Introduction

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.

Background

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...
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The overall benefit of the intervention would improve weight gain leading to reduced hospital stays.

Purpose of Review

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.

Theoretical Framework

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.…