嬰幼兒吞嚥評估工具 POFRAS :Preterm Infant Oral Feeding Readiness Assessment Scale,

Preterm Infant Oral Feeding Readiness Assessment Scale, POFRAS

是一份針對 "早產兒在由口進食前之先備能力" 的評估工具

文獻中有提供完整的評估表單及評估層面的指引

評估表單共評量5個大層面,每個細項0~2分,有18個細項,總分36分

POFRAS後來也有被其他的研究做為研究中的評估工具

在臨床上可以針對嬰幼兒的吞嚥評估作為一個參考的方向

以下為文獻內容摘要:

(對於細節有興趣者可以直接看作者的paper (2007), 內文已附上相關連結)

source from:

Reliability of an instrument to assess the readiness of preterm infants for oral feeding

FUJINAGA, C. I.; ZAMBERLAN, N. E.; RODARTE, M. D. O.; SCOCHI C. G. S. Reliability of an instrument to assess the readiness of preterm infants for oral feeding( original title: Confiabilidade do instrumento de avaliação da prontidão do prematuro para alimentação oral). Pró-Fono Revista de Atualização Científica, Barueri (SP), v. 19, n. 2, p. 143-150, abr.-jun. 2007.

 http://www.scielo.br/scielo.php?pid=S0104-56872007000200002&script=sci_arttext&tlng=en

摘要:

早產兒由胃轉換到由口進食是相關專業人員關心的事，因此需要一套客觀的標準去支持早產兒適合開始由口進食的時間點。

研究的目的是希望能夠建立 "早產兒在由口進食前之先備能力"評估工具之信度(Preterm Infant Oral Feeding Readiness Assessment Scale, POFRAS)。而所編製的評估工具內容包含以下層面：

corrected gestational age; behavioral state;global posture and tonus;lips and tongue posture;rooting, suck, bite and gag reflexes; tongue and jaw movements;tongue cupping; sucking strain; sucking and pause; maintenance sucking/pause;maintenance alert state and stress signs.)

(包含: 矯正年齡，全身的姿勢和張力，雙唇和舌頭的型態，反射行為(尋乳、吸吮、咬合和嘔吐反射)，舌頭和下頷的動作，舌頭包覆的能力，吸吮力量，吸吮與暫停，持續吸吮與暫停的能力，持續警醒度和壓力徵狀等層面。)

這份研究於巴西的照護中心執行。研究對象為30位早產兒：矯正年齡<36週+6天,臨床狀況穩定,排除顏面異常,呼吸,心血管,腸胃道或神經性疾病.且尚未由口餵奶。由兩位觀察者去觀察同一位嬰兒，再使用Kappa Test 檢視評分者間信度。研究結果如下:

有高度的信度的項目為:behavioral state, global posture and tonus, lips and tongue posture, gag reflex and maintenance of alert state.

可接受的信度的項目為:rooting reflex, sucking and biting and jaw movement, sucking strain and sucking and pause.

不佳的信度項目為:tongue cupping, maintenance of sucking/pause and stress signs

(文章中有進一步解釋)

整體來說，該評估工具在評分者間的信度是在合適的範圍。

ABSTRACT

BACKGROND: the transition from gastric to oral feeding of preterm infants is one of the greatest concerns of health professionals and therefore needs an objective criterion to support the beginning of this process.
AIM: to test the reliability of an instrument that assesses the readiness of preterm infants for the transition from gastric to oral feeding.
METHOD: the instrument is composed by the following items: corrected gestational age; behavioral state; global posture and tonus; lips and tongue posture; rooting, suck, bite and gag reflexes; tongue and jaw movements; tongue cupping; sucking strain; sucking and pause; maintenance sucking/pause; maintenance alert state and stress signs. The study was conducted at the Intermediate Care Unit of the Hospital de Clínicas da Faculdade de Medicina de Ribeirão Preto - University of São Paulo. The research sample consisted of 30 preterm infants who attended the following inclusion criteria: corrected gestational age <36 weeks and 6 days; clinically stable; absence of facial deformities; respiratory, cardiovascular, gastrointestinal and neurological disorders or syndromes that prevent or make oral feeding difficult; and not having received oral feeding of milk. The Kappa Test was used to verify interjudge reliability.
RESULTS: the items that presented high reliability levels were: behavioral state, global posture and tonus, lips and tongue posture, gag reflex and maintenance of alert state. The items that presented satisfactory reliability levels were: rooting reflex, sucking and biting and jaw movement, sucking strain and sucking and pause. Only the items of tongue cupping, maintenance of sucking/pause and stress signs presented unsatisfactory reliability levels.

