Introduction
The synthesis of knowledge by nursing scholars has a wide range of approaches as well as intentions that address a wide range of purposes. Some of these methods are focused on gathering knowledge in a particular area while others are focused on the clarification of a single concept (Knafl & Dietrick, 2000, p. 49). Nonetheless, "there exists a long-standing recognition of the importance of concept development for the advancement of nursing theory and practice" (Knafl & Dietrick, 2000, p. 39).
In the clinical setting of the Neonatal Intensive Care Unit, premature and other critically ill infants are hospitalized every day. These infants and their families require the specialized training and skills of the NICU nurse. Awareness of varying concepts that are utilized on a daily basis within this clinical setting is central to the application of these concepts in providing evidence-based best practice nursing care delivery. Often these concepts related to care provision in the NICU are laden with assumptions that require a demonstration of how these concepts are applied in order to better understand them.
This analysis intends to focus on one of those concepts in an attempt to provide conceptual meaning and usefulness to the daily practice of the NICU nurse (Avant, 2000). The concept that is being analyzed is that of oral feeding readiness in the hospitalized preterm infant. In order to further examine this concept, the Wilsonian concept analysis technique as described by Avant (2000) will be utilized, as it "is an effective, easy-to-use method for discovering the essential features of a concept" (Avant, 2000, p. 64). In addition, this technique will provide a clear understanding of the essential elements of oral feeding readiness in the preterm infant as they apply to daily nursing practice in the NICU (Avant & Abbott, 2000, p. 65).
Background and Significance
The primary goal of care during hospitalization in the NICU for a preterm infant is that of discharge from the NICU. The gold standards for discharge readiness from the NICU include physiologic stability, consistent weight gain, and successful oral feeding (McGrath & Braescu, 2004). The American Academy of Pediatrics recommends that preterm infants demonstrate competent oral feeding skills before hospital discharge, referring to the attainment of exclusive oral feedings and coordination of feeding, swallowing and breathing (American Academy of Pediatrics, 1998). One might assume that when a preterm infant has met the requirements of physiologic stability, maturity and weight gain, that oral feeding readiness would be attainable. This, however, is not always the case. While physiologic stability and weight gain tend to be more concrete in their definitions, oral feeding readiness is a concept that frequently requires further analysis and clarification.
Oral feedings come more naturally to infants born at term, but they can be a significant task for infants born at less than 34 weeks gestational age. Interest in oral feeding is rarely shown until approximately 32 weeks postconceptional age and safe oral feeding patterns tend to be problematic until 34 weeks postconceptional age (Georgiff, 2005). Neurodevelopmental maturation is also a factor in oral feeding readiness and includes issues of state arousal, neuro-motor skills and respiratory control (Gardner & Goldson, 2002). A preterm infant's readiness to feed orally is determined not only by understanding the physiological and behavioral components of readiness, but NICU environmental influences as well (McGrath & Braescu, 2004).
Empirical research has shown that preterm infants need to have the ability to organize physiologic, motor and state systems prior to the initiation of oral feedings. Oral feeding readiness is also determined by receptivity to non-nutritive sucking opportunities, elicitation of the rooting reflex, general muscle tone and supplemental oxygen requirement (Koch, 1999). There are also behavioral components of oral feeding readiness, such as alertness and hunger cues (McGrath & Braescu, 2004). The transition time to oral feedings has also been shown to be significantly influenced by apnea, desaturations of oxygenation with oral feeding attempts, birth weight, gestational age, presence of lung disease and the age at first oral feeding attempts (Gardner & Goldson, 2002).
Oral feeding readiness is also based on nursing observations and judgment. There are frequent inconsistencies among nurses and other NICU caregivers in determining oral feeding readiness of preterm infants and these practices are further affected by staffing and time allotted to provide care for the assigned workload during feeding times (Premji, McNeil & Scotland, 2004). The concept of oral feeding readiness was chosen for this analysis because of these very reasons; it is an issue that is seen on a daily basis in NICU nursing practice and an issue requiring further clarity and analysis.
Isolating Questions
Questions frequently arise in relation to oral feeding readiness. These include: (1) What is the gestational age of the infant? (2) Is there physiologic stability? (3) Is there motor and state stability? (3) Is there good muscle tone? (4) Does the infant root? (5) Does the infant have lung disease or require supplemental oxygen? (6) Have there been non-nutritive sucking opportunities? (7) Does the infant show signs of hunger and alertness prior to feeding times? (8) Should oral feedings be attempted? Avant (2000) suggest separating these questions by fact, value and concept (p. 56). The gestational age of the infant, whether or not the infant roots, whether there is lung disease or an oxygen requirement and whether non-nutritive sucking opportunities have been offered are all questions of fact. Whether there is physiologic stability, motor and state stability and whether the infant show signs of hunger and alertness before feedings are questions of value. The remaining question of whether oral feedings should be attempted is a question of concept and will be the primary focus for this analysis.
