早 產 兒 口 腔 餵 食 與 心 肺 功 能 調 節 之 關 係 張 雅 雯 張 瑩 如 * 由 於 早 產 兒 生 理 成 熟 及 疾 病 因 素, 導 致 其 在 學 習 口 腔 餵 食 時 心 肺 功 能 調 節 反 應 有 個 別 性 的 差 異, 因 而 影 響 其 餵 食 成 效 由 於 觀 察 餵 食 過 程 的 生 理 反 應 是 護 理 人 員 的 重 要 職 責, 故 本 文 統 整 文 獻 探 討 早 產 兒 口 腔 餵 食 與 其 心 肺 功 能 調 節 之 機 轉 及 關 係, 以 增 進 護 理 人 員 之 認 知 及 臨 床 觀 察 之 敏 感 度 本 文 統 整 四 個 重 要 概 念 :⑴ 早 產 兒 可 藉 由 成 熟 的 吸 吮 技 巧, 配 合 吸 吮 吞 嚥 和 呼 吸 間 的 協 調, 進 而 提 昇 口 腔 餵 食 成 效 ⑵ 早 產 兒 的 口 腔 餵 食 與 心 肺 功 能 調 節 具 有 絕 對 關 係, 心 肺 功 能 調 節 良 好, 餵 食 成 效 越 佳 ⑶ 早 產 兒 在 口 腔 餵 食 期 間 會 降 低 迷 走 神 經 反 應 使 心 跳 速 率 增 加, 以 平 衡 身 體 新 陳 代 謝 機 能, 在 餵 食 完 後 則 會 逐 漸 回 復 至 餵 食 前 之 速 率 ⑷ 早 產 兒 在 口 腔 餵 食 初 期 的 動 脈 血 氧 飽 和 濃 度 (arterial oxygen saturation, SaO 2 ) 持 續 低 下 情 況, 可 藉 由 經 驗 累 積 逐 漸 達 到 成 熟 的 口 腔 餵 食 動 作 來 改 善 這 些 概 念 可 提 供 臨 床 護 理 人 員 開 始 嘗 試 早 產 兒 口 腔 餵 食 時 機 的 依 據 或 參 考, 以 避 免 過 早 及 強 迫 口 腔 餵 食 而 導 致 心 肺 負 荷 早 產 兒 口 腔 餵 食 心 肺 功 能 調 節 餵 食 成 效 23 32 34 Thomas, 200 32 arterial oxygen saturation, SaO 2 gestational age 13 1 2 McGrath & Braescu, 2004 32 Pickler & Reyna, 200432 1 1. McGrath & Braescu, 2004; Pickler & Reyna, 2004 34 3 10 30 1 1 1 McGrath * 9 3 13 9 13 0101 1 0 2333 4
Oral Feeding and Cardiorespiratory & Braescu, 2004 32 SaO 2 Medoff & Ray, 199 Daniel, Julie, & William, 2002 Ludwig 14 respiratory sinus arrhythmia, RSAPorges, 19 Yasuma & Hayano, 2004 Brown, 200; Hill, 1992; Portales et al., 199; Suess et al., 2000 Portales et al., 199 Porges Lipsitt 1993 13 RSA nucleus ambiguous, NA Suess et al., 2000 RSA Veerappan 2000 12 feeding bradycardia 10 34 (McCain, Fuller, & Gartside, 200 German, Crompton, McCluskey, & Thexton, 199 Medoff & Ray, 199 Simpson, Schanler, &
Lau, 2002 McGrath & Braescu, 2004 Medoff & Ray, 199 Shivpuri Martin Carlo Fanaroff 193 / Hill, 1992 Thoyre, S. M. & Carlson, J. R., 2003 Bu Lock, Woolridge, & Baum, 1990 Thoyre, S. M., & Carlson, J. R., 2003 SaO 2 oxyhemoglobin, HbO 2 Hb DiFiore, 2004 SaO 2 SaO 2 Chang, Anderson, Dowling, & Lin, 2002 SaO 2 SaO 2 McGrath & Braescu, 2004 Hill, 1992 SaO 2 SaO 2 Thoyre, S. M. & Carlson, J., 2003 SaO 2 Shiao, Brooker, & DiFiore, 199 Cheung, Barrington, Finer, & Robertson, 1999 SaO 2 Thoyre, S. M. & Carlson, J., 2003 Shiao et al., 199 Shiao 199 SaO 2 Thoyre, S. M. & Carlson, J. R., 2003 Chang et al., 2002
Oral Feeding and Cardiorespiratory Thoyre, S. M. Carlson, J. 2003 22 very low birth weight, VLBW 20 SaO 2 90SaO 2 bottle-in-mouth 3. SaO 2 SaO 2 SaO 2 Medoff & Ray, 199 SaO 2 SaO 2 SaO 2 Hill, 1992 SaO 2 SaO 2 SaO 2 McGrath & Braescu, 2004 Brown, L. (2007). Heart rate variability in premature infants during feeding. Biological Research for Nursing, 8(4), 283 293. Bu Lock, F., Woolridge, M. W., & Baum, J. D. (1990). Development of coordination of sucking, swallowing and breathing: Ultrasound study of term and preterm infants. Developmental Medicine and Child Neurology, 32(8), 669 678. Chang, Y. J., Anderson, G. C., Dowling, D., & Lin, C. H. (2002). Decreased activity and oxygen desaturation in prone venti-
