1. What is the Current Nursing Practice of Non‐Nutritive Sucking (NNS) During Tube Feeding Premature Infants on the Neonatal Intensive Care Unit Donghong Langley A partnership between Nottinghamshire Healthcare NHS Trust and the University of Nottingham Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

2. Premature infants < 34 weeks gestation- uncoordinated breathing, sucking and swallowing reflex (Kenner & Lott 2007) Insertion of ETT due to respiratory disease deprives the necessary sucking experience (Palmer 1993) Practical feeding problems- tube feeding before establishing independent oral feed (Medhurst 2005) Background 1 Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

3. What is Non-nutritive sucking (NNS); the use of a gloved finger; the baby’s mother’s breast after expressing; a dummy or a soother. No nutrition is delivered compared to nutritive sucking (Harding 2006). NNS enhances nutritive sucking (NS) skills (Bernbaum 1983, Field 2006) NNS is used for pain relief and soothing a unsettled baby (Boyle et al 2006) NNS is also believed to facilitate social learning (Tenhaaf 2008) and neuro development (Barlow 2010) and help with bonding between infants and parents (Tenhaaf 2008). Background 2 Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

4. Pinelli & Symington (2005), assessed as up to date 2010- Cochrane Systematic Review Total 21 studies included, 15 of which are RCT; assessing the effect of NNS (pacifier use) before/during/after tube feeding; before/after bottle feeding or outside feeding times in premature infants<37 weeks GA. Outcomes measures: weight gain/length of hospital stay/transition to oral feedings/HR/SaO2/ activity behaviour Results: reduced hospital stay (WMD -7.1days, CI -12.6, 1.7) ; positive effect on transition time from tube to bottle/better feeding performance What is the evidence on the use of NNS? Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

5. Pinelli &Symington A (2010) Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

6. Harding C (2006) studied NNS on 14 infants (27-35GA)’s feeding performance; stratified random sampling technique to achieve matched pairs (on GA/weight). Results: treatment group took fewer(15vs18) days to achieve oral feeding [U=11(n=14) p=0.082]; shortened hospital stay(23vs28) days [U=16 (n=14) p=0.277] Improved NOMAS score in treated infants[mean diff=2.5, U=9.5 p=0.034] NNS is oral stimulation by means of stroking the bottom lip with a finger/pacifier, then moving intraorally to stimulate the tongue until a NNS suck pattern is achieved. NNS evidence 2: Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

7. Liverpool Cambridge Brighton Edinburgh East Cheshire Southernwest Midlands Network North Devon North Bristol More……. NNS evidence 3 Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Slide from www.cuh.org.uk/rosie/service www.cuh.org.uk/rosie/service

9. In February 2012 Nottingham tube feeding guideline updated with an added paragraph: “Non- nutritive sucking can be used during gavage feeding and in the transition from gavage to breast/ bottle feeding in preterm infants. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behaviour and improves digestion of enteral feeding. Non–nutritive sucking has the potential to have negative effects on breastfeeding (Pinelli J, Symington A )” Dummies do not affect breast feeding (Collins et al 2004) Are we using the NNS evidence? Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

10. Breastfeeding at Discharge: No (%) with no dummyNo (%) with dummy Odds ratio (95% Cl); P value Fully ‡ ‡ 79/152 (52)85/151 (56)0.84 (0.51 to 1.39); 0.50 Any § § 107/152 (70)108/151 (72)0.83 (0.45 to 1.50); 0.53 Any breast feeding 3 months after discharge § § 58/142 (41)53/141 (38)0.99 (0.56 to 1.77); 0.98 Any breast feeding 6 months after discharge § § 43/141 (30)34/140 (24)1.23 (0.66 to 2.30); 0.51 Collins et al(2004) breastfeeding outcomes Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

11. What is the current nursing practice of NNS during tube feeding premature infants? How best to answer this question? How to implement the evidence and translate into clinical practice in day to day nursing? Application of a NIHR CLAHRC NDL funded £1000 Research into Practice Award 2012 and was successful The work began….. The Clinical Question: Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

12. A service evaluation using a qualitative approach by direct observation of nursing practice Advice sought from local NHS Trust R&D Talked to neonatal consultants Dr Jon Dorling and colleagues Contacted CLAHRC NDL Ethics expert Dr Carl Edwards Followed guidance from CLAHRC advisor Dr Neil Chadborn Good Clinical Practice principles followed/Confidentiality Followed NMC Code of Practice, aware of professional duty/boundary; adhered local relevant policies/guidelines Ethical Considerations Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

13. Information given to members of nursing and medical team via emails Promoting the study via managers “Thought of the Week” newsletters Posters displayed on both campuses of the neonatal service Open letter nursing staff sent via emails Publicising the project Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

14. Direct observation using semi-structured pre-designed forms to aid observation (Always asked for permission prior to any observations/always explained to parents that their infants care will not be affected) Field notes taken on or right after the observation One observation per staff on one episode of tube feeding of a premature infant Data description from the field notes; each detailed description was transcribed and organised into colour codes, categories then themes Each nurse and the baby under care was given a unique code to protect their identities Methods Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