The "right answers"
Gestational age has a direct relationship to neural maturity. Neural maturation is the developmental guideline for initiation of oral feedings and typically occurs between 34 and 35 weeks postconceptional age (Gardner & Goldson, 2002) although other research has also shown that some infants are ready for oral feedings at an earlier postconceptional age, even as early as 30 to 34 weeks (Simpson, Schanler & Lau, 2002). Maturation of feeding skills occurs because of both changes in the central nervous system and as a result of practice opportunities that enhance motor skills (Gardner & Goldson, 2002).
According to McGrath & Braescu (2004), oral feeding readiness can also be defined in terms of readiness for initiation of oral feedings and in terms of readiness for a particular feeding event. Parameters used for assessing readiness to initiate oral feedings are usually more related to maturation than to the other physiologic or behavioral factors that are used to assess feeding event readiness (McGrath & Braescu, 2004). The physiologic parameters utilized to assess readiness for oral feeding include color, heart rate, and respiratory rate and effort. An apnea or bradycardia during oral feeding or a color change may indicate that the infant is not yet ready for oral feeding attempts (Koch, 1999).
Stability of the motor system is characterized by mature muscle tone, posture, smoothness of activity and ability to interact with caregivers and environmental stimuli (McGrath & Braescu, 2004). Infants who have good motor stability are able to maintain flexion and mid-line positioning, are able to remain organized, and are able to respond appropriately to the caregiver and environmental stimuli without losing their state of alertness or muscle tone. Motor stability and maturity within each of these areas is needed for successful oral feeding (Koch, 1999).
Infants with respiratory or breathing problems that require supplemental oxygen tend to be older when oral feedings are initiated. This is often related to the severity of their illness as well as other medical complications that may procure oral feeding readiness (McGrath & Braescu, 2004). When asking if there is lung disease or a supplemental oxygen requirement, one must also consider the physiologic and motor stability of the infant when considering readiness for oral feedings.
Several studies document the effectiveness of non-nutritive sucking on a pacifier prior to feeding with increased alertness during the feeding as well as with better oral feeding ability. In a meta-analysis by Daley (2000) interventions that included non-nutritive sucking ameliorated successful oral feeding in preterm infants and additionally, these infants were also more likely to be in an aroused state during the feeding (Daley, 2000). Infants exposed to non-nutritive sucking also have fewer behavioral changes during feedings and are found to have a greater oral feeding success (Koch, 1999). Assessing the rhythmicity of non-nutritive sucking also has potential as a reliable indicator of feeding skills as it may integrate the many characteristics of an infant that influence oral motor development ( Bingham, Ashikaga & Abbasi, 2009).
Behavioral signs of hunger in a preterm infant may be described as behavioral state change from a period of sleep to that of a state of restlessness or wakefulness. Preterm infants who exhibit behavioral signs of hunger prior to oral feeding attempts, frequently have a shortened time until exclusive oral feedings are achieved (Crossen & Pickler, 2005).
Case Examples
The Wilson Method of concept analysis uses various case studies to allow correct use of the concept undergoing analysis. Case examples are chosen based on the analysts' working definition of the concept in an attempt to make essential features of the concept more clear (Avant, 2000, p.58). In this case, the concept that is central to the cases being described is that of oral feeding readiness in preterm infants.
When utilizing the Wilson Method of concept analysis, model cases are used to identify essential features of the concept and to make them obvious (Avant, 2000, p. 58). The following case presentations are actual scenarios and include all of the attributes for the concept of oral feeding readiness in preterm infants. Multiple cases are being presented for comparison of essential features and for further concept clarity (Avant, 2000, p. 59).