CONCLUSION: in general, the items investigated by the assessment instrument presented adequate interjudge reliability.

而作者後來針對Preterm Infant Oral Feeding Readiness Assessment Scale, POFRAS)進行效度的探討(2013)

研究結果建議可30分為決定是否適合由口進食切截分數

詳細的文獻內容如下:

Clinical validation of the Preterm Oral Feeding Readiness Assessment Scale.

Latino-Am. Enfermagem Original Article 2013 Jan.-Feb.;21(Spec):140-5

Cristina Ide Fujinaga^I; Suzana Alves de Moraes^II; Nelma Ellen Zamberlan-Amorim^III; Thaíla Corrêa Castral^IV; Andreara de Almeida e Silva^V; Carmen Gracinda Silvan Scochi^VI

source from:http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692013000700018

Preterm Oral Feeding Readiness Assessment Scale

(作者並針對每一個評估層面給予指引)

Instruction Guide - Preterm Infant Oral Feeding Readiness Assessment Scale

CORRECTED GESTATIONAL AGE (gestational age - Ballard plus postnatal age) 矯正年齡

. 32 weeks or less.

. Between 32 and 34 weeks.

. 34 weeks or more.

BEHAVIORAL ORGANIZATION

Behavioral state  行為狀態

. Alert: eyes open and shining, responsive to stimulation, some spontaneous activity.

. Drowsy: eyes open and close, confused and dull look, takes time to respond to stimulation, varied spontaneous

activity.

. Sleep: eyes closed, non-responsive to stimulation; no motor activity.

Global Posture 全身姿態

. Flexed: flexed upper and lower limbs and neck position in median line in relation to trunk.

. Partly flexed: flexed lower limbs and neck position in median line in relation to trunk.

. Extended: upper and lower limbs and neck extended in relation to trunk.

Global tonus  全身張力 (parameter considered according to what is expected for preterm infant's maturity)

. Normotonic: light resistance to passive flexion and extension movements, slightly stronger in the latter.

. Hypertonic: increased resistance to passive flexion and extension movements.

. Hypotonic: decreased resistance to passive flexion and extension movements.

ORAL POSTURE

Lips posture 雙脣姿態

. Closed: upper and lower lip side by side.

. Half-open: upper and lower lip partially separated.

. Open: upper and lower lip totally separated.

Tongue posture 舌頭姿態  (observed by lowering the lower lip and, if necessary, the jaw)

. Flat: tongue in flat position inside oral cavity, with a rounded tip.

. Elevated: tip of the tongue in elevated position, pressing the palate.

. Retracted: tongue in retracted position in the oral cavity.

. Protruded: tongue in protruded position in the oral cavity, beyond labial border.

ORAL REFLEXES

Rooting reflex  尋乳反射

. Present: when four main points are stimulated in the perioral region, immediately seeks stimulated region,

directing the head towards the stimulus and/or opening the mouth.

. Weak: when four main points are stimulated in the perioral region, slowly seeks the stimulated region, directing

the head towards the stimulus and/or opening the mouth.

. Absent: absence of response.

Sucking reflex 吸吮反射

. Present: readily sucks own hand or examiner's gloved finger.

. Weak: takes some time to start sucking own hand or examiner's finger.

. Absent: absence of response.

