研究背景：早產兒因合併症以及口腔運動系統的不成熟，管灌飲食是常見的腸道營養給予方式，當歷經管灌期，在達到獨立經口進食以完成整個腸道餵食歷程前，早產兒開始經口進食是一關鍵因素，除了受到早產兒本身的因素亦受到環境相關因素影響，大部分的研究以單一地區的早產兒為樣本且主要以獨立經口進食之妊娠週數(postmenstrual age, PMA)為結果變項，鮮少探討不同醫院對早產兒腸道餵食歷程的影響以及護理人員對早產兒腸道餵食歷程主觀做法的相關文獻。
研究目的：了解國內南北兩家醫學中心新生兒加護病房早產兒腸道餵食歷程臨床現況分佈情形以及護理人員臨床照護現況情形及差異，並進一步探討早產兒腸道餵食歷程之影響因素。
研究方法：採相關鑲嵌式混合研究方法進行研究，採用量性及質性方法收集資料。研究場域為南北兩家醫學中心之新生兒加護病房，研究對象包含早產兒及護理人員。早產兒部分，採立意取樣，以病歷回顧的方式收集出生週數小於33週或出生體重小於1500公克早產兒之人口學變項及腸道餵食歷程等相關資料。護理人員量性資料收集部分，採立意取樣，以「護理師發展性照護能力量表」加上研究者所擬題項收集護理人員發展性照護及協助早產兒經口進食策略之能力。質性資料之收集則採分層隨機抽樣，以半結構式訪談大綱收集護理人員對早產兒腸道餵食歷程之照護策略，將收集到的文本以內容分析法進行各主題之次數計算，之後整合早產兒及護理人員之資料，探究及分析兩研究結果是否吻合並進行結果的詮釋及比較。
研究結果：本研究收集達獨立經口進食之早產兒共104位，包括72位(69.2%)南部及32位(31.8%)北部早產兒，兩家醫院早產兒基本人口學等基本屬性無統計上顯著差異(p>0.05)。南部較北部早產兒於「開始腸道營養PMA」(29.4±2.5 vs 31.0±2.6週，p<0.01)、「獨立經口進食PMA」(35.0±1.8 vs 36.6±3.1週，p=0.01)以及「餵食轉換期」(13.6±8.3 vs 22.0±17.2天，p=0.01)早達成且餵食轉換期間體重增加變化趨勢(24.1±10.7 vs 19.1±11.8公克，p=0.03)也較多，且均達統計上顯著差異。兩家醫學中心護理師基本人口學等基本屬性及「護理師發展性照護能力量表」得分無統計上顯著差異(p>0.05)，協助早產兒經口進食策略上，北部護理師給予早產兒口腔刺激的餵食策略分數(3.09±0.82 vs 2.72±0.72, p=0.03)以及常規照會復健師的照護策略比例(p=0.01)均較南部護理師高，並達統計上顯著差異；南部護理師給予早產兒非營養性吸吮的餵食策略分數(3.90±0.31 vs 3.60±0.65, p=0.01)以及奶瓶餵食過程中採半高姿位(p<0.01)姿勢較北部護理師多，並達統計上顯著差異。進一步以混合線性模型檢定結果顯示出生週數、出生體重、開始經口進食PMA 及肺支氣管發育不良等因素影響腸道餵食歷程時間，且有統計上顯著差異。醫院別對獨立經口進食PMA及餵食轉換期的影響有統計上顯著差異且開始經口進食PMA對獨立經口進食PMA的影響亦有統計上顯著差異。
結論/實務應用：醫院別影響早產兒達到獨立經口進食PMA及餵食轉換期，獨立經口進食PMA又受到早產兒開始經口進食PMA的影響。早產兒開始經口進食的時機由臨床護理人員被動式的給予，因此當護理人員具有良好發展性照護並運用相關照護策略可以協助早產兒渡過餵食轉換期進而盡早達到獨立經口進食及完成腸道餵食歷程的任務。

Background: Enteral feeding progression includes both enteral and oral feeding milestones. Empirically derived guidelines for starting or progressing oral feeds are not available. Currently, rarely relevant studies are exploring the enteral feeding progression of preterm infants in different regions, and there is a lack of related subjective practices of clinical medical staff members on enteral feeding progression. Purposes: This study aims to understand the current clinical distribution of the enteral feeding progression of preterm infants and the clinical care feeding strategies of the nursing staff members in the neonatal intensive care units at two medical centers in Southern and Northern Taiwan. Furthermore, this study explores the influencing factors of enteral feeding progression in preterm infants. Methods: An embedded correlational mixed-method was conducted at two medical centers in Southern and Northern Taiwan. It includes a retrospective medical chart review for preterm infants’ enteral feeding progression, and