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DONNA DOWLING, PHD, RN Section Editor

Effect of the Premature Infant Oral Motor

Intervention on Feeding Progression and
Length of Stay in Preterm Infants
Brenda S. Lessen, PhD, RN

ABSTRACT
PURPOSE: Preterm infants frequently experience oral feeding difficulties due to underdeveloped oral motor skills and
the lack of coordination of sucking, swallowing, and respiration. The infants ability to consume all feedings orally while
maintaining physiologic stability and weight gain is necessary for their discharge. Therefore, difficulty with oral feeding
leads to longer hospital stays and higher costs. For example, with more than half a million of premature infants born each
year, a 3-day decrease in hospital stay would save more than 2 billion dollars annually. There is a need for evidenced-
based interventions that facilitate development of oral-motor skills, leading to improved oral feeding, thus shortening
hospital stays and lowering costs. The purpose of this research was to test the newly developed Premature Infant Oral
Motor Intervention (PIOMI) beginning at 29 weeks postmenstrual age (PMA), before oral feedings were introduced, to
determine whether the prefeeding intervention would result in a shorter transition from gavage to total oral feedings
and a shorter length of hospital stay (LOS). The PIOMI is a 5-minute oral motor intervention that provides assisted move-
ment to activate muscle contraction and provides movement against resistance to build strength. The focus of the inter-
vention is to increase functional response to pressure and movement and control of movements for the lips, cheeks, jaw,
and tongue. The cheeks (internal and external), lips, gums, tongue, and palate were stimulated per specific protocol with
finger stroking.
SUBJECTS: A total of 19 infants from 1 level III NICU born between 26 and 29 weeks PMA: 10 in the experimental group
and 9 in the control group.
DESIGN: A randomized, blinded, clinical trial was conducted to examine outcomes related to the newly developed PIOMI.
METHODS: Beginning at 29 weeks PMA (and before the introduction of oral feeding), the experimental group received
the PIOMI for 5 minutes per day for 7 consecutive days. The control group received a sham intervention to keep staff
and parents blinded to the infants group assignment. Physiological and behavioral stabilities were continually assessed
throughout the intervention. A chart review was then conducted to compare the transition from gavage feeding to total
oral feedings between the experimental and control group, as well as LOS.
RESULTS: The PIOMI was well tolerated by 29-week PMA infants, as evidenced by physiological and behavioral cues.
Infants who received the once-daily PIOMI transitioned from their first oral feeding to total oral feedings 5 days sooner
than controls (P  .043) and were discharged 2.6 days sooner than controls.
CONCLUSION: This pilot work supports further study on the use of the PIOMI with preterm infants to enhance oral-
feeding skills and decrease LOS.
KEY WORDS: feeding, length of stay, neonatal, neonatal intensive care, newborn, oral motor, oral stimulation, PIOMI,
preterm infant

Author Affiliation: School of Nursing, Illinois Wesleyan
University, Bloomington.
Correspondence: Brenda S. Lessen, PhD, RN, School of
Nursing, Illinois Wesleyan University, STV Hall, 203 Beecher
St, Bloomington, IL 61702(blessen@iwu.edu).
DOI: 10.1097/ANC.0b013e3182115a2a
T
he preterm birth rate in the last 2 decades has
steadily increased,1 nearly doubling the
national goal of 7.6%, articulated in Healthy
People 2010 Objectives.2 The survival of preterm
infants has also greatly increased,3 with younger post-
menstrual age (PMA) infants requiring a lengthy and
costly hospital stay. Contributing to this increase is