15. Total 22 staff were approached; one declined and one no opportunity to observe; 19.5 hours 20 actual observations made across 2 campuses of one NHS Trust 20/20 tube feeding steps followed such as preparing equipment, good hand washing; testing pH; double checking of EBM 20/20 practised developmental care such as containment holding, supportive positioning of premature infants 7/20 utilised NNS during tube feeding; 8/20 observed infants’ feeding/behaviour cues; 6/20 responded these cues 9/20 recorded the pacifier use (discussion/asking permission) Findings Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

16. Three themes emerged from the data analysis: 1) task orientated versus-baby led nursing 2) developmental care practice 3) knowledge and application of NNS during tube feeding in premature infants Identified themes Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

17. Theme 1-task orientated versus-baby led nursing Staff W prepared feeding equipment, milk, tested pH from the nasogastric tube and started gravity feed while Baby J (GA 31+) was 32+5 days old, awake, rooting eagerly with mouth wide open: it tried to suck on its own finger fist; then turning its head aiming to reach Staff W’s finger Staff A did cares for Baby A first, this involved changing baby’s nappy and clothes. Staff A then commenced the tube feeding after checking the position of the tube. The baby was awake and alert, staff A did not seem to notice. Examples of the three themes Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

18. Theme 2- developmental care practice Staff C talked to Baby C and looked at it at feeding time; Baby C was sucking on a dummy prior to tube feeding but it fell out of its mouth and Staff C didn’t put the dummy back into Baby C’s mouth instead She held its hand at feeding time. Staff P talked to the baby and put it in a supportive position; did containment holding; she was looking at the baby all the time while she stroked the baby’s chin and cheek during feeding… Examples of the three themes Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

19. Theme 3 - knowledge and application of NNS during tube feeding in premature infants Staff E told me that a syringe feed would be given to Baby E if she was awake and inserted a small dummy into the baby’s mouth and it was sucking rhythmically and she told me that Baby E’s mother intended to breastfeed her baby Staff L did comment on the dummy found next to baby L’s cheek, though she did not put the dummy back into the baby’s mouth. She did the routine pH checking after manipulating the position of the tube and commenced the gravity feed. Baby L was chewing on the OGT and was alert but Staff L did not seem to notice this….’ More examples of the three themes Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

20. Role change Observed approximate 10% work force, different staff practice may vary, thus affecting the results “Hawthorn effect” staff may behave differently as being observed Aimed to capture “naturally occurring events” in the field though this method may be vulnerable to criticism of being subjective Validity issues- tried to address this by using external checkers for interpretation and to avoid bias Limitations of the study Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

21. NNS was infrequently used among general good tube feeding practice The use of NNS could be increased by developing a training package to highlight/promote the use of the evidence on NNS during tube feeding All nurses could take a unified approach in practising/ teaching parents Appreciation of EBP and continue to work to bring research into practice Learning experience for me to conduct this service evaluation independently Conclusions Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

22. Many sincere thanks to Dr Neil Chadborn (CLAHRC NDL) Dr Jon Dorling (Consultant Neonatologist, Associate Professor) Dr Jo Cooper (Head of Nursing and Midwifery Research) For their guidance and advice and encouragement and thanks to all the neonatal managers and neonatal staff and parents who supported me during the study. Acknowledgement Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

23. Kenner C & Lott J (2007) Comprehensive neonatal care an interdisciplinary approach. Fourth edition. Saunders Elsevier. Pp696. Palmer MM et al (1993) Neonatal oral –motor assessment scale: a reliability study. Journal of Perinatology. 8:28-34 Medhurst A (2005) Feeding protocols to improve the transition from gavage feeding to oral feeding in healthy premature infants: A systematic review. Evidence in Health Care Reports 3 (1):1-27 Bernbaum et al (1983) Nonnutritive sucking during gavage feeding enhances growth and maturation in premature infants. Pediatrics. 71 (1) 41-45. Field T et al (2006) Prenatal, perinatal and neonatal stimulation: A survey of neonatal nurseries. Infant Behavior and Development. 29 (1): 24-31 Boyle EM et al (2006) Sucrose and non-nutritive sucking for the relief of pain in screening for retinopathy of prematurity: a randomised controlled trial. Arch Dis Child Fetal Neonatal ;91:F166-F168 doi:10.1136/adc.2005.087668 Tenhaaf JJ (2008) Critical Review: The effects of oral stimulation on feeding behaviours in preterm infants. http// publish.uwo.ca. Harding C, Law J and Pring T (2006) The use of non-nutritive sucking to promote functional sucking skills in premature infants: An exploratory trial. Infant 21 (6): 238-243 Pinelli J&Symington A (2010) Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infnats. The Cochrane Library, Issue 4. Barlow S (2010) Feeding Skills in the Premature Infants. The ASHA Leader. www.asha.org/publication.www.asha.org/publication Collins CT, Ryan P, Crowther CA et al. (2004) Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial. BMJ [online] www.bmj.com accessed [13 th November 2012]www.bmj.com References: Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

24. Thank you for listening ntxdl3@nottingham.ac.uk www.clahrc-ndl.nihr.ac.uk Twitter: @CLAHRC_NDL Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL