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Development of arm posture during bottle feeding in preterm infants
INFANT BRIEF
BEHAVIOR
AND
DEVELOPMENT
8, 241-244
(1985)
REPORT
Development of Arm Posture During Bottle Feedingin Preterm Infants* HANS DANIELSAND PAUL CASAER Katholieke Universiteit Leuven, Universiteit Ziekenhuis Gasthuisberg arm posture
bottle
feeding
preterm
infants
In a previous study, during the first week of bottle feeding in preterm infants, feeding efficiency and the occurrence of an arm posture correlated well with some aspects of perinatal assessment, with some aspects of the neonatal neurological evaluation, and with developmental assessment at 7 months of age (Casaer, Daniels, Devlieger, De Cock, & Eggermont, 1982). In the present study we wanted to answer two questions: First, is the typical arm posture of the fullterm infant during feeding seen in preterm infants during their first bottle feeding? Second, is the arm posture of the preterm infant a result of maturation (gestational age) or of feeding experience? We studied 100 consecutive preterm infants born at the University Obstetrical Department with a birth weight below 2,000 g. Only babies with major congenital abnormalities were excluded. Age at birth varied from 25 to 37 weeks (median, 32 weeks) and birth weights ranged from 780 to 1,995 g (median, 1,530 g). After parental or gastric feeding was changed to bottle feeding, one feeding session was observed weekly. A sketch of every arm posture was made during the observations and about every 2 min a picture was taken using a light-sensitive film so that no disturbing flashlights were employed. The observer did not interfere with the habits of the nursing staff such as wrapping the baby during feeding outside the incubator. Arm posture and eye condition were observed and coded after every nipple insertion and after every change in posture. The coding system is described,in Fig. 1. According to this coding system, arm postures were described by a series of three letters. An asymmetrical posture was coded separately left and right. When a change in arm posture was observed due to fatigue or sleep, only the initial arm posture was coded. l We acknowledge the skillful help of the Nursing Staff at the Neonatal Special Care Unit and R. Lindstedt for a thorough critique of the manuscript. This research is supported by a grant from the Nationaal Werk voor Kinderwelzijn of Belgium (National Child Health Organization) and by Grant 3.0041-82 of the Fonds voor Geneeskundig Wetenschappelijk Onderzoek of Belgium (Medical Research Council). Correspondence and requests for reprints should be sent to Hans Daniels, Developmental Neurology Unit, Neonatal Special Care Unit, Department of Paediatrics, Katholieke Universiteit Leuven, Universitair Ziekenhuis Gasthuisberg, B-3000 Leuven. Belgium.
241
DANIELS
242
Code
Items
AND
A
CASAER
Code
B
Code
C
Flexion at the elbow
Adduction of upper extremities
Hands Q$&P
Figure circle
1. Coding is indicating
system for the infants
3
describing head.
orm
postures
during
bottle
feeding.
The
The observed arm postures were arranged according to gestational age at the time of the observation and according to the number of weeks of feeding experience. For every box (corresponding to a particular gestational age associated with a particular number of weeks of feeding experience), the most frequently observed arm posture, that is, the modus, was calculated and is shown in Fig. 2. After a gestational age of 33 weeks, the majority of the infants showed some degree of flexion at the elbows and adduction of the arms (codes B and C). After a gestational age of 34 weeks, the majority of the infants had their eyes open during feeding. The degree of adduction of the arms changed as a function of the feeding experience. During the first 2 weeks of oral feeding, the modus of the observed postures (see Fig. 2, weeks 0 and week 1, sum of the gestational age groups combined) was one with the upper extremities tightly against the lateral thorax with the elbows in extreme flexion and with fisted hands (code CBC). After 2 weeks of feeding experience, the modus of the observed postures (see Fig. 2, weeks 2,3,4, and 5) was one with the arms closer to the midline, and in most infants, the former extreme flexion at the elbows with fisted hands was replaced by a moderate flexion at the elbows and semiflexed hands (codes CCC and BCB) (Fig. 2). Typical examples of these early and later arm postures during feeding are given in Fig. 3. Most preterm infants (60%) show some degree of flexion at the elbows and adduction of the arms during their first feedings; 80% showed it from the second week onward. The arm posture observed during the first 2 weeks of oral bottle feeding is very similar to that noted by many authors in the fullterm infant during the first week of feeding (Casaer, 1979; Gesell & Ilg, 1937; Halverson, 1938; Prechtl & Lenard, 1968; Sugar, 1976). After about 2 weeks of feeding experience, we observed the arm posture to change. Initially, the arms were held tightly against the lateral thorax. Following this, the arms came closer to the midline with the hands sometimes converging toward the bottle.