Biting reflex  咬合反射

. Present: responds to stimulus exerted by the examiner's finger in the gingival line of the oral cavity by jaw

clenching, followed by relaxing.

. Exacerbated presence: responds to stimulus exerted by examiner's finger in the gingival line of the oral cavity,

maintaining jaw clenching.

. Absent: absence of response.

Gag reflex  嘔吐反射

. Present: responds to stimulus exerted by introduction of examiner's finger by nauseas and/or vomiting when

reaching the middle-posterior tongue region.

. Present in anterior region: already responds to stimulus exerted by introduction of examiner's finger by nauseas or

vomiting when reaching the anterior tongue region.

. Absent: absence of response.

NONNUTRITIVE SUCKING   非營養性吸吮

Tongue movement 舌頭動作

. Normal: intraoral stimulus generates anterior-posterior and coordinated tongue movement.(前-後動作且具協調性)

. Altered: intraoral stimulus generates posterior-anterior or uncoordinated movement.(後-前動作 或不協調的動作)

. Absent: absence of movement.(未出現反應)

Tongue cupping   舌頭包覆的能力

. Present: elevated tongue sides and presence of groove in central tongue region.(舌側邊較高,舌面中間成凹槽狀-像杯狀的凹槽)

. Absent: absence of response.(未出現反應)

Jaw movement 下頷動作

. Normal: reduced jaw excursion, rhythmic and spontaneous jaw movement.(下頷偏移少,具有節律性的動作)

. Altered: wide jaw excursion and/or arrhythmic jaw movement and/or jaw clenching.(下頷偏移大,下頷動作不規律或是出現 jaw clenching)

. Absent: absence of movement.(未出現動作)

Sucking strain 吸吮力量

. Strain: strain compression against palate and negative intraoral pressure with resistance to withdrawal of

examiner's finger from oral cavity.(吸吮力量足夠)

. Weak: weak compression against palate and negative intraoral pressure without resistance to withdrawal of

examiner's finger from oral cavity.(弱的吸吮力量)

. Absent: absence of response.(未有反應)

Sucking and pause 吸吮和暫停 (Use the average obtained in three groups of suck/pause)

. Between 5 and 8 sucks per respiratory pause.  (5~8次吸吮/1次暫停)

. More than 8 sucks per respiratory pause   .(>8次吸吮/1次暫停)

. Less than 5 sucks per respiratory pause     (<5次吸吮/1次暫停)

Maintenance of rhythm of sucking and pause  持續吸吮和暫停的節律 (Use the number of sucks/pause obtained in three groups of suck/pause and verify if this number varied between set intervals)

. Rhythmic: maintains the number of sucks per pause expected in one and the same interval (less than 5, between 5and 8 or more than 8 sucks per pause).(吸吮和暫停的情形是規律的)

. Arrhythmic: changes the number of sucks per pause between intervals (less than 5, between 5 and 8 or more than 8 sucks per pause).(吸吮和暫停的情形是不規律的)

. Absent: absence of sucking. (未出現吸吮)

Maintenance of alert state 持續的警醒度

. Yes: continues alert throughout the nonnutritive sucking test.(在吸吮測試中保持警醒)

. Partial: continues alert only at beginning or end of nonnutritive sucking test.(僅在吸吮測驗一開始或結束時保持警醒)

. No: does not continue alert during the nonnutritive sucking test.(在吸吮測試中未有持續性警醒表現)

Stress signs  壓力徵狀

Absent: absence of stress signs. (未出現)

. Up to 3 stress signs.  (1~3個徵狀)

. More than 3 stress signs. (>3個徵狀) 

The following stress signs must be observed during assessment: saliva accumulation; nose wings trembling; color

changes; apnea; tonus variation; posture variation; tongue or jaw tremors; hiccupping; crying

(口水堆積、鼻翼顫動、膚色改變、窒息、張力改變、姿勢改變、舌頭或是下頷顫抖、打嗝、哭）

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