatment group received the oral motor protocol during hospitalization from 2008 to 2010. At the time this study was completed, occupational therapy received a standard consult to facilitate feeding behaviors in all infants born with single- ventricle anatomy starting with oral motor stimulation. Consequently, it would have been against the current standard of care to accept participants in this study that would be randomized to a control group only. The comparison and treatment groups were carefully matched for diagnosis (univentricle anatomy), surgical intervention (Norwood, right-ventricle to pulmonary artery conduits, modified Blalock–Taussing shunts, or pulmonary artery banding), birth weight, and gestational age (full term). The infants in both groups were born full term between 37 and 40 weeks’ gestational age and had birth weights between 2,400 and 3,999. These infants were further matched for gestational age and birth weight to the majority of all infants born in Charleston County in 2006 without medical complications.

Participants

Eighteen infants in the treatment group completed the study, 13 males and 5 females. Ten infants met inclusion for the comparison group, 9 males and 1 female (Table 1). Inclusion criteria for both the comparison and treatment groups were matched as described above. Exclusion criteria were significant genetic disorders, structural or functional defects (i.e., malrotation, pyloric stenosis, and cleft palate),

complex cardiac defects that did not require surgical intervention after birth, and aspiration on thin and thick liquids during a modified barium swallow study resulting in an inability to feed orally.

Procedure

The study was completed at MUSC in the pediatric cardiothoracic intensive care unit. Infants in the treatment group were referred from pediatric cardiologists. The oral motor treatment protocol was developed by occupational therapists (OTs) to meet the unique needs of the cardiac infants enrolled in the study and is based on Debra Beckman’s oral motor exercises (a detailed description of the protocol is shown in Appendix; Beckman, 2007). The OTs conducting this study were trained in the Beckman Oral Motor Treatment approach in the spring of 2008, and to assure fidelity of treatment procedures, the only staff providing the oral motor protocol to study participants were these therapists (Beckman, 2007). To guarantee adherence to the treatment protocol before this study was initiated, the OTs piloted the oral motor protocol clinically to assure accuracy in administration of the protocol and consistency of data collection documentation.

The oral motor treatment was provided to each study participant one time a day, 6 days a week. Our oral motor protocol involved 10 minutes of perioral and intraoral exercises to the cheeks, gums, jaw, and tongue. Two to three minutes of nonnutritive stimulation with a pacifier was provided after the oral motor exercises. The oral motor treatment was initiated just prior to cardiac surgery and continued immediately following cardiac surgery when study participants were determined to be medically stable by the cardiologist. The oral motor treatment continued until the infant reached full daily oral breast-/bottle-feeds (Appendix). Postoperative standardized enteral nutrition and oral feeding was implemented after sternal closure. This consisted of continuous feeds, ear/nose/throat evalua- tion, and modified barium swallow study (if aortic arch reconstruction was performed) and several days of slow compression of nasogastric feeds prior to oral feeding attempts. The postoperative standardized enteral nutrition and oral feeding regimen was consistent for infants in the comparison and treatment groups.

Oral motor stimulation may support the maturation and growth of essential oral feeding behaviors in infants born with univentricle anatomy who are unable to participate in

67Oral Stimulation and Infants With Univentricle Anatomy

normal feeding experiences until several weeks after birth. The first component of the oral motor stimulation program consists of stroking and positive stimulation of perioral and intraoral structures (i.e., gums, hard palate, and tongue). This stroking may strengthen the oral musculature required for adequate and efficient sucking and may enhance the maturation of central and peripheral nervous system structures, thus leading to improved sucking skills, rate of milk transfer, milk intake, and coordination of the suck– swallow–breathe reflex (Fucile et al., 2002, 2005). A second component of oral motor stimulation is nonnutritive sucking, which allows infants to engage the neuromuscular structures necessary for sucking at a more efficient rate and with greater endurance. Efficient and coordinated feeding is critical for infants born with univentricle anatomy who are known to have deficits in nutritive sucking strength, endurance, and coordination in swallowing, which affects attainment of full oral feedings (Golbus et al., 2011; St. Pierre et al., 2010).