Model Cases
The first case involves breastfeeding as the method of oral feeding. M.M. is an ex-33 5/7 week, 1764 gram, black female who was delivered was by C-section under spinal anesthesia for maternal indications related to a diagnosis of pre-eclampsia. Her mother's feeding plan was to breastfeed. M.M. had no issues with respiratory distress and was brought to the NICU on her day of admission due to prematurity and low birth weight. She was active, alert and had good tone and response. Reflexes were appropriate for gestational age. Vital signs were stable and she was placed in a heated incubator for thermoregulation. Serum glucose levels were stable. She sucked vigorously on a pacifier and readily rooted. Orders were written to initiate enteral feedings. The nurse assigned to M.M. waited for M.M.'s mother to visit on her way up from the recovery room to her assigned post-partum room, and offered the first feeding as a breast feeding. M.M's mother was agreeable and the first feeding was initiated orally at the breast. M.M was able to latch, suck and swallow with minimal encouragement while remaining cardiovascularly stable and with stable serum glucose levels following the feeding attempt.
The second case being presented involves bottle feeding as the method of oral feeding. A.J. is an ex-30 1/7 week, 1232 gram, white female born by hurry-up C-section under general anesthesia to a mother with a history of placenta previa and an episode of acute vaginal bleeding on the day of delivery. A.J.'s mother had made a feeding plan to formula feed. A.J. was initially intubated, received surfactant, and was successfully extubated on day of life number two. She remained in room following extubation with no acute respiratory issues. Apnea and bradycardia of prematurity remained minimal and mostly self-resolving following extubation as well. In the absence of breast milk, enteral feedings were initiated with preterm infant formula by gavage via a nasogastric tube on the second day of life and advanced to full feedings without complications by day of life number six. Before and during nasogastric feedings, she was offered a pacifier as a component of oral stimulation. She was also offered intermittent attempts at oral feeding from a bottle beginning on day of life number ten, with inconsistent amounts taken at each attempt and a poor sucking effort. A.J.'s overall muscle tone and reflexes remained appropriate for gestational age. On day of life number twenty, A.J. was noted to be in a quiet awake state prior to her scheduled feeding time, and to be rooting and sucking on her hand. On this day, A.J. was offered a bottle and was able to take the entire ordered amount orally with minimal encouragement, and while remaining cardiovascularly stable.
In both of these cases the infant involved is able to take their entire feeding orally, thus showing readiness to orally feed. Each infant also exhibits stability of physiologic parameters utilized to assess readiness for oral feeding including heart rate, respiratory rate and effort (Koch, 1999). The additional parameters of motor stability characterized by mature tone and posture, in addition to the ability to interact with the environment without losing the state of alertness were also achieved. Neither infant required supplemental oxygen at the time of oral feeding readiness, and both infants had relatively uncomplicated hospital courses (McGrath & Braescu, 2004). Both infants exhibited behavioral signs of hunger prior to the feeding which has been shown not only to indicate readiness to orally feed, but to shorten time until exclusive oral feedings are achieved (Crossen & Pickler, 2005). All of these are integral components of the concept of oral feeding readiness.
Contrary Cases
As the first contrary case being presented, F.T. is an ex-28 week, 832 gram, white female who was born by vaginal vertex delivery to a mother with chorioamnionitis and a feeding plan to breastfeed. F.T. required intubation in the delivery room and received one dose of surfactant. She was brought to the NICU for respiratory distress, prematurity, low birth weight and an evaluation for sepsis. On her third day of life, vital signs were stable and she was able to wean to minimal amounts of supplemental oxygen via an endotracheal tube and ventilator. She was mildly hypotonic with an inconsistent rooting reflex, both of which were appropriate for her gestational age. Following daily rounds, an order was written to initiate enteral feedings with fortified breast milk or preterm infant formula. F.T.'s feeding was administered via an oral gastric tube by gravity. She was given a pacifier for five minutes prior to the feeding and during the feeding. Oral feedings were not attempted.
B.W. is the second contrary case being presented. He is an ex-27 4/7 week, 876 gram black male born by vaginal delivery to a mother with an antenatal course complicated by severe pre-eclampsia that was treated with Magnesium Sulfate for 72 hours prior to delivery. She also received two doses of Betamethasone prior to delivery to accelerate fetal lung maturity. Her plan was to provide breast milk by bottle, but not to breastfeed. At delivery B.W. had moderate respiratory distress and was noted to be hypotonic and floppy. He was brought to the NICU for prematurity and further evaluation of his respiratory status. He was intubated for 48 hours and successfully extubated to a high flow nasal cannula at two liters per minute. He began to have frequent apnea and bradycardia and was started on IV Caffeine. On day of life number three an order was written to begin enteral feedings of breast milk. Prior to his first feeding he was offered a pacifier for oral stimulation and during this time had three bradycardias that were associated with moderate color changes and requiring tactile stimulation and increased supplemental oxygen for recovery. His feeding was administered by gravity via his nasogastric tube with no attempt at oral feeding.