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130 Cervantes et al
the rising rate of late childbearing and of multiple
births (42% increase from 1990 to 2002), more than
half of whom are born preterm.3 Hospital stays for
newborns without complications average 1 to 2 days
costing $1 500, while the prolonged hospital stays for
infants with a principal diagnosis of prematurity aver-
age $79 000.4 Although preterm births account for
only 12% of total (preterm and term) births, the cost
for their prolonged hospital stays consumes 50% of
the total cost for all infant hospital stays.4
Preterm infants frequently experience oral-feeding
(bottle feeding with an artificial nipple) difficulties
due to underdeveloped oral motor skills5 and the lack
of coordination of sucking, swallowing, and respira-
tion.5,6 The infants ability to consume all feedings
orally while maintaining physiologic stability and
weight gain is necessary for their discharge. Difficulty
with oral feeding leads to longer hospital stays and
higher costs.7 With more than half a million of pre-
mature infants born each year, a 3-day decrease in
hospital stay would save more than 2 billion dollars
annually.1,4
There is a need for evidenced-based interventions
that facilitate development of oral motor skills lead-
ing to improved oral feeding for infants 30 weeks
PMA or younger, thus shortening hospital stays and
lowering costs. The purpose of this research was to
test the Premature Infant Oral Motor Intervention
(PIOMI) beginning at 29 weeks PMA, before oral
feedings were introduced, to determine whether the
prefeeding intervention would result in a shorter
transition from gavage to total oral feedings and a
shorter length of hospital stay (LOS).
BACKGROUND
Few studies have tested the effect of oral stimulation
on feeding ability, especially when the interventions
done before oral feedings are attempted, and no stud-
ies were located that tested the effects of oral stimula-
tion on feeding progression of preterm infants before
reaching 30 weeks PMA.8 Nonnutritive sucking
(NNS) with a pacifer has been the most widely tested
oral-stimulation intervention to improve feeding pro-
gression for preterm infants. Nonnutritive sucking
has been found to decrease the transition time from
gavage to oral feedings9,10 and improve feeding per-
formance.11 However, more focused perioral-stimu-
lation interventions are being studied.
Oral stimulation is traditionally defined as stroking
and/or pressure to the structures in and around the
mouth. The preterm infant has poor oral motor con-
trol related partly to weaker muscle tone around the
mouth, less sensation, and less tongue strength when
compared with the full-term infant.12 These factors
affect sucking strength and endurance. More sophis-
ticated supplemental oral motor programs have been
developed in recent years to increase functional
Copyright 2011 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
strength and control of movement for feeding.13
Preliminary evidence suggests that oral stimulation
given before a feeding to preterm infants 32 to 36
weeks PMA (born 30-34 weeks PMA) can increase
weight gain, decrease transition time from gavage to
total oral feedings, and decrease LOS.14 Oral stimu-
lation that included NNS offered during gavage feed-
ings to preterm infants 31 to 32 weeks PMA (born
between 26 and 32 weeks PMA) demonstrated a
shorter transition to full oral feedings and a decreased
LOS.15 Fucile et al8 found similar results with oral
stimulation before gavage feedings in infants at 34.5
weeks PMA (born 26-29 weeks PMA). Both stud-
ies8,15 used the 15-minute Beckman Oral Motor
Intervention (BOMI).13 However, no studies were
located that examined the use of a structured supple-
mental oral stimulus program with infants born
before 30 weeks PMA, as was the purpose of this
study. This study tested the following hypotheses.
Hypothesis 1
Infants who receive the PIOMI before a feeding once
per day for 7 consecutive days before the introduc-
tion of oral feeding will have a faster transition from
gavage to total oral feedings when compared with
controls who receive routine NICU care.
Hypothesis 2
Infants who receive the PIOMI given before a feed-
ing once per day for 7 consecutive days before the
introduction of oral feeding will have a faster transi-
tion through phase 1 of the 6-phase feeding progres-
sion when compared with controls who receive rou-
tine NICU care.
Hypothesis 3
Infants who receive the PIOMI given before a feed-
ing once per day for 7 consecutive days before the
introduction of oral feeding will result in a shorter
LOS when compared with controls who receive rou-
tine NICU care.
METHODS
Design and Setting
This study used a triple-blind experimental design,
with the intervention taking place over 7 consecutive
days and outcomes (feeding progression and LOS)
measured until discharge. Subjects were recruited
from a 45-bed level III NICU in the Midwest.
Inclusion and Exclusion Criteria
Infants from all racial and ethnic backgrounds were
eligible for study inclusion. Infants were enrolled if
they were born between 2607 and 2907 weeks PMA
and were appropriate for gestational age. Infants had
to be clinically stable per the medical staff at the time
of entry but could be receiving oxygen per high-flow
nasal cannula. The allowance of high-flow nasal
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ANC200174.qxp 3/10/11 8:49 AM Page 131
cannula was necessary to include infants at such a low
PMA. Breast milk, when available, could be used
with or in place of formula in the bottle. (Infants in
this study were not put to breast during the feeding
progression.) Exclusion criteria included infants who
(a) had documented or suspected congenital anom-
alies, (b) were experiencing necrotizing enterocolitis
(NEC), (c) had a brain injury (including intraventric-
ular hemorrhage greater than grade 1), (d) had a his-
tory of prenatal illicit drug exposure, or (e) were
receiving assistive ventilation (other than high-flow
nasal cannula) were not eligible. Inclusion criteria
were assessed at the time of enrollment, at the time
of intervention, and throughout the data collection
period until infant discharge. For example, if an
infant was eligible at birth, still eligible at the inter-
vention period, but developed NEC later during his
feeding progression, the infant was excluded.
Sample
The target population was clinically stable preterm
infants born between 26 and 29 weeks PMA. Infants