Outcome Measures

Data were collected before, during, and after each oral treatment session by the OT providing treatment using documentation approved by IRB to assure reliability of information collected for each participant. Primary outcome measures for both the treatment and comparison groups were (a) length of time to reach full bottle-feeding (defined as the first time an infant reached eight oral feedings per day) and (b) length of hospital stay (defined as the number of days from birth to discharge from the hospital). Variables that could influence attainment of full bottle-feeding and discharge from the hospital included infant weight, length of time (days) from birth to cardiac surgery, and length of time from birth to initiation of oral feeding were also collected. Because infants born with univentricle anatomy are at high risk for airway and swallowing issues, additional data were collected on the results of ear, nose, and throat evaluation; results of modified barium swallow study; and feeding regimen at discharge (bottle vs. gastrostomy tube [g-tube] placement).

Table 2 Participant Baseline Characteristics

Variable

Treatment (n = 18)

M SD

Birth weight 3,110.6 g 455.0 Discharge weight 3,397.1 g 423.7 No. of days until surgery

6.0 2.1

Days to initiation of oral feeding

18.1 5.75

Note: No statistically significant differences in baseline variables for weight and

Statistical Analysis

A one-sided, independent sample t test was performed to test the hypotheses that time to attain full oral feeding and length of hospital stay were significantly shorter for infants with univentricle anatomy who received oral motor stimu- lation than those in the comparison group. Because of the exploratory nature of the study, no adjustment of p values was conducted for multiple statistical comparisons of the outcome measures (Rothman, 1990). Chi-square tests were used to assess differences in other categorical data related to the infant ear, nose, and throat evaluation; modified barium swallow study; and type of nutrition at discharge from the hospital (bottle-feeding or g-tube placement). A two-sided, independent sample t test was used to assess differences in baseline variables (birth weight, discharge weight, days from birth to cardiac surgery, and days from surgery to initiation of oral feeding). Statistical significance was set at p b .05 using a Type I error of 0.05, 95% confidence interval and all analyses were performed using Statistical Package for the Social Sciences (SPSS) Version 18.0 software (SPSS Inc, Chicago, IL).

Results

Both the treatment and comparison groups were compa- rable with regard to baseline variables of birth weight, discharge weight, length of time from birth to cardiac surgery, and length of time to initiation of oral feedings, and no statistical significance was found between any of these variables (Tables 1 and 2). A statistically significant difference was seen in the length of hospital stay of infants in the treatment group, who were discharged an average of 6.7 days sooner than infants in the comparison group (p = .04; Table 3). The length of hospital stay of infants in the treatment group was on average 28.6 days (±8.30 days). The length of stay of infants in the comparison group was 35.3 days (±11.4 days). The infants in the treatment group achieved full bottle-feeds 2 days earlier than infants in the comparison group, although this was not statistically significant (p = .17; Table 3).

Comparison (n = 10)

pM SD

3,314.0 kg 402.4 .25 3,638.0 kg 444.0 .17 5.9 2.0 .90

19 5.85 .70

number of days from birth to cardiac surgery.

Table 3 Oral Feeding Milestones

Variable

Treatment (n = 18) Comparison (n = 10)

p ⁎M SD M SD

Days to attainment of full oral feeds 6.3 3.9 8.3 4.5 .17 Length of stay in hospital (days) 28.61 8.3 35.3 11.4 .04 ⁎

⁎ Length of stay statistically significant.

68 P. Coker-Bolt et al.

With regard to airway, swallowing, and nutrition vari- ables, 40% of infants from the comparison group were discharged from the hospital with a g-tube (4 of 10 infants), whereas only 22% of infants from the treatment group required g-tube placement (4 of 18 infants), although the difference between groups was not statistically significant (Table 4). Both the treatment and comparison groups were comparable with regard to percentage of infants with abnormal ear/nose/throat evaluations and abnormal modified barium swallow studies (Table 4). There was no statistically significant difference between the two groups on any of these variables (p = .32). The average discharge weight of infants in the comparison group was greater than the treatment group, although not statistically significant (p = .17). We attribute this to the fact that the comparison group infants were in the hospital for an average of 6.7 days longer, allowing for additional days of weight gain prior to discharge.

Discussion

This pilot study investigated the effects of an oral motor stimulation treatment for full-term infants with univentricle anatomy who were unable to begin oral feeding shortly after birth because of the need for cardiac surgery. Results of this study support the hypothesis that oral motor stimulation can reduce the length of stay in the hospital and may have some effect on the feeding behaviors of infants with univentricle

Table 4 Airway, Swallowing, and Nutrition Issues

Variable Treatment (n = 18)

Comparison (n = 10) p

G-tube placement, % discharged home with g-tube

22 40 .32

Ear, nose, and throat evaluation, % abnormal ⁎

22 30 .39

Modified Barium Swallow Study, % abnormal†

(aspiration or penetration)

33 20 .17

⁎ Abnormal ear, nose, and throat evaluation was defined as the presence of atypical structural finding such as vocal fold paralysis.