we use the developmental support competency scale for nurses (DSCS-N) with self-proposed items and a semi-structured interview guide to evaluate NICU nurses’ ability on the developmental care of enteral feeding progression. Results: The “PMA of starting nutritional feeds”, the “PMA of full oral feeding”, and the “transitional feeding period” in preterm infants of the southern medical center were reached early, and the trend of weight gain during the “transitional feeding period” in preterm infants of the southern medical center also increased more than those of the northern one. Regarding the scores of feeding strategy “oral stimulus” for preterm infants and the proportion of the “consultation of rehabilitation routinely”, the northern nurses’ scores were higher than those of the southern nurses. Regarding the scores of feeding strategy of “providing nonnutritive sucking” for preterm infants and the proportion of the ”semielevated side-lying” posture during feeding, the southern nurses scores’ were higher than those of the northern nurses. Furthermore, the results of the mixed effect model showed that factors of the “PMA of the first date of oral feeding” affected the time of enteral feeding progression. Conclusion: Nursing staff members need to have good developmental care knowledge and use relevant feeding strategies to help preterm infants passing the transitional feeding period to complete the tasks of enteral feeding progression as soon as possible.

王淯汶、張瑩如（2013）．早產兒需求性餵食的實證探討．榮總護理，30（4），417-
424。doi:10.6142/VGHN.30.4.417
王淯汶、張瑩如（2015）．發展性照護之理論發展與研究趨勢．護理雜誌，62（5），
89-95。doi:10.6224/JN.62.5.89
全國法規資料庫（2018 年1 月24 日）．醫療法．取自
http://law.moj.gov.tw/LawClass/LawAll.aspx?PCode=L0020021
呂淑華、戴玉慈（2010）．病歷回顧研究之方法學．台灣醫學，14（5），583-587。
doi: 10.6320/FJM.2010.14(5).13
宋曜廷、潘佩妤（2010）．混合研究在教育研究的應用．教育科學研究期刊，5
（4），97-130。
林貞秀、張瑩如、林佳霓、黃美智（2012）．發展性照護在早產兒餵食過程之應用．
護理雜誌，59（3），107-112。doi: 10.6224/JN.59.3. 107
張雅雯、張瑩如（2008）．早產兒口腔餵食與心肺功能調節之關係．護理雜誌，55
（3），5-10。doi: 10.6224/JN.55.3.5
許世昌、郭純綺（2013）．新編解剖學‧臺北市：永大書局有限公司。
黃希文、陳佩珊、鄭素芳、王儷穎（2008）．早產兒餵食困難之評估與介入．物理治
療，33（3），188-196。
謝志偉、王慧玉（譯）（2010）．混合方法研究導論（原作者Creswell, J. W., & Clark,
V. L. P.）臺北市：正恒實業股份有限公司。（原著出版於2007）
謝淑娟、陳季員（2012）．應用統合發展理論於一位吸吮困難之早產兒之照護經驗．
doi:10.6844/NCKU202000316
106
護理雜誌，59（2），113-119。doi: 10.6224/JN.59.2.112
Blackburn, S. T. (2003). Maternal, fetal, & neonatal physiology: A clinical perspective.
USA: Philadelphia, PA:Elsevier.
Brumbaugh, J. E., Colaizy, T. T., Saha, S., Meurs, K. P., Das, A., Walsh, M. C., & Bell, E.