born before 26 weeks are likely to have neurologic
morbidities that would confound the study, if not
exclude them from being eligible. No other study was
found regarding oral stimulation and feeding that
included preterm infants born before 26 weeks.
Rogers and Arvedson16 suggest that on the basis of
the findings by Lau et al,6 there is no significant in
utero maturation of sucking occurring between 26
and 29 weeks PMA; thus, there should be no bias in
baseline sucking ability. Sampling infants born no
later than 29 weeks was necessary to complete the 7-
day prefeeding intervention before reaching the
point where oral feeding may begin, which is 30
weeks in the NICU where this study occurred.17
The PMA was determined by dates using the
mothers last menstrual period and/or antenatal
ultrasound assessments. In the event of a discrep-
ancy, the neonatologists admission assessment note
was determinative. A convenience sample of 30
infants who met inclusion criteria were originally
enrolled. Because this was the first study to imple-
ment the PIOMI and to measure oral stimulation
done with infants younger than 30 weeks PMA, it
was considered to be a pilot study and power analy-
sis was not done.
Independent Variables
Experimental Condition
The PIOMI is an oral motor program that provides
assisted movement to activate muscle contraction
and provides movement against resistance to build
strength. The PIOMI was developed on the basis of
the principals of BOMI.13 The original BOMI was a
15-minute intervention designed for term infants,
children, and adults with developmental delays that
Advances in Neonatal Care Vol. 11, No. 2
Copyright 2011 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
Effect of the PIOMI on Feeding and Length of Stay 131
resulted in feeding difficulties and was not designed
for use with preterm infants. It is ideal for those who
cannot respond to commands during therapy, as it
does not require the cognitive participation of the
subject. The components of movement are func-
tional, not age specific, so it can be used from birth
to geriatric clients.13
Preterm infants may have difficulty tolerating the
15-minute procedures in BOMI without exhibiting
signs of stress. In addition, the small size of the
preterm infants oral cavity made it difficult to
spend the full amount of time on each oral area
(palate, tongue, upper gum, lower gum, etc) that the
15-minute intervention required. In consultation
with Debra Beckman, this researcher modified the
original BOMI by decreasing the number of steps
and the length of time required to perform it for use
specifically in preterm infants as young as 29 weeks
PMA. The revised instrument is called the PIOMI.
The BOMIs original 11 steps were consolidated
into 8 steps, and the 15 minutes were reduced to
5 minutes (Figure 1). Techniques were slightly
modified to accommodate the small size of the oral
cavity, and correct positioning was included to
ensure proper head and neck support of the preterm
infant. Tolerance parameters were also included
specific to the preterm infants physiological and
behavioral cues.
More focused than traditional types of oral stimu-
lation found in the literature, the PIOMI is designed
to increase functional response to pressure and
movement and control of movements for the lips,
cheeks, jaw, and tongue. The cheeks (internal and
external), lips, gums, tongue, and palate were stimu-
lated per specific protocol with finger stroking.
The intervention was done by the principal inves-
tigator (PI) or research assistant (RA). The 3 RAs
were experienced neonatal nurses employed in the
NICU. The RAs and PI trained to criteria for reliabil-
ity regarding correct order of steps in the protocol,
correct technique at each step, and correct time spent
at each step.
Control Condition
All infants received the standard of care, which
included several developmentally supportive inter-
ventions, including nesting; swaddling; assessment of
infant behavioral state; and autonomic, motor, and
behavioral signs of organization and disorganization
at least every 8 hours and with each infant interac-
tion. There are also policies in place that cycle light-
ing, limit noise, and unnecessarily disrupt sleep-wake
patterns (eg, rounds do not take place at the bedside,
decibel meters on ceilings, cluster care around alert
periods).
The control infants did not receive the 5-minute
oral-stimulation intervention. The PI or trained RA
stood at the bedside during that time with both hands
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132 Cervantes et al
FIGURE 1.
Length of stay.
inside the isolette for 5 minutes, not touching the
infant. The curtain was pulled around the infants for
blinding the groups.
Demographic characteristics of gender, race, eth-
nicity, PMA at birth and at entry, and weight at birth
and at entry were obtained from the medical record.
Dependent Variables
Feeding Progression
Feeding progression was calculated from the day
when oral feedings were initiated to the day when full
oral feedings were attained. Fewer days indicated
faster progression. Total oral feedings were defined as
consuming 100% of 8 oral feedings per bottle per day
(feedings may contain mothers milk but may not be
breastfeeding) for 48 hours without physiologic or
feeding intolerance. The PMA at the initiation of oral
feedings and at the attainment of total oral feedings
was obtained from the medical record.
Copyright 2011 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
The feeding progression protocol has 6 phases
(Table 1). Advancing to the next phase relies on the
infants ability to consume at least 50% of each bottle
feeding offered for 48 hours without adverse effects
or feeding intolerance. The number of days infants
remained in each of the 6 phases was examined and
compared between the experimental group and the
control group.
Length of Stay
Length of hospital stay was defined as the number of
days from the entry point of 29 weeks PMA to the
date of discharge. Length of hospital stay was meas-
ured from the 29-week entry point rather than from
birth to control for the 3-week variance in birth PMA
(26-29 weeks PMA). This control was necessary since
the random assignment to groups did not include
stratification by PMA. There are no discharge criteria
in this NICU for minimum weight or PMA that could
limit early discharge.
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Effect of the PIOMI on Feeding and Length of Stay 133