In both of these cases, the infants that were observed did not receive oral feedings. They each exhibited motor instability, physiologic instability and acute medical issues that contraindicated oral feeding attempts (McGrath & Braescu, 2004).
Related Case
C.A. is an example of a related case. He is an ex-34 2/7 week, 1987 gram, black male born by vaginal delivery to a mother with an uncomplicated antenatal course except for premature rupture of membranes of unknown etiology. Her feeding plan was to breast feed. C.A had no respiratory issues at birth and was brought to the NICU for prematurity. His vital signs remained stable and his tone and reflexes were appropriate for gestational age. He was active, alert and had good tone and response. He sucked vigorously on a pacifier. On day of life number one feeding orders were written for initiation of enteral feedings. C.A.'s mother was at the bedside to breast feed. Oral feeding at the breast was attempted and C.A. was able to obtain a successful latch for almost 20 minutes. C.A's mother continued to be available for all of his feedings and C.A orally fed at the breast for a period of 20 to 30 minutes at every feeding each day without supplementation. On day of life number ten, C.A.'s weight was almost five percent below his birth weight and he had been consistently losing weight for the last three days. He was not able to be discharged due to his ongoing weight loss. Options for care were discussed with C.A.'s mother and she chose to provide expressed breast milk or preterm infant formula by bottle supplementation after breastfeeding. Following the initiation of bottle supplementation, C.A began to gain weight steadily and was able to be weaned from his heated bed and discharged to home.
Despite the ability to orally feed from the breast there existed the inability to be successful with oral feeding when viewed within the context of adequate oral intake to support weight gain, an essential component of discharge readiness (Simpson, Schanler & Lau, 2002, p. 517). This case is considered to be a related case affected by a network of multiple related concepts; some which are related to readiness to orally feed and some which are not (Avant, 2000, p. 60).
Borderline Case
P.D. is an ex-34 week white male, 2643 grams, and infant of a diabetic mother with the feeding choice for breastfeeding. He was delivered vaginally after premature rupture of membranes. His mother was an insulin-controlled gestational diabetic with good control of her blood sugars during her pregnancy. Following delivery, P.D. was brought to the NICU for prematurity. He had no respiratory issues. He was mildly hypotonic; reflexes were appropriate for gestational age. He was noted to be alert and active, but did not suck vigorously when offered a pacifier during procedures. His vital signs were stable except for an initial glucose that was borderline low. An order was written for initiation of enteral feedings with colostrum or formula. His mother was available to breastfeed. The first feeding was initiated orally at the breast. P.D. appeared very disinterested in feeding and was unable to successfully latch after a 15 minute assisted attempt. Per protocol, he was offered a supplemental feeding by bottle and after an additional five minutes of oral feeding attempts, he continued to show disinterest and had minimal sucking and swallowing and the oral feeding attempt was ended. Vital signs remained stable during these attempts to feed; however, a serum glucose level 30 minutes after the feeding was a critical low and an IV was started for immediate glucose delivery.
This is a borderline case as it involves only some of the elements of the concept of readiness to orally feed (Avant, 2000, p. 61). Although P.D. was physiologically stable, he had some components of state and motor immaturity that interfered with his ability to be successful with oral feeds (McGrath & Braescu, 2004).
Invented Cases
For the concept of oral feeding readiness, invented cases are not needed. There are a sufficient number of actual cases depicting the concept (Avant, 2000, p. 61).
Social Context
The concept of "oral feeding readiness" as it relates to preterm infants, is most often used within the context of healthcare in the NICU by physicians, nurses, parents, lactation specialists, feeding specialists, and insurance case managers. Within these various groups there may also be varying opinions as to when and why oral feeding readiness becomes an important aspect of care for the preterm infant in the NICU.
Physicians in the NICU have historically been responsible for the initiation of oral feedings (Shaker & Woida, 2007, p. 77). According to McGrath & Braescu (2004) "physician order may be the most powerful driving force in this decision-making process" (p. 356). NICU physicians today may not be primarily responsible for the task of feeding, however, they may have a growing concern related to this task because attainment of oral feeding is one of the prerequisites for hospital discharge (Lau, 2006). As a result, many NICU physicians may be most concerned with asking the question: if oral feedings are successful when can this baby be discharged? On the other hand, many of these physicians are also concerned with suck-swallow-breath coordination issues, gestational age and weight at the time of oral feeding initiation, and the belief that oral feeding in the preterm infant causes poor weight gain (Simpson et al., 2002, p. 521). Perhaps the question being asked within this context is: will initiating oral feedings cause a delay in physiologic stability and overall medical progress to this point? All of these factors may play a role in an individual physician's decisions to promote or discourage oral feedings for a particular preterm infant. Therefore, decisions related to determining medical stability for oral feeding readiness by the physician are an important factor when considering a preterm infant's readiness to begin oral feedings.
