Processo de transição da Sonda para via oral em recém nascidos prematuros internados em unidade neonatal

Abstract

Introduction: Preterm newborns (PTNB) are those born with less than 37 weeks of gestational age. They are more likely to have a wide range of abnormal conditions, including those related to feeding, as they begin receiving it through a gastric tube for the food to go directly to the NB's stomach due to their various immature systems. Thus, the tube must be gradually removed to provide oral feeding, in a transition process defined as the time from the beginning of oral feeding until the tube is removed and the NB is exclusively on oral feeding. Although the literature on the topic addresses this process in low-risk PTNB, few studies approach the transition process and associated factors among NBs with different degrees of severity. Objectives: To analyze the transition process from the feeding tube to the oral route and associated factors in PTNBs admitted to the neonatal intensive care unit. The specific objectives were to describe the NBs in terms of sociodemographic, maternal, and neonatal factors, speech-language-hearing care and follow-up, and hospital discharge; analyze the factors associated with the transition time from the tube to the oral route in PTNBs; compare oral skills and breastfeeding performance at the speech-language-hearing assessment and PTNB’s tube removal; compare the transition time and evaluate the factors associated with the transition process from tube to oral route between groups of PTNBs with more and less severe conditions; and describe the PTNB’s feeding route at hospital discharge. Methods: This cross-sectional and longitudinal analytical observational study was carried out at the Sofia Feldman Hospital in Belo Horizonte, Brazil, a national reference in mother and child healthcare. The study included PTNBs admitted to the institution’s neonatal unit, who required a gastric tube for feeding and were evaluated by the speech-language-hearing team to transition from the tube to the oral route. It excluded NBs with a syndrome, infection, or congenital malformations, who had been abandoned by their mothers, or who died during the research period. Data were collected based on medical requests for speech-language-hearing evaluation. The researchers obtained the parents’/guardians’ authorization for the NBs to participate by having them read and sign an informed consent and assent form. Data on prenatal, birth, and socioeconomic history were obtained from the NBs’ medical records or by interviewing their mothers. NBs were assessed as follows: I. Assessment of NB sucking and readiness for oral feeding, using the Preterm Oral Feeding Readiness Scale (POFRAS); II. Assessment of nutritive sucking at their mothers’ breast and with finger feeding at their feeding time. Their functional breastfeeding performance was assessed with the LATCH scale – Brazilian version, and their oral performance was assessed with finger feeding, considering the proficiency and transfer rate (ml/min) as oral feeding skills. According to these responses, NBs were classified into four levels of oral feeding skills (level I, the most immature, to level IV, the most mature); III. Assessment of exclusive oral feeding on the day of tube removal with the collection of profile data and application of the LATCH scale and oral skill level; IV. Information collected at hospital discharge regarding oral feeding and profile. Descriptive statistical analysis was performed, presenting frequencies and proportions of categorical variables and the means, medians, and standard deviations of continuous variables. The first stage of the research considered PTNBs without serious pathologies. The transition time (in days) until reaching the oral route was assessed based on its median and the Kaplan-Meier curve. The oral skill levels and LATCH scores of breastfeeding PTNBs were compared at both the time of assessment and tube removal with the Wilcoxon test. Lastly, NBs were distributed into two groups (Group 1 – less severe and Group 2 – more severe). The Mann-Whitney test compared the groups concerning continuous variables, and the chi-square test, concerning categorical variables. The transition time between groups was assessed with Kaplan Meier curves and the log-rank test. Poisson regression models evaluated the variables associated with transition time for each group, adjusted for birth weight and gestational age. The stepwise backward method was used to select the variables – those significant at 20% in the univariate analysis were considered suitable for entering the multivariate model. Only the ones significant at 5% remained in the final multivariate model. The analyses were performed in Stata software, version 16.0, with a 5% significance level and 95% confidence interval. The study was approved by the Research Ethics Committees of the Federal University of Minas Gerais (evaluation report no. 5,040,543) and of the Sofia Feldman Hospital (evaluation report no. 5,077,779). Results: The first study stage comprised 45 PTNBs with a mean gestational age of 32.2 weeks and a mean weight of 1,787.0 g. The transition from tube to oral feeding took a mean of 5.5 days. Gestational age at birth under 32 weeks, birth weight under 1,500 grams, unreadiness for oral feeding, and hospital discharge on infant formula were related to longer transitions. The second stage analyzed data from 126 PTNBs to compare oral skills and functional performance during breastfeeding at the time of speech-language-hearing assessment and tube removal. There was a statistically significant difference between these two moments, with improvement in both variables. Lastly, 106 PTNBs were classified in Group 1 and 49 PTNBs in Group 2 (totaling 155 PTNBs) to compare the groups regarding severity, according to the Ministry of Health Regulation no. 930, of May 10, 2012. The transition from tube to oral feeding took a mean of 3.7 days in Group 1 and 6.0 days in Group 2, with statistical significance. In the less severe PTNB group, the following were associated with the transition time from tube to oral feeding: oral skill level IV at the assessment, with a transition time 38% shorter than in level I (RR = 0.62; 95% CI = 0.48-0.78), and being on infant formula at tube removal, with a transition time 60% longer than in those on exclusive breastfeeding (RR = 1.60; 95% CI = 1.08-2.37). In the group with greater severity, the following were associated with the transition time from tube to oral feeding: oral skill levels III and IV at the assessment, with a transition time respectively 49% shorter (RR = 0.51; 95% CI = 0.33-0.80) and 55% shorter (RR = 0.45; 95% CI = 0.32-0.64) than in level I, and the presence of clinical complications at the oral feeding assessment, with a transition time 53% longer than in those who had no complications (RR = 1.53; 95% CI = 1.17-2.00). Most participating PTNBs were discharged from the hospital on either exclusive or mixed breastfeeding. However, there was a lower proportion of this practice among PTNBs with a greater severity. Conclusions: The study found that some particularities must be considered, despite similarities in PTNBs’ transition process from tube to oral feeding. Therefore, specific protocols and treatment must be individually established for each PTNB to manage these cases better. Also, further studies on this topic are needed to provide a basis for multidisciplinary teams to treat PTNBs more precisely, establishing specific criteria to define the most assertive procedure regarding this population’s oral feeding.