F. (2018). Oral feeding practices and discharge timing for moderately preterm
infant. Early Human Development, 46-52.
http://doi.org/10.1016/j.earlhumdev.2018.04.001
Dodrill, P., Donovan, T., Cleghorn, G., McMahon, S., & Davies, P. S. (2008). Attainment
of early feeding milestones in preterm neonates. Journal of Perinatology, 28, 549-
555. doi:10.1038/jp.2008.56
Dodrill, P., McMahona, S., Ward, E., Weir, K., Donovanc, T., & Riddle, B. (2004). Long
term oral sensitivity and feeding skills of low risk preterm infants. Early Human
Development, 76, 23-37. doi:10.1016/j.earlhumdev.2003.10.001
Dutta, S., Singh, B., Chessell, L., Wilson, J., Janes, M., McDonald, K., . . . Fusch, C.
(2015). Guidelines for feeding very low birth weight infants. Nutrients, 7(1), 423-
442. doi:10.3390/nu7010423
Fanaro, S. (2013). Feeding intolerance in the preterm infant. Early Human Development,
89(Suppl 2), S13-S20. doi:10.1016/j.earlhumdev.2013.07.013
Foster, J. P., Psaila, K., & Patterson, T. (2017). Non-nutritive sucking for increasing
physiologic stability and nutrition in preterm infants (Review). Cochrane Database
of Systematic Reviews 2017; 10: CD001071.
doi:10.1002/14651858.CD001071.pub3
Ghomi, H., Yadegari, F., Soleimani, F., Knoll, B. L., Noroozi, M., & Mazouri, A. (2019).
The effects of premature infant oral motor intervention (PIOMI) on oral feeding of
doi:10.6844/NCKU202000316
107
preterm infants: A randomized clinical trial. International Journal of Pediatric
Otorhinolaryngology, 120, 202-209. https://doi.org/10.1016/j.ijporl.2019.02.005
Girgin, B. A., Gözen, D., & Karatekin, G. (2018). Effects of two different feeding positions
on physiological characteristics and feeding performance of preterm infants: A
randomized controlled trial. Journal for Specialists in Pediatric Nursing, 23,
e12214. https://doi.org/10.1111/jspn.12214
Greene, Z., O’Donnell, C. P. F., & Walshe, M. (2016). Oral stimulation for promoting oral
feeding in preterm infants (Review). Cochrane Database of Systematic Reviews
2016; 9: CD009720. doi:10.1002/14651858.CD009720.pub2
Griffith, T., Rankin, K., & White-Traut, R. (2017). The relationship between behavioral
states and oral feeding efficiency in preterm infants. Advances in Neonatal Care,
17(1), E12-E19. doi:10.1097/ANC.0000000000000318
Griffith, T. T., Bell, A. F., White-Traut, R., Medoff-Cooper, B., & Rankin, K. (2018).
Relationship between duration of tube feeding and success of oral feeding in
preterm infants. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 47(5),
620-631. https://doi.org/10.1016/j.jogn.2018.06.002
Hack, M., Estabrook, M. M., & Robertson, S. S. (1985). Development of sucking rhythm
in preterm infants. Early Human Development, 11, 133-140.
Hanin, M., Nuthakki, S., Malkar, M. B., & Jadcherla, S. R. (2015). Safety and efficacy of
oral feeding in Infants with BPD on nasal CPAP. Dysphagia, 30(2), 121-127.
doi:10.1007/s00455-014-9586-x
Hwang, Y. S., Ma, M. C., Tseng, Y. M., & Tsai, W. H. (2013). Associations among perinatal
factors and age of achievement of full oral feeding in very preterm infants.
Pediatrics and Neonatology, 54, 309-314.
doi:10.6844/NCKU202000316
108
Hwang, Y. S., Tsai, W. H., & Chen-Sea, M. J. (2005). Factors associated with bottle
feeding performance of preterm infants: A literature review. Journal of
Occupational Therapy Association, 20, 13-25. doi:10.6594/JTOTA.2005.23.02
Ibrahim, M. H., Azab, A. A., Kamal, N. M., Salama, M. A., Elshorbagy, H. H., Abdallah, E.