The context of oral feeding readiness from a nursing perspective is also influenced by a variety of factors. A growing base of evidence regarding oral feeding readiness has inspired NICU nurses to seek more autonomy in making independent decisions about oral feeding readiness (Shaker & Woida, 2007). Assessment of oral feeding readiness and the decision to orally feed is often considered a routine nursing task that is less of a priority than many other nursing tasks in this critical care area (McGrath & Braescu, 2004, p. 364). For the NICU nurse, assessment of a preterm infant's readiness to orally feed is not only intuitive and "based on individual caregiver perspectives and knowledge of respiratory status, gestational age, tolerance of bolus feedings and weight gain" (McGrath & Braescu, 2004, p. 354), but also dependent on time management skills. Acquiring feeding skills to feed a preterm infant is a process involving attention to infant cues and the ability to monitor for consequences of instability (Shaker & Woida, 2007). Nursing assessment of oral feeding readiness is also "an interactive process that requires reciprocity between the caregiver and the infant and competency of both members of the feeding dyad" (McGrath & Braescu, 2004, p. 355). If a preterm infant's oral feeding skills are not well-developed, or the nurse is not experienced in providing oral feedings, the feeding will take a longer period of time. Therefore, it can be concluded that the nurse's decision to attempt oral feedings or to forgo them at a particular feeding may be directly affected by her NICU experiences with feedings, a particular infant's ability to orally feed, and the time to be able to complete the task. A good example of the potential impact of this social context is seen in Woods (1991) observations of NICU nurses and preterm infants during two different oral feeding sessions. Wood observed 27 NICU nurses feeding preterm infants in order to examine the ability of the nurse to respond to the infant's cues, and the infant to respond to the nurse's cues. What Wood discovered through these observations was that as the nurse's workload increased, the response to infant cues was diminished. In addition, feedings during the daylight shift had the same impact (Wood, 1991). Therefore, within the context of nursing assessment of feeding readiness, answers may not only vary depending on the workload at any particular feeding time, but by the time of day the feeding is taking place as well.
Parents of hospitalized preterm infants may view oral feeding readiness in a whole different social context and at opposing ends of the oral feeding readiness spectrum, depending on their own personal adaptation to having an infant in the NICU and accompanying psychological adjustments to having a sick newborn (Siegel, Gardner & Merenstein, 2002, p. 726). The mother who has planned to breastfeed her preterm infant may desire oral feeding readiness as a way of enhancing her own attachment and enabling personal contribution to her child's care (Gardner, Snell & Lawrence, 2002, p. 381). For other parents, readiness for oral feedings may be seen as a step closer to home. If parents are ready for this psychological task, they may welcome oral feeding readiness; in actuality, they may want to orally feed their child when assessment by other health care team members indicates that the infant is not yet ready to do this. In contrast, other parents may not want their child to orally feed. Although health care team members may feel that oral feeding readiness has been attained by a particular infant, the parent is hesitant to participate in this aspect of care; if their child is able to feed, he/she may be medically stable for discharge, a psychological task that the parents are not yet ready to confront. "Discharge is an anxiety-provoking event and ushers in the crisis of homecoming, which parents must face and master" (Siegel et al., 2002, p. 747).
Lactation consultants may view the social context of oral feeding readiness differently than other members of the health care team. They are concerned with the following question: is the infant stable to go to the breast? "Although breastfeeding is a normal, natural function, it is not a reflex, but rather a highly complex interaction and interdependence between mother and infant" (Gardner et al., 2002, p. 382). In the NICU "oral readiness to feed" is often used interchangeably with "readiness to go to the breast" when in fact, they are two separate concepts. Facilitating successful breastfeeding involves two distinctive types of sucking: nonnutritive and nutritive. Nonnutritive sucking is "sucking activity in which no fluid or nutrition is delivered to the infant" (Gardner et al., 2002, p. 382). Nutritive sucking, on the other hand, is characterized by an organized, rhythmic pattern of sucking that is used by an infant to obtain fluid or nutrition. Nutritive sucking requires coordination between sucking, swallowing and breathing and an increased level of organization and maturity (Gardner et al., 2002, p.383). Therefore, when a lactation consultant is asking if a preterm baby may go to breast, they are not always asking if that infant is ready to orally feed. In order to answer that question, the goal of going to the breast must first be determined to be that of either a nonnutritive or nutritional nature.
