Feeding intolerance Integrative Review Paper

Despite major medical advancements over several decades, nearly 10 percent of births in the US continue to occur prematurely each year (Martin, Hamilton, Osterman, Driscoll, & Matthews, 2017). Creating a significant socioeconomic burden, preterm birth is one of the leading causes of infant morbidity and mortality in the United States resulting in approximately $16.9 billion in medical care costs annually (Institute of Medicine [IOM], 2007). After days, weeks, or even months of intensive care, weight gain becomes a major criterion for hospital discharge. Feeding intolerance (FI) is a common complication among these preterm infants, which disrupts enteral feeding, resulting in feeding advancement delays, prolonging adequate weight gain and growth, and increasing hospital stays (Carter, 2012). Additionally, FI is associated with necrotizing enterocolitis (NEC), a gastrointestinal emergency and a leading cause of morbidity and mortality in this group of patients (Moore & Wilson, 2011). The underlying cause for these problems is associated with the infant’s immature gastrointestinal tract. Thus, optimizing enteral nutrition to support normal growth and development without increasing the risks of NEC becomes a challenging task for nurses and neonatologists.

Several strategies are used to improve feeding intolerance including the use of standardized feeding protocols, early trophic feedings, human milk feedings, continuous or slow gavage feedings, infant body placement post feeding, thickening feeds and the use of medications and pre or probiotics (Dutta et al., 2015; Fanaro, 2013). Despite these interventions, an adequate solution to the problem remains unclear. Part of the problem may be due to a poor understanding and definition for feeding intolerance. Various factors are thought to contribute to the pathophysiology of FI. Biochemical and functional maturation of the GI system normally occurs gradually over the last trimester of pregnancy, however, in the preterm infant, mechanical function, enzymatic digestion, hormonal responses, bacterial colonization and local immunity are impaired (Fanaro, 2013). Delayed gastric emptying and reduced motility resulting in abnormal sphincter tone is attributed to the immaturity of duodenal motor function and the absence of coordination between the antrum and duodenum (So, Ng, & Fok, 2003). As a physiologic consequence, infants born prematurely have many of the symptoms associated with FI including gastric residuals, abdominal distension, delayed meconium passage and emesis (Fanaro, 2013).

Moore and Wilson (2011) conceptually define FI intolerance in the preterm infant as the inability to digest enteral feeding presented as gastric residual volumes (GRV) of more than 50%, abdominal distention or emesis or both, and the disruption of the patient’s feeding plan. Carter (2014) further develops the concept of FI to include apnea, bradycardia, and temperature instability as additional symptoms of FI for nursing assessment in her guidelines of care. Fanaro (2013) agrees with the above definition and further elaborates in her report on FI to include delayed meconium passage as a contributing factor in FI, concluding that the interpretation of these clinical symptoms is difficult when taking into consideration multiple confounding variables such as safety of nutritional supply, and various prenatal, perinatal and postnatal environments of the preterm infant. For the purpose of this review the conceptual definition of feeding intolerance described by Moore and Wilson (2011) will be used and outcome variables are operationally defined to include a reduction in GRV, reduced abdominal distention measured by abdominal circumferences, reduced daily emesis, and increased frequency of stools.

The information provided can assist nurses in deciding whether or not massage therapy can be used as a nursing intervention to increase infant adaptation and improve GI function. The overall benefit of the intervention would improve weight gain leading to reduced hospital stays.

The purpose of this review is to identify, critically appraise, and present new research investigating the use of massage therapy as an intervention for reducing feeding intolerance in infants born less than 37 weeks.

Roy’s Adaptation Model, which emphasizes patient adaptation to the environment is an ideal conceptual framework to address the PICO question: Does providing massage, as compared to standard care only, to infants born less than 37 weeks gestation, improve feeding intolerance. Essentially, RAM emphasizes positive, constant interaction and adaptation within a dynamic environment.  Adaptation is the process and outcome of the integration of the person and environment.  Innate or acquired coping mechanisms are used to lead the person towards optimal health or assist with illness challenges (Polit & Beck, 2017; Roy, 2011).

Viewing the individual or the family as an adaptive system, Roy’s model asserts that the role of the nurse is to foster adaptation to change in four areas: physiological needs, self-concept, role function, and interdependent relationships. Coping mechanisms within these realms allow identification and response to internal and external stimuli leading to change. The model implies a holistic approach as these dimensions interact to influence the overall health and well being of the person, and the family unit (Modrcin-Talbott et al., 2003; Nyqvist & Karlsson, 1997; Polit & Beck, 2017; Roy, 2011). Interdependent relationships are emphasized, which is imperative for ensuring a better understanding of patient and family needs, thereby facilitating the formulation of interventions unique to the NICU (Modrcin-Talbott et al., 2003; Nyqvist & Karlsson, 1997). Adaptive behaviors are enhanced by applying nursing interventions that manipulate underlying causes, resulting in physiological adaptation, as well as adaptation in role function. The role of the nurse is to evaluate and implement the best treatment available, which will alter the stimulus and assist patient coping (Polit & Beck, 2017).

As described by Polit and Beck (2017), a systematic approach based on the IOWA Model of Evidenced-Based Practice was used to identify a clinical problem, develop and organize a search strategy, and disseminate the relevant evidence into an integrative review for nursing use. The following databases, PubMed, CINAHL, and Ovid were searched between September 19 and October 21, 2017, using the following search terms alone or in combination: infant massage, feeding intolerance, feeding tolerance, abdominal distention, gastric residuals, preterm infants and tactile stimulation. The search was limited to studies in English, newborn infants, and studies published in the last five years. Only original peer reviewed articles that used massage as an intervention and specifically reported feeding intolerance outcomes for preterm infants, born less than 37 weeks gestation, were selected. The feeding intolerance outcomes of interest included gastric residuals, abdominal distension, emesis, and stooling patterns. Additionally, only studies done by health care providers on infants who were hospitalized in a Neonatal Intensive Care Unit (NICU) were chosen. The analysis of these articles will expand the current body of knowledge about the issue and provide opportunities to improve nursing care. Further implementation of the IOWA Model would include introducing the intervention into the NICU as a pilot study and monitoring the outcomes (Polit & Beck, 2017).

Does providing massage, as compared to standard care only, to infants born less than 37 weeks gestation, improve feeding intolerance?

The neonatal timespan is one of the most susceptible phases for the infant. In particular, there continues to be a high death rate of preterm infants. In order for such infants to gain weight and have the ideal growth, they have to have an ingestion of energy by feeding. Feeding intolerance is presently one of the top underlying causes of weight loss in preterm infants. The four articles of this paper discuss the impact of abdominal massage in facilitating feeding tolerance (Shaeri et al., 2017; Tekgunduz et al., 2014), enteral feeding improvement massage (Kim and Bang, 2017) and how massage therapy enables physical growth and gastrointestinal function (Choi et al., 2016) in preterm infants. In particular, the physical growth and development of premature babies can be hampered by undeveloped functions, mainly those of the gastrointestinal body system. Progressions in medical technology and massage therapy can aid in helping such infants grow and develop to the optimum size. Throughout this section of the paper, this hypothesis will be studied.

In their two articles, Shaeri et al. (2017) and Tekgunduz et al. (2014) examine the impacts of abdominal massage on the treatment of feeding intolerance in preterm infants. The focus of the first study was to evaluate the effects of abdominal massage on preterm infants’ feeding tolerance. The study was based on a randomized controlled clinical trial including 64 premature infants, with 32 babies randomly selected for the control group and the intervention group. Within the intervention group, the infants were fed after every two hours and an hour later an abdominal massage conducted for 15 minutes twice in a day for five days whereas those in the control group obtain normal unit care (Shaeri et al., 2017). The results of the study indicated that the massage was effective as the average circumference of the abdomen, recurrence of vomiting incidents, and the gastric residual volume significantly declined. These outcomes are in line with the research study undertaken by Tekgunduz et al. (2014) whose purpose was to analyze the efficacy of abdominal massage in precluding feeding intolerance in premature babies. The study was based on a control-grouped pre and post-test quasi-experiment on 27 preterm infants in the neonatal intensive care unit (ICU) in a university hospital in Turkey. The outcomes of the study showed a decline in the abdominal circumference, similar to those obtained by Shaeri et al. (2017). The inference of this is that the massage can enhance the functioning of the babies’ digestive systems and therefore is suitable and fitting to employ abdominal massage to preclude, diminish or eradicate feeding intolerance in preterm infants.

Other studies discussed the idea of enteral feeding improvement massage (Kim and Bang, 2016) and improvement in physical growth and gastrointestinal growth (Choi et al., 2016) in premature infants. In the first article, Kim and Bang (2016) piloted the research to show the impact of enteral feeding improvement massage for preterm babies with respect to their feeding and growth aspects. This was based on a randomized controlled trial comprising 55 preterm babies with 26 randomly allotted into an experiential group and the rest 29 into a control group within a hospital’s NICU. The babies in the experimental group were given EFIM twice every day for two weeks while those in the control group received a pretense exercise. The outcomes of the study indicated that EFIM can be supportive to accomplish earlier full enteral feeding, improved SMA blood flow and quicker infant growth. Moreover, enteral feeding is better and preferred for the reason that it is safer in general, results in cost savings, is nutritionally superior and more physiologically advantageous in comparison to parenteral nutrition (Kim and Bang, 2016). On the other hand, the article by Choi et al. (2016) delves into the impact that massage therapy has on not only the physical growth of the premature babies but also on their gastrointestinal function. This was based on a pilot study that employed recurrent measures design and applied to examine the potential impact of massage therapy on preterm infants. The participants included 28 premature infants that were carefully chosen from one general university hospital positioned in Seoul, South Korea. The experimental group and the control group were allocated using the matching technique to control extraneous variables for instance gestational age and birth weight in relation to the order of NICU admission. Outcomes of the study indicated that massage therapy may augment physical growth and gastrointestinal function (Choi et al., 2016).

It has been found that abdominal massage facilitates feeding tolerance in premature babies by increasing the mean circumference of the abdomen, the frequency of vomiting incidents, and the gastric residual volume amongst the infants. This indicates that neonatal intensive care units may be utilized as part of developmental treatment and care. In addition, if the nurses are trained and educated in massage therapy methods, it means that a better and more efficacious level of clinical care can be offered to premature babies.

In spite of the key technological developments that have taken place over the past decade, approximately 10 percent of babies born annually in the United States are premature. One of the key problems experienced by preterm infants is feeding intolerance. This includes the lack of optimum metabolic functions, lacking the ability to properly swallow, suck, and gag, fragile abdominal muscles, a restricted storage of nutrients, minimal stomach capacity, and diminished capability to digest and absorb nutrients. According to research studies conducted by Shaeri et al., (2017), Tekgunduz et al. (2014), Kim and Bang (2017) and Choi et al. (2016) have shown positiv results for providing massage to infants to improve feeding tolerance. Massage conducted regularly to premature infants after feeding proves to be beneficial for increasing the average circumference of the abdomen, diminishes the recurrence of vomiting incidents, and the gastric residual volume significantly declines. However, there is a need for having research studies in the future that encompass a greater number of participants, increased number of massages, as well as increased number of days.




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