A. A., . . . Sherief, L. M. (2015). Outcomes of early ligation of patent ductus
arteriosus in preterms, multicenter Experience. Medicine, 94(25), e915.
doi:10.1097/MD.0000000000000915
Jackson, B. N., Kelly, B. N., McCann, C. M., & Purdy, S. C. (2016). Predictors of the time
to attain full oral feeding in late preterm infants. Acta Paediatrica, 105(1), e1-6.
doi:10.1111/apa.13227
Jadcherla, S. R., Khot, T., Moore, R., Malkar, M., Gulati, I. K., & Slaughter, J. L. (2017).
Feeding methods at discharge predict long term feeding and neurodevelopmental
outcomes in preterm iinfants referred for gastrostomy evaluation. The Journal of
Pediatrics, 181, 125-130. doi:10.1016/j.jpeds.2016.10.065
Jadcherla, S. R., Wang, M., Vijayapal, A. S., & Leuthner, S. R. (2010). Impact of
prematurity and co-morbidities on feeding milestones in neonates: A retrospective
study. Journal of Perinatology, 30, 201-208.
Jaillard, S., Larrue, B., Rakza, T., Magnenant, E., Warembourg, H., & Storme, L. (2007).
Consequences of delayed surgical closure of patent ductus arteriosus in very
premature infants. The Annals of Thoracic Surgery, 81(1), 231-235.
doi:10.1016/j.athoracsur.2005.03.141
Kamitsuka, M. D., Nervik, P. A., Nielsen, S. L., & Clark, R. H. (2017). Incidence of
nasogastric and gastrostomy tube at discharge is reduced after implementing an oral
feeding protocol in premature (< 30 weeks) infants. American Journal of
doi:10.6844/NCKU202000316
109
Perinatology, 34(6), 606-613. doi:10.1055/s-0037-1601443
Katsumi, M., & Aki, U. (2005). Neonatal feeding performance as a predictor of
neurodevelopmental outcome at 18 months. Developmental Medicine and Child
Neurology, 47(5), 299-304.
Khan, Z., Sitter, C., Dunitz-Scheer, M., Posch, K., Avian, A., Bresesti, I., & Urlesberger, B.
(2019). Full oral feeding is possible before discharge even in extremely preterm
infants. Acta Pædiatrica, 108(2), 239-244. doi:10.1111/apa.14478
Kish, M. Z. (2013). Oral feeding readiness in preterm infants: A concept analysis.
Advances in Neonatal Care, 13(4), 230-237. doi:10.1097/ANC.0b013e318281e04e
Lainwala, S., Kosyakova, N., Power, K., Hussain, N., Moore, J. E., Hagadorn, J. I., &
Brownell, E. A. (2019). Delayed achievement of oral feedings is associated with
adverse neurodevelopmental outcomes at 18 to 26 months follow-up in preterm
infants. American Journal of Perinatology. https://doi.org/10.1055/s-0039-1681059
Lau, C. (2015). Development of suck and swallow mechanisms in infants. Annals of
Nutrition and Metabolism, 66(suppl 5), 7–14. doi:10.1159/000381361
Lau, C., Alagugurusamy, R., Schanler, R. J., Smith, E. O., & Shulman, R. J. (2000).
Characterization of the developmental stages of sucking in preterm infants during
bottle feeding. Acta Paediatrica, 89, 846-852.
Lavalléea, A., Clifford-Faugèrea, G., Garciaa, C., Oviedo, A. N. F., Héona, M., & Aitaa, M.
(2018). Part1: Narrative overview of developmental care interventions for the
preterm newborn. Journal of Neonatal Nursing, 25, 3-8.
https://doi.org/10.1016/j.jnn.2018.08.008
Leaf, A., Dorling, J., Kempley, S., McCormick, K., Mannix, P., Linsell, L., . . .