The feeding specialist has an additional role in questioning oral readiness to feed: that of providing an answer from a developmental perspective. Neurobehavioral organization is considered essential for a smooth transition to oral feedings. It involves coordination of autonomic, motor and state organization as well as development of the nervous system (McGrath & Braescu, 2002, p. 356). The ability to coordinate suck, swallow and breathing is evidence of neurodevelopmental maturation. The role of the feeding specialist in assessing oral feeding readiness is often that of assessing behavioral state organization, postconceptual age, organization, swallowing ability and physiologic stability as indicators for oral feeding readiness (American Speech-Language-Hearing Association, 2005). For the feeding specialist the question that may be asked is: are oral feedings appropriate from a neurodevelopmental, physiological and organizational perspective for this infant? The answer to this question may be "no" yet if infants can suck effectively enough to take full volume feedings, they are often discharged home before high quality of behavioral state and neurodevelopmental organization is achieved (McGrath & Braescu, 2004, p. 357).
The role of the insurance case manager within the NICU may also provide social context to the definition of oral feeding readiness. Intensive care cost is one of the largest components of inpatient care worldwide and the NICU is ranked as one of the most costly hospital admissions (Geitona, Hatzikou, Hatzistamatiou, Anastasiadou & Theodoratou, 2007, p. 1). In today's managed care environment, most preterm infants are discharged within 24 - 48 hours of achieving exclusive oral feedings if other physiologic parameters for discharge readiness have been met (McGrath & Braescu, 2004, p. 357). The impact of reimbursement or denial of reimbursement for care may influence readiness for oral feedings as well as progression of oral feedings when other parameters for discharge from the NICU have been met. In 1996 Glied & Gnanasekaran reported on the significant effects of insurance coverage on the provision of care in a New York City NICU and concluded that differences in care of low birth weight infants exist between those who are privately insured, those who are insured through Medicaid or those who are uninsured (p. 593).
Underlying Anxiety
There are several issues that may cause underlying anxiety to parents, nurses, physicians and other healthcare providers when viewing the social context of oral feeding readiness. For parents, the potential anxiety related to oral feeding readiness and discharge was previously described. In addition to this anxiety, is the anxiety of learning to assess for oral feeding readiness as an active participant in the care of their preterm infant. This anxiety is not only related to the parent role of transitioning their infant to exclusive oral feeding, but to the role of becoming the primary care provider for this infant.
For nurses as the primary caregiver for most infants in the NICU, anxiety exists related to the completion of a comprehensive assessment of a preterm infant's readiness to orally feed. Anxiety may be experienced as the nurse attempts to complete this task within an allotted amount of time and while also attempting to prioritize other assignments and duties in an intensive care environment.
For physicians, it may be anxiety related to the establishment of medical and physiologic stability for oral feeding readiness. Medical decisions that physicians make related to oral feeding readiness may produce this anxiety as they struggle to make decisions that are medically necessary, patient-focused and yet also cost-effective.
Practical Results
This analysis has shown that there are multiple issues involved with defining oral readiness to feed and as a result, has provided clarification of this concept. If approached with the premise of providing patient-centered and best practice care, the NICU nurse can appropriately determine oral readiness to feed and will further be able to educate family members about this concept as well. With successful implementation of this concept into practice, the ultimate goal of interventions that are appropriate and individualized to the care needs of the hospitalized infant will be met.
Results in Language
The result of this concept analysis is clarification of the essential elements of oral feeding readiness to be as follows:
Oral feeding readiness is affected by neurodevelopmental maturity, behavioral state organization and physiologic stability.
Oral feeding readiness can be defined in terms of readiness for initiation of oral feedings and in terms of readiness for a particular feeding event.
Oral feeding readiness in preterm infants is directly and indirectly influenced by the caregivers and environment of the NICU.
Infants exposed to non-nutritive sucking are found to have a greater oral feeding success.
Conclusion
Oral feeding readiness is a complex concept involving a multitude of factors for consideration. Awareness of the essential elements of this concept will provide clarity for determining oral feeding readiness as well as leading to greater consistency in the provision of evidence-based feeding related care for the preterm infant hospitalized in the NICU.