† Abnormal Modified Barium Swallow Study evaluation was defined as presence of aspiration or penetration.

anatomy. Infants in our treatment group who received the oral motor stimulation program protocol were discharged from the hospital approximately 7 days earlier than infants in the comparison group who did not receive the intervention. This value was also clinically significant when considering the cost for each day an infant remains hospitalized. Cost for an infant hospitalized in our hospital is approximately $1,800 to $2,650 per day, depending on the level of care required (MUSC Medical Director’s Office/Clinical Effectiveness, personal communication, 2009). A discharge of up to 7 days earlier than expected could mean savings of approximately $12,600 to $18,550 per infant. Further study of the costs associated with providing oral stimulation programs and potential overall savings is warranted.

Similar studies on oral motor stimulation programs have shown that premature infants, with delayed initiation of oral feedings, have improved feeding behaviors in response to oral motor stimulation programs (Boiron et al., 2007; Fucile et al., 2002, 2005; Rocha et al., 2007). Premature infants who receive oral motor stimulation have demonstrated statistical- ly significant decreases in hospital length of stay (Rocha et al., 2007). Research has shown that positive oral stimulation prior to the introduction of oral feeding enhances the maturation of oral motor skills and reduces the transition to total oral feeding, thus reducing the future development of oral feeding difficulties. In addition, oral motor stimulation has been associated with large positive effects on other outcomes such as rate of breast milk/formula transfer and overall milk intake (Arvedson, Clark, Lazarus, & Frymark, 2010; Boiron et al., 2007; Fucile et al., 2002, 2005; Rocha et al., 2007). This enhanced oral feeding maturation can possibly be attributed to several factors. Infant feeding, especially for a high-risk infant, is a complex process dependent on dynamic interactions between the infant, the caregiver, and the environment. Feeding success depends on the infant’s ability to balance the growth and development of physiological subsystems with environ- mental demands (St. Pierre et al., 2010).

A higher percentage of infants in the treatment group were discharged from the hospital successfully taking full oral feeds demonstrating a decreased need for g-tube placement than infants in the comparison group (Table 4). Studies on infants born with single ventricles have shown that infants are placed on prolonged nasogastric tube feeds or require alternate means of nutrition at hospital discharge because of increased caloric needs and delayed oral motor skills (Atallah

69Oral Stimulation and Infants With Univentricle Anatomy

et al., 2008; Owens & Musa, 2009; Gillespie et al., 2006). Studies have shown major side effects to placement of oral feeding tubes or g-tubes, including delayed oral motor development, increased gastroesophageal reflux, changes in typical swallowing patterns, and potential oral aversion later in life (Doddrill et al., 2003; Mason et al., 2005). Although the difference between the treatment and comparison group for placement of a g-tube was not statistically significant, success attaining oral feeds and decreased need for g-tube placement could have contributed to the decreased overall length of hospital stay in the treatment group. Studies have shown that infants requiring g-tube placement on average remain in the hospital three additional days for an infant without dysphagia (Fortunato et al., 2010). This may be because of minor postoperative complications, such as wound infections, that can occur in up to 50% of patients (El-Matary, 2008; Fortunato et al., 2010). Many infants with shunted circulation that require g-tube placement have some form of dysphagia, whether due to gastroesophageal reflux, vocal cord involvement, or exercise-induced fatigue. These infants were reported to have a median hospitalization of 8 days after g-tube placement (Fortunato et al., 2010).

Lastly, the study design and data collection of comparison and treatment groups at different time points could impact our data on participant’s attainment of oral feeding and length of hospitalization. Differences in medical practice and procedures from these different periods could have some effect on the medical outcome of participants in the each group. Overall, there was clinically no difference in the types of cardiac surgical approaches used for infants in the treatment group versus the comparison group. At the time the comparison group received cardiac surgery, the Single Ventricle Reconstruction Trial was occurring with the randomization of shunts for the Norwood: four right ventricle to pulmonary artery conduits versus seven of the modified Blalock–Taussing shunts. In the treatment group, there was one hybrid procedure, one pulmonary artery banding, 11 Norwood procedures with modified Blalock– Taussing shunts (the preferred method of this institution’s surgeon), and four shunts without arch reconstruction. In the treatment group, those infants who did not undergo cardiopulmonary bypass and infants who had the hybrid procedure required fewer days to attain full oral feeds. This may be due to factors related to cardiopulmonary bypass effects and reduced risk for recurrent laryngeal nerve damage