Brocklehurst, P. (2012). Early or delayed enteral feeding for preterm growthdoi:
10.6844/NCKU202000316
110
restricted infants: A randomized trial. Pediatrics, 129, e1260 -e1268.
doi:10.1542/peds.2011-2379
Lessen, B. S. (2011). Effect of the premature infant oral motor intervention on feeding
progression and length of stay in preterm infants. Advances in Neonatal Care,
11(2), 129-139. doi:10.1097/ANC.0b013e3182115a2a
Lopez-Maestro, M., Cruz, J. D., Perapoch-Lopez, J., Gimeno-Navarro, A., Vazquez-
Roman, S., Alonso-Diaz, C., . . . Pallas-Alonso, C. (2019). Eight principles for
newborn care in neonatal units: Findings from a national survey. Acta Paediatrica,
1-8. doi:10.1111/apa.15121
Lubbe, W. (2018). Clinicians guide for cue‐based transition to oral feeding in preterm
infants: An easy‐to‐use clinical guide. Journal of Evaluation in Clinical Practice,
24, 80-88. doi:10.1111/jep.12721
McCain, G. C., del Moral, T. D., Duncan, R. C., Fontaine, J. L., & Pino, L. D. (2012).
Transition from gavage to nipple feeding for preterm infants with
bronchopulmonary dysplasia. Nursing Research, 61(1), 380–387.
McClure, R. J., & Newell, S. J. (1999). Randomised controlled trial of trophic feeding and
gut motility. Archives of Disease in Childhood: Fetal and Neonatal Education, 80,
F54-F58.
McGinley, B. (2016). Non-invasive mechanical ventilation in children: An overview. In L.
M. Sterni & J. L. Carroll (Eds.), Caring for the ventilator dependent child: A
clinical guide. (pp. 19-35). doi:10.1007/978-1-4939-3749-3_2
Mizuno, K., & Ueda, A. (2003). The maturation and coordination of sucking swallowing
and respiration in preterm infants. The Journal of Pediatrics, 142(1), 36-40.
Morgan, J., Young, L., & McGuire, W. (2014). Delayed introduction of progressive enteral
doi:10.6844/NCKU202000316
111
feeds to prevent necrotising enterocolitis in very low birth weight infants (review).
Cochrane Database of Systematic Reviews 2014; 12: CD001970.
doi:10.1002/14651858.CD001970.pub5
Overmeire, B. V. (2018). Patent ductus arteriosus. In G. Buonocore, R. Bracci, & M.
Weindling (Eds.), Neonatology: A practical approach to neonatal management (pp.
1079-1091). https://doi.org/10.1007/978-3-319-29489-6_219
Pahsini, K., Marinschek, S., Khan, Z., Urlesberger, B., Scheer, P., & Dunitz-Scheer, M.
(2018). Tube dependency as a result of prematurity. Journal of Neonatal-Perinatal
Medicine, 11, 311-316. doi:10.3233/NPM-1799
Park, J., Knafl, G., Thoyre, S., & Brandon, D. (2015). Factors associated with feeding
progression in extremely preterm infants. Nursing Research, 64(3), 159-167.
doi:10.1097/NNR.0000000000000093
Park, J., Thoyre, S., Estrem, H., Pados, B. F., Knafl, G. J., & Brandon, D. (2016). Mothers'
psychological distress and feeding of their preterm infants. MCN: The American
Journal of Maternal Child Nursing, 41(4), 221-229.
doi:10.1097/NMC.0000000000000248
Park, J., Thoyre, S., Knafl, G. J., Hodges, E. A., & Nix, W. B. (2014). Efficacy of
semielevated side-lying positioning during bottle-feeding of very preterm infants: A
pilot study. The Journal of Perinatal & Neonatal Nursing, 28(1), 69-79.
doi:10.1097/JPN.0000000000000004
Pickler, R. H., Best, A., & Crosson, D. (2009). The effect of feeding experience on clinical
outcomes in preterm infants. Journal of Perinatology, 29(2), 124-129.
doi:10.1038/jp.2008.140
Pickler, R. H., Best, A. M., Reyna, B. A., Wetzel, P. A., & Gutcher, G. R. (2005).
doi:10.6844/NCKU202000316
112
Prediction of feeding performance in preterm infants. Newborn and Infant Nursing
Reviews, 5(3), 116-123. doi:10.1053/j.nainr.2005.04.001
Pickler, R. H., Reyna, B. A., Wetzel, P. A., & Lewis, M. (2015). Effect of four approaches
to oral feeding progression on clinical outcomes in preterm infants. Nursing
Research and Practice, 2015, 1-7. doi:10.1155/2015/716828
Rommel, N., van Wijk, M. V., Boets, B., Hebbard, G., Haslam, R., Davidson, G., & Omari,
T. (2011). Development of pharyngo-esophageal physiology during swallowing in
the preterm infant. Neurogastroenterology and Motility, 23, e401-e408.
doi:10.1111/j.1365-2982.2011.01763.x
Salas, A. A., Kabani, N., Travers, C. P., Phillips, A., Ambalavanan, N., & Carlo, W. A.