GESTATIONAL AGE ( 31
32
33
34
35
36
: Lc
37 \
N
6
19
45
56
70
62
38
>39
SUM
N
t%
402
62
Figure 2. The observed orm postures during feeding, orronged according to gestotionol oge ot the time of the observation and according to the number of weeks of feeding experience. For every box (corresponding to o porticulor gestotionol oge ossocioted with o particular number of weeks of feeding experience), the modus of the observed orm postures is shown. At the right side in the column “Sum” (per week of feeding experience), the modus of all the gestotionol age groups is shown. At the bottom, per week of gestotionol age, the modus of the different weeks of feeding experience is shown.
Figure 3. A typical arm posture (right
example side).
of an early
arm
posture
(left
side)
and
a typical
later
243
244
DANIELS
AND
CASAER
To our knowledge, only Gesell and Ilg (1937) described a developmental change of the arm posture during feeding in the full-term infant, which is very similar to the developmental change observed in preterm infants in this study. This developmental change takes place over a comparable number of weeks, resulting in a more mature feeding posture at a younger gestational age in preterm than in full-term neonates. REFERENCES Casaer, P. (1979). Postural behavior in newborn infants. Clinics in Developmental Medicine, 72. London: Lippincott, W. Heineman Medical. Casaer, P., Daniels, H., Devlieger, H., De Cock, P., & Eggermont, E. (1982). Feeding behaviour in preterm neonates. Early Human Development, 7, 331-346. &sell, A., & Ilg, F. L. (1937). Feeding behavior of infants. Philadelphia, PA: Lippincott. Halverson, H. M. (1938). Infant sucking and tensional behavior. The Journal ofGeneticfsychology, 53, 365-430. Prechtl, H. F. R., & Lenard, H. G. (1968). Uber die Koppehmg von Saugen and Greifreflex beim Saugling. [On coupling between sucking and Pahnar grasp in infants] Naturwissenschajten, 40, 347-348. Sugar, M. (1976). Feeding and hunger reflexes in human neonates. Journal of the American’Academy of Child Psychiatry, 15. 269-277. 10 August
1983:
Revised
14 November
1984
n
BEHAVIOR
AND
DEVELOPMENT
8, 241-244
(1985)
REPORT
Development of Arm Posture During Bottle Feedingin Preterm Infants* HANS DANIELSAND PAUL CASAER Katholieke Universiteit Leuven, Universiteit Ziekenhuis Gasthuisberg arm posture
bottle
feeding
preterm
infants
In a previous study, during the first week of bottle feeding in preterm infants, feeding efficiency and the occurrence of an arm posture correlated well with some aspects of perinatal assessment, with some aspects of the neonatal neurological evaluation, and with developmental assessment at 7 months of age (Casaer, Daniels, Devlieger, De Cock, & Eggermont, 1982). In the present study we wanted to answer two questions: First, is the typical arm posture of the fullterm infant during feeding seen in preterm infants during their first bottle feeding? Second, is the arm posture of the preterm infant a result of maturation (gestational age) or of feeding experience? We studied 100 consecutive preterm infants born at the University Obstetrical Department with a birth weight below 2,000 g. Only babies with major congenital abnormalities were excluded. Age at birth varied from 25 to 37 weeks (median, 32 weeks) and birth weights ranged from 780 to 1,995 g (median, 1,530 g). After parental or gastric feeding was changed to bottle feeding, one feeding session was observed weekly. A sketch of every arm posture was made during the observations and about every 2 min a picture was taken using a light-sensitive film so that no disturbing flashlights were employed. The observer did not interfere with the habits of the nursing staff such as wrapping the baby during feeding outside the incubator. Arm posture and eye condition were observed and coded after every nipple insertion and after every change in posture. The coding system is described,in Fig. 1. According to this coding system, arm postures were described by a series of three letters. An asymmetrical posture was coded separately left and right. When a change in arm posture was observed due to fatigue or sleep, only the initial arm posture was coded. l We acknowledge the skillful help of the Nursing Staff at the Neonatal Special Care Unit and R. Lindstedt for a thorough critique of the manuscript. This research is supported by a grant from the Nationaal Werk voor Kinderwelzijn of Belgium (National Child Health Organization) and by Grant 3.0041-82 of the Fonds voor Geneeskundig Wetenschappelijk Onderzoek of Belgium (Medical Research Council). Correspondence and requests for reprints should be sent to Hans Daniels, Developmental Neurology Unit, Neonatal Special Care Unit, Department of Paediatrics, Katholieke Universiteit Leuven, Universitair Ziekenhuis Gasthuisberg, B-3000 Leuven. Belgium.