9 lated preterm infants during the first postnatal week. Heart & Lung, 31(1), 34 42. Cheung, P. Y., Barrington, K. J., Finer, N. N., & Robertson, C. M. (1999). Early childhood neurodevelopment in very low birth weight infants with predischarge apnea. Pediatric Pulmonology, 27(1), 14 20. Daniel, J. S., Julie, A. A., & William, T. (2002). Heart rate and gender: Neurohumoral basis and clinical implications. Philippine Journal of Cardiology, 30(1), 1 5. DiFiore, J. M. (2004). Neonatal cardiorespiratory monitoring techniques. Seminars in Neonatology, 9(3), 195 203. German, R. Z., Crompton, A. W., McCluskey, C., & Thexton, A. J. (1996). Coordination between respiration and deglutition in a preterm infant mammal, Sus scrofa. Archives of Oral Biology, 41(6), 619 622. Hill, A. S. (1992). Preliminary finding: A maximum oral feeding time for premature infants, the relationship to physiological indicator. Maternal Child Nursing Journal, 20(2), 81 92. McCain, G. C., Fuller, E. O., & Gartside, P. S. (2005). Heart rate variability and feeding bradycardia in healthy preterm infants during transition from gavage to oral feeding. Newborn and Infant Nursing Reviews, 5(3), 124 132. McGrath, J. M., & Braescu, A. V. (2004). State of the science: Feeding readiness in the preterm infant. Journal of Perinatal and Neonatal Nursing, 18(4), 353 368. Medoff, C. B., & Ray, W. (1995). Neonatal sucking behaviors. The Journal of Nursing Scholarship, 27(3), 195 200. Pickler, R. H., & Reyna, B. A. (2004). Effects of non-nutritive sucking on nutritive sucking, breathing, and behavior during bottle feedings of preterm infants. Advances in Neonatal Care, 4(4), 226 234. Porges, S. W. (1986). Respiratory sinus arrhythmia: Physiological basis, quantitative methods, and clinical implications. In P. Grossman, K. Janssen, & D. Vaitl (Eds.), Cardiorespiratory and cardiosomatic psychophysiology (pp. 101 115). New York: Plenum. Porges, S. W., & Lipsitt, L. P. (1993). Neonatal responsivity to gustatory stimulation: The gustatory-vagal hypothesis. Infant Behavior and Development, 16, 487 494. Portales, A. L., Porges, S. W., Doussard-Roosevelt, J. A., Abedin, M., Lopez, R., Young, M. A., et al. (1997). Vagal regulation during bottle feeding in low-birthweight neonates: Support for the gustatory-vagal hypothesis. Developmental Psychobiology, 30(3), 225 233. Shiao, S. Y., Brooker, J., & DiFiore, T. (1996). Desaturation events during oral feedings with and without a nasogastric tube in very low birth weight infants. Heart & Lung, 25(3), 236 245. Shivpuri, C. R., Martin, R. J., Carlo, W. A., & Fanaroff, A. A. (1983). Decreased ventilation in preterm infants during oral feeding. The Journal of Pediatrics, 103(2), 285 289. Simpson, C., Schanler, R. J., & Lau, C. (2002). Early introduction of oral feeding in preterm infants. Pediatrics, 110(3), 517 522.. Suess, P. E., Alpan, G., Dulkerian, S. J., Doussard-Roosevelt, J. A., Porges, S. W., & Gewolb, I. H. (2000). Respiratory sinus arrhythmia