(2017). Short versus extended duration of trophic feeding to reduce time to achieve
full enteral feeding in extremely preterm Infants: An observational study.
Neonatology, 112(3), 211-216. doi:10.1159/000472247
Shaker, C. S. (2013). Cue-based feeding in the NICU: Using the infant's communication as
a guide. Neonatal Network, 32(6), 404-408. doi:10.1891/0730-0832.32.6.404
Simpson, C., Schanler, R. J., & Lau, C. (2002). Early introduction of oral feeding in
preterm infants. Pediatrics, 110(3), 517-522. doi:10.1542/peds.110.3.517
Stevens, E. E., Gazza, E., & Pickler, R. (2014). Parental experience learning to feed their
preterm infants. Advances in Neonatal Care, 14(5), 354-361.
doi:10.1097/ANC.0000000000000105
Thomas, J. A. (2007). Guidelines for bottle feeding your premature baby. Advances in
Neonatal Care, 7(6), 311-318.
Tubbs-Cooley, H. L., Pickler, R. H., & Meinzen-Derr, J. K. (2015). Missed oral feeding
opportunities and preterm infants' time to achieve full oral feedings and neonatal
doi:10.6844/NCKU202000316
113
intensive care unit discharge. American Journal of Perinatology, 32(1), 1-8.
doi:10.1055/s-0034-1372426
Vargas, C. L., Berwig, L. C., Steidl, E. M., Prade, L. S., Bolzan, G., Keske-Soares, M., &
Weinmann, A. R. (2015). Premature: Growth and its relation to oral skills. CoDAS,
27(4), 378-383. doi:10.1590/2317-1782/20152014179
Viswanathan, S., & Jadcherla, S. (2019). Transitioning from gavage to full oral feeds in
premature infants: When should we discontinue the nasogastric tube. Journal of
Perinatology, 31, 1257-1262. https://doi.org/10.1038/s41372-019-0446-2
Wang, Y. W., Hung, H. Y., Lin, C. H., Wang, C. J., Lin, Y. J., & Chang, Y. J. (2018). Effect
of a delayed start to oral feeding on feeding performance and physiological
responses in preterm infants: A Randomized clinical trial. The Journal of Nursing
Research, 26(5), 324-331. doi:10.1097/jnr.0000000000000243
Watson, J., & McGuire, W. (2015). Responsive versus scheduled feeding for preterm
infants. Cochrane Database of Systematic Reviews 2015; 10: CD005255.
doi:10.1002/14651858.CD005255.pub4
Wellington, A., & Perlman, J. M. (2015). Infant-driven feeding in premature infants: A
quality improvement project. Archives of Disease in Childhood Fetal and Neonatal
Edition, 100(6), F495-F500. doi:10.1136/archdischild-2015-308296
White-Traut, R., Pham, T., Rankin, K., Norr, K., Shapiro, N., & Yoder, J. (2013). Exploring
factors related to oral feeding progression in premature infants. Advances in
Neonatal Care, 13(4), 288-294. doi:10.1097/ANC.0b013e31829d8c5a
White-Traut, R. C., Berbaum, M. L., Lessen, B., McFarlin, B., & Cardenas, L. (2005).
Feeding readiness in preterm infants: The relationship between preterm behavioral
state and feeding readiness behaviors and efficiency during transition from gavage
doi:10.6844/NCKU202000316
114
to oral feeding. MCN: The American Journal of Maternal/Child Nursing, 30(1), 52-
59.
Wrotniak, B. H., Stettler, N., & Medoff-Cooper, B. (2009). The relationship between birth
weight and feeding maturation in preterm infants. Acta Paediatrica, 98(2), 286–
290. doi:10.1111/j.1651-2227.2008.01111.x.