Getting the Best Start in Life An Investigation of Oral Feeding for Neonates in Aotearoa’s Neonatal Units

Abstract

Introduction: Oral feeding is an important skill for preterm and newborn infants to master, both to take nutrition orally, and to develop neurological and muscular coordination for continued maturation. Infants who are born prematurely, or who are unwell at birth, may not be ready to feed orally immediately post-birth; therefore oral feeding introduction needs to be carefully moderated so that the infant is able to progress at a pace they are able to maintain. The purpose of this thesis was to develop a comprehensive benchmark of what oral feeding in Aotearoa New Zealand’s neonatal units looks like, specifically focussing on external and environmental factors such as unit design and staff beliefs. The intention was to create a set of recommendations to improve current practice in our neonatal units, and therefore provide the best possible start to a vulnerable population. Methods: This thesis consists of four parts. 1. A scoping review of international oral-feeding guidelines identified current international policy recommendations. This created a snapshot of what best practice was internationally, to provide a comparison to Aotearoa’s policy. 2. A focussed ethnography consisting of five visits to neonatal units around the country provided the main source of data for current neonatal feeding practice. Across these site visits, field notes, policy documents, photographs, feeding observations, and staff and whānau (family) interviews, provided the baseline of current practice. 3. A national survey of neonatal staff. The purpose of this survey was two-fold; to confirm practices that had already been identified in the units under investigation, and also to determine if the perspectives I was gathering in the ethnography were true across the country. 4. Once the results of these three studies were collated, focus groups were run to feed back the results and to engage in collaborative problem-solving. Groups from each site, as well as professionals’ special interest groups, were invited to discuss current issues in oral infant feeding, and identify practises from their own units that mitigated some of these issues. Results: The scoping review identified that international oral feeding guidelines were inconsistent and of relatively poor quality; where there was academic evidence available, this was being used, and was added to by clinical experience. Policies did not show the whole story. The results from this thesis identified that environmental factors surrounding quality of oral infant feeding were complex and multi-factorial. Three groups of factors were identified. Organisational factors impacting infant feeding included staffing of the unit, bedspace size and whānau accommodation, coordination between maternity and neonates, and policy. Staff factors included relationship building with whānau, multi-disciplinary team working, and consistency of care and advice. Whānau factors included control over the infant, presence at the bedside, and external pressures. Conclusion: Improving oral feeding of preterm infants in Aotearoa’s neonatal units requires changes to a complex web of relationships, resources, and requirements in organisational, staff, and whānau factors. Some changes seem fairly unambiguous, such as the case to increase allied health and nursing FTE (full-time equivalent) to provide these professions with more time to spend with whānau, and with each other, learning about their respective fields of practice and upskilling. Some changes are unambiguous but resource-intensive, such as changing the physical environment of the neonatal unit to be more homey, private, and inclusive for whānau, and increasing whānau overnight accommodation capacity. In an ideal world, neonatal units would function as whānau units, where maternity and neonatal care professionals would jointly care for the birthing parent and the infant, and whānau had their own room to bond and develop feeding skills privately with staff support. The aspect of whānau control is the most multi-factorial of all, which requires a range of solutions from encouraging kangaroo mother care for older infants, to facilitating whānau to be the lead in the multidisciplinary team, and providing peer support groups to allow whānau to problem-solve their way through feeding issues semi-independently.