order of a physician. This did not include pacifiers,

TABLE 1. Six-Phase Feeding Progression which were available to all infants at any time unless
Protocol limited per parent request. A laminated card was
taped to the subjects isolette as a reminder to staff.
Day/phase 1 1 nipplea per day When Consumes
There were no orders received for additional NNS.
50% for 48 h,
progress
Procedure
Day/phase 2 Nipple BID When consumes The university and community institutional review
50% for 48 h, board as well as the hospitals nursing review board
progress approved the research protocol. The nursing staff
Day/phase 3 Nipple TID When consumes used an infants inclusion/exclusion criteria checklist
50% for 48 h, to determine the infants eligibility for participation
progress in the study. If eligible, the nurse requested permis-
Day/phase 4 Nipple QID When consumes sion from the mother (or other parent/guardian) for
50% for 48 h, the PI to approach her to explain the study. When
progress granted, the PI presented the purpose of the study to
the parent and/or guardian(s) and obtained informed
Day/phase 5 6 nipples per dayb When consumes consent for their infant to participate in the research.
50% for 48 h, All infants were randomly assigned to the inter-
progress vention or control group in blocks of 2 to ensure that
Day/phase 6 8 nipples per day (all) When consumes the groups would be equal after every 2 enrollees. If
100% for 48 h, subjects in either group were dropped, they were
full replaced by assigning the next enrolled subject to
that group to maintain equal numbers in groups. A
Abbreviations: BID, 2 times a day; QID, 4 times a day; TID, card on each infants bed identified him or her as
3 times a day. being a subject in the study; however, group assign-
a
Nipple means oral feeding with a bottle/nipple. ments were blinded to the nursing and medical staff
b
Three nipple feeds, then 1 gavage, repeated. and the parents by pulling a curtain around the
infants bed for both the control (sham) and the inter-
vention group.
Data collection began on the day the infant
Confounding Variables
reached 29 weeks PMA and continued once per day
Illness Severity
for 7 consecutive days, ending at 30 weeks PMA
Illness severity data came from the medical record (Figure 2). Each intervention was separated by a min-
and were scored within 12 hours after birth and again imum of 9 hours and a maximum of 36 hours, with
at 29 weeks PMA to test the homogeneity of groups 24 hours being ideal. This flexibility was important in
by using the Postnatal Complications Score.18 This the case the infant had been stressed by medical or
mortality risk instrument measures respiratory dis- nursing procedures such as intravenous restart or
tress, infection, ventilatory assistance, noninfectious temperature instability immediately before the
anomaly, metabolic disturbance, seizure, hyper- scheduled time of intervention. The PIOMI could
bilirubinemia or exchange transfusion, temperature then be postponed until the next feeding period.
disturbance, initiation of feeding within 48 hours The PI/RA consulted the staff nurse (or attending
after birth, and surgery. physician) before the intervention on each day to
ensure that the infant was clinically stable and the
Parent Feedings
medical record was reviewed for any changes in
The number of oral feedings done by a parent/ health or medications that may affect subject eligibil-
guardian was measured to determine whether signif- ity. It is a policy in this NICU that when any type of
icant differences in progression of oral feeding existed
between a nurse experienced in preterm infant feed-
ing and inexperienced parent feeder. The effect the
feeder might have on how fast the infant progresses FIGURE 2.
through each phase of the feeding progression was
important to note because feeding progression was a
major outcome measure in the study.
To prevent additional NNS (other than that
included in the oral-stimulation intervention) from
being a confounding variable, it was not allowed on
any subjects throughout the study period without the Study timeline.