241
DANIELS
242
Code
Items
AND
A
CASAER
Code
B
Code
C
Flexion at the elbow
Adduction of upper extremities
Hands Q$&P
Figure circle
1. Coding is indicating
system for the infants
3
describing head.
orm
postures
during
bottle
feeding.
The
The observed arm postures were arranged according to gestational age at the time of the observation and according to the number of weeks of feeding experience. For every box (corresponding to a particular gestational age associated with a particular number of weeks of feeding experience), the most frequently observed arm posture, that is, the modus, was calculated and is shown in Fig. 2. After a gestational age of 33 weeks, the majority of the infants showed some degree of flexion at the elbows and adduction of the arms (codes B and C). After a gestational age of 34 weeks, the majority of the infants had their eyes open during feeding. The degree of adduction of the arms changed as a function of the feeding experience. During the first 2 weeks of oral feeding, the modus of the observed postures (see Fig. 2, weeks 0 and week 1, sum of the gestational age groups combined) was one with the upper extremities tightly against the lateral thorax with the elbows in extreme flexion and with fisted hands (code CBC). After 2 weeks of feeding experience, the modus of the observed postures (see Fig. 2, weeks 2,3,4, and 5) was one with the arms closer to the midline, and in most infants, the former extreme flexion at the elbows with fisted hands was replaced by a moderate flexion at the elbows and semiflexed hands (codes CCC and BCB) (Fig. 2). Typical examples of these early and later arm postures during feeding are given in Fig. 3. Most preterm infants (60%) show some degree of flexion at the elbows and adduction of the arms during their first feedings; 80% showed it from the second week onward. The arm posture observed during the first 2 weeks of oral bottle feeding is very similar to that noted by many authors in the fullterm infant during the first week of feeding (Casaer, 1979; Gesell & Ilg, 1937; Halverson, 1938; Prechtl & Lenard, 1968; Sugar, 1976). After about 2 weeks of feeding experience, we observed the arm posture to change. Initially, the arms were held tightly against the lateral thorax. Following this, the arms came closer to the midline with the hands sometimes converging toward the bottle.
GESTATIONAL AGE ( 31
32
33
34
35
36
: Lc
37 \
N
6
19
45
56
70
62
38
>39
SUM
N
t%
402
62
Figure 2. The observed orm postures during feeding, orronged according to gestotionol oge ot the time of the observation and according to the number of weeks of feeding experience. For every box (corresponding to o porticulor gestotionol oge ossocioted with o particular number of weeks of feeding experience), the modus of the observed orm postures is shown. At the right side in the column “Sum” (per week of feeding experience), the modus of all the gestotionol age groups is shown. At the bottom, per week of gestotionol age, the modus of the different weeks of feeding experience is shown.
Figure 3. A typical arm posture (right
example side).
of an early
arm
posture
(left
side)
and
a typical
later
243
244
DANIELS
AND
CASAER
To our knowledge, only Gesell and Ilg (1937) described a developmental change of the arm posture during feeding in the full-term infant, which is very similar to the developmental change observed in preterm infants in this study. This developmental change takes place over a comparable number of weeks, resulting in a more mature feeding posture at a younger gestational age in preterm than in full-term neonates. REFERENCES Casaer, P. (1979). Postural behavior in newborn infants. Clinics in Developmental Medicine, 72. London: Lippincott, W. Heineman Medical. Casaer, P., Daniels, H., Devlieger, H., De Cock, P., & Eggermont, E. (1982). Feeding behaviour in preterm neonates. Early Human Development, 7, 331-346. &sell, A., & Ilg, F. L. (1937). Feeding behavior of infants. Philadelphia, PA: Lippincott. Halverson, H. M. (1938). Infant sucking and tensional behavior. The Journal ofGeneticfsychology, 53, 365-430. Prechtl, H. F. R., & Lenard, H. G. (1968). Uber die Koppehmg von Saugen and Greifreflex beim Saugling. [On coupling between sucking and Pahnar grasp in infants] Naturwissenschajten, 40, 347-348. Sugar, M. (1976). Feeding and hunger reflexes in human neonates. Journal of the American’Academy of Child Psychiatry, 15. 269-277. 10 August
1983:
Revised
14 November
1984
n