that is more likely to occur in the Norwood than in the shunt/ hybrid procedure. Recent studies have found that shunt-type and hybrid surgical approach do not lessen any of the risk factors seen in the patients undergoing the Norwood procedure with cardiopulmonary bypass or result in significant differences in overall hospital length of stay (Golbus et al., 2011; Luce et al., 2011).

Limitations

This study relates specifically to infants born with single ventricles who require surgery shortly after birth; therefore, results cannot be generalized to all infants with complex congenital heart defects. Limitations to this pilot study include the small sample size and the use of a none- quivalent group study design using a historical group for comparison. Although the participants in the study were not randomized, participants from the comparison group and treatment group experienced the same developmental processes early in life and were carefully matched for characteristics such as cardiac diagnosis, surgical approach, gestational age, and weight.

Conclusion

Results of this pilot study provide positive support for the use of oral motor stimulation programs to improve the oral feeding behaviors of infants born with univentricular anatomy. A systematic and routine oral motor stimulation program can provide a means of addressing the lack of positive oral motor experiences many of these infants experience early in life because of the need for cardiac surgery shortly after birth. Current studies have shown that there are several ongoing challenges regarding nutrition and oral feeding for infants born with this particular defect. Future studies for infants with complex univentricle anatomy should focus on the long-term feeding behaviors of infants who receive oral motor stimulation programs. Investigations should also consider additional issues that could affect the oral feeding behaviors of infants with single-ventricle anatomy including gastroesophageal reflux, airway and swallowing abnormalities, and changes due to advancements in cardiac surgical procedures.

70 P. Coker-Bolt et al.

Appendix. Oral Motor Stimulation Protocol

Description of Oral Motor Exercise

Frequency or Number of Repetitions
Purpose

UPPER LIP: Side to side stretch: place index finger across upper lip; press tissue; move lip slowly back and forth.

3 times across and back = 1

Stretch and strengthen lips
LOWER LIP: Side to side stretch: place index finger at indention just below lower lip; press tissue; move across and down.

3 times across and back = 1

Stretch and strengthen lips
GUM MASSAGE: Start in middle of upper gum. 1 second per tooth move to back of mouth. Go in a circle around the mouth heading toward bottom gum and back to upper gum. Be sure to be on gums – not part where teeth emerge.

3 times around mouth

Desensitize gums; tongue movement; Stretch lip and cheek
BITING: Place pressure to area where molar is. If no biting occurs apply tapping pressure at 1 per second.

10 bites on each side or 10 seconds on each side

Jaw strength

CHEEK STRETCH LOWER: Place finger inside cheek near upper gum. Slide finger gently far back in cheek. Come down toward lower gum. Keep finger here and grab outer lip; with other finger just below ear (on jaw bone) gently applying opposing stretch.

3 times Hold stretch for 3 seconds

Stretch and strengthen cheek

Alternate with upper cheek stretch

3 times

CHEEK STRETCH UPPER: Place finger inside cheek pocket near lower gum. Slide finger gently far back in cheek. Come up toward upper gum. Keep finger here and grab outer lip; with other finger just below eye (on cheek bone) gently applying opposing stretch.
Hold stretch for 3 seconds

Stretch and strengthen cheek
Alternate with lower cheek stretch

3 times for each side

TONGUE SWEEP: Start on roof of mouth by molar; gentle firm pressure move across roof of mouth to opposite side; move toward lower gum; press the side of the tongue to lift the tongue up (at the back of the tongue)
Tongue strength and movement

SUCKING: Place finger on tongue and allow child to suck. Offer pacifier

1 minute or longer

Sucking
References

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71Oral Stimulation and Infants With Univentricle Anatomy

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The Effects of Oral Motor Stimulation on Feeding Behaviors of Infants Born With Univentricle Anatomy
Background
Oral Motor Stimulation
Methods
Study Design and Setting
Participants
Procedure
Outcome Measures
Statistical Analysis
Results
Discussion
Limitations
Conclusion
Appendix. Oral Motor Stimulation Protocol
References

 

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