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134 Cervantes et al
stimulation is presented to the infant, negative phys-
iological cues (such as apnea, bradycardia, and/or
oxygen desaturation) and behavioral cues (signs of
stress) are continually monitored. During the PIOMI,
if any stimulation resulted in negative cues, the stimu-
lation was paused to allow the infant to regain stability.
The early feeding protocol in this nursery allowed
oral feedings to be initiated as early as 30 weeks PMA
(although not usually done until 31 weeks PMA) with
a physician order, which was after the 7-day PIOMI
was completed. Subsequent feeding progression was
assessed per chart review for the date of first oral
feeding, the date total oral feedings were attained,
and the date of discharge. The PMA of first oral feed-
ing, PMA of total oral feedings, and LOS were calcu-
lated for both groups.
Data Analysis
SPSS-PC 15.0 (IBM, Somers, New York) was used
for all analysis. Preliminary data analysis began with
the examination of descriptive statistics. The  was
set at .05 (1-tailed).
Demographics and other independent variables were
reported by group. Group differences for nominal data
were tested with 2, ordinal data with the Mann-Whitney
U test, and interval data with independent t tests.
The primary dependent variables of (1) feeding
progression (days from first oral feeding to total oral
feedings), (2) length of time in feeding phase 1 (first
phase of 6 phases comprising the total feeding pro-
gression), and (3) LOS (days from 29 weeks PMA to
discharge) were analyzed by using general linear
models univariate to determine group differences
while controlling for covariates.19,20
RESULTS
A total of 30 preterm infants were enrolled. Two
infants were dropped because of being transferred to
a referring hospital, and another was dropped
because of a late recalculation of birth PMA, render-
ing that data invalid. Three infants were dropped
because of being intubated at the time of intervention
(29 weeks PMA); an additional 4 infants were
dropped after the intervention period due to later
being nil per os (NPO) during the feeding progres-
sion (transition from gavage feedings to total bottle
feedings) because of the diagnosis of ileus or bowel
inflammation. One infant died from NEC before
feeding progression began. Nineteen infants
remained in the study: 10 in the intervention group
and 9 in the control group.
Safety
There were no instances throughout this study of an
oral-stimulation intervention having to be terminated
because of adverse physiological or behavioral cues
from the infant. The 5-minute PIOMI was done 112
Copyright 2011 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
times to 16 infants. (Note: Although the experimental
group had 10 infants, there was a total of 16 infants
enrolled who received the PIOMI.) Nine of those 16
infants experienced 1 to 3 mild apnea/bradycardia
episodes across the 7 days that were self-corrected
after pausing the intervention, and the intervention
was continued with no further signs of intolerance.
Subject Characteristics
The intervention and control groups did not differ
statistically regarding PMA at birth, illness severity at
birth (Postnatal Complications Score), illness severity
at entry (29 weeks), number of parent/guardian feed-
ings during feeding progression, and the number of
parent/guardian feedings between total oral feedings
and discharge (Table 2).
The intervention group had a greater mean birth
weight compared with the control group (1017  127 g
vs 913  88 g, respectively; P .028). However,
group means for infant weight at study entry
(29 weeks) were not statistically different (P .079).
Hypothesis 1
The mean number of days for the control group to
transition from gavage to total oral feedings was
23.4  5.8 days, compared with the intervention
group (18.1  3.7 days; P .043).
There was a statistically significant difference
between groups in days to reach total oral feedings
(P .029); however, when infant birth weight was
used as a covariate in the model, the statistical dif-
ference was eliminated (P .068) (Figure 3).
Hypothesis 2
Infants in the experimental group spent 2 days less in
phase 1 and greater than 1 day less in phases 4 and 6
compared with the infants in the control group.
These differences were not statistically significant per
the Mann-Whitney U test (Figure 4).
Hypothesis 3
Length of hospital stay from 29 weeks PMA to dis-
charge was similar for both groups (P .72). The
mean LOS from 29 weeks for the control group was
44.4  4.8 days and for the intervention group was
45.9  10.7 days. Two outliers in the intervention
group were identified, and when removed, the mean
LOS for the intervention group was 41.8  7.2 days
(P .541). The infants who received the PIOMI were
discharged 2.6 days sooner than controls (Figure 5).
PMA Analysis
There was no significant difference between the
groups regarding the infant PMA at first oral feeding
(control, 31.4  0.6 weeks; intervention, 31.6  0.8
weeks; P .97). There was no significant difference
between groups regarding the infant PMA at the
completion of total oral feedings (control, 34.7  1.0
weeks; intervention, 34.2  1.0 weeks; P .28)
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Effect of the PIOMI on Feeding and Length of Stay 135