during feeding: A measure of vagal regulation of metabolism, ingestion, and digestion in premature infants. Developmental Medicine and Child Neurology, 42(3), 169 173. Thomas, J. A. (2007). Guidelines for bottle feeding your premature baby. Advances in Neonatal Care, 7(6), 311 318. Thoyre, S. M., & Carlson, J. (2003). Occurrence of oxygen desaturation events during preterm infant bottle feeding near discharge. Early Human Development, 72(1), 25 36. Thoyre, S. M., & Carlson, J. R. (2003). Preterm infants behavioural indicators of oxygen decline during bottle feeding. Journal of Advanced Nursing, 43(6), 631 641. Veerappan, S., Rosen, H., Craelius, W., Curcie, D., Hiatt, M., & Hegyi, T. (2000). Spectral analysis of heart rate variability in premature infants with feeding bradycardia. Pediatric Research, 47(5), 659 662. Yasuma, F., & Hayano, J. I. (2004). Respiratory sinus arrhythmia: Why does the heartbeat synchronize with respiratory rhythm? Chest, 125(2), 683 690.
10 Oral Feeding and Cardiorespiratory The Relationship Between Oral Feeding and Cardiorespiratory Regulation of Premature Infants Ya-Wen Chang Ying-Ju Chang * Abstract: Levels of maturity and diseases of premature infants are factors that produce individual differences in cardiorespiratory responses to oral feeding and feeding performances. Recognition of mechanisms and cardiorespiratory regulation of oral feeding may increase sensitivity of clinical observation of nurses and facilitate safe and comfort feeding experiences for premature infants. Four major concepts of this integrated literature review are: (a) The maturation of sucking skills and coordination of sucking, swallowing, and breathing play an important role in successful oral feeding. (b) There are significant relationships between the feeding performances and cardiorespiratory stability of premature infants in the early period of oral feeding. (c) During the oral feeding period, the reduction of vagal tone will increase the heart rate of premature infants in order to balance physiological metastasis. (d) During the early period of oral feeding, the SaO 2 of premature infants might decrease continually. This condition can be improved gradually with experience of oral feeding. These concepts provide knowledge for assessing feeding readiness and facilitate protocols for safe feeding by reducing the cardiorespiratory workload of premature infants. Key Words: premature infants, oral feeding, cardiorespiratory regulation, feeding performance. RN, MSN, Instructor, Department of Nursing, National Tainan Institute of Nursing; *RN, PhD, Associate Professor, Department of Nursing & Institute of Allied Health, College of Medicine, National Cheng Kung University. Received: March 13, 2008 Revised: March 31, 2008 Accepted: May 13, 2008 Address correspondence to: Ying-Ju Chang, No. 1, Ta-Hsueh Rd., Tainan 70101, Taiwan, ROC. Tel: +886 (6) 235-3535 ext. 5854; E-mail: yxc2@mail.ncku.edu.tw