TABLE 2. Characteristics of the Sample

Intervention, n 10 Control, n  9 Pa

Gender, n
Male 4 3
Female 6 60.57
Race, n
White 7 6
Black 0 2
Asian/Indian 3 1 .22
Ethnicity, n
Non-Hispanic 10 9
Hispanic 0 0
PMA, wks; M  SD
At birth 28.1  0.6 28.0  0.9 .842
PCS; M  SD
At birth 4.4  0.5 4.3  0.7
At entry 3.8  0.9 3.8  0.7 .968
Weight, g; M  SD
At birth 1017.3  127.1 913.3  87.8 .028
At entry 1.0  124.6 915.5  145.2 .079
Parent feedings; M  SD
During feeding progression 3.2  2.6 3.0  3.2 .661
Total to discharge 1.6  1.2 2.2  2.2 .458

Abbreviations: PCS, Postnatal Complications Score; PMA, postmenstrual age.

a
Mann-Whitney U test.

Phases of Feeding Progression
There was no statistically significant difference
between groups on how long infants took to progress
through each of 6 individual feeding phases.
However, looking at each phase individually, phase
1 was clinically the most relevant, as the control
group took 2 additional days to complete phase 1.
The control group also took a mean of 1 day longer
to complete phases 4 and 6. Two control infants took
more than 5 days to progress out of phase 6, while all
experimental infants took minimum 48 hours. Fucile
et al8 found similar results in meeting the same 3 feed-
ing milestones. The PIOMI seems to have the great-
est effect on the success of the first oral-feeding
attempts, oral feedings 4 times per day, and the
infants ability to handle all 8 oral feedings per day
without relapse (Figure 4).
DISCUSSION
The purpose of this pilot study was to determine the
effect of the newly designed PIOMI on preterm
infants feeding progression and LOS. Study findings
suggested that the 5-minute PIOMI significantly short-
ened the number of days from gavage feedings to total
oral feedings compared with the number of days for
the infants who did not receive the intervention.
The intervention group was able to transition from
gavage to total oral feedings on an average of 5 days
sooner than controls.
Birth weight was a covariate in this study and
might influence feeding success. Pickler and cowork-
ers22 found that preterm infants who weighed less
than 1000 g at birth remained on assisted ventilation
longer, initiated feedings later, and progressed to
total oral feedings slower. In this study, the infants
in the control group had a mean birth weight
slightly less than 1000 g, which might have con-
tributed to the slower transition from gavage to total
oral feedings when compared with the infants in
intervention group who had a mean birth weight
more than 1000 g. While birth weight was a hetero-
geneous covariate between groups, infant weight at
study entry was not statistically different. Thus,
when the preterm infants in this study reached
29 weeks PMA, their weights had equalized and

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136 Cervantes et al
FIGURE 3.
Total days to full oral feedings.
became homogenous between groups before the
intervention. While statistical significance was lost
when the covariate of birth weight was included,
5 days less in the PIOMI group to reach total oral
feedings remained clinically significant.
Feeding experience may also increase feeding
progression.21-22 This pilot study illustrates that even
with both groups experiencing initiation of early
feedings resulting in a faster feeding progression than
the standard protocol, the addition of the PIOMI still
reduced the time to reach total oral feedings by
5 days. These results support the important distinc-
tion between sucking experience from early feedings
and the more-complex oral-stimulation program of
training the oral motor structures to respond func-
tionally to pressure; movement; range; strength; and
control for the lips, cheeks, jaw, and tongue.13
The provision of the PIOMI done once per day for
7 days as early as 29 weeks was demonstrated to be
safe in this study. There were no instances of the
intervention having to be terminated because of
adverse physiological or behavioral cues from the
infant.
This pilot study supported the findings of Fucile
et al8 and Rocha et al.15 There was no difference
between groups with PMA at first feedings. Fucile
et al8 introduced first feedings at a mean of 34.5 weeks,
and Rocha et al15 between 35 and 36 weeks, while
this study introduced oral feedings much sooner, at a
mean of 31.5 weeks. Initiation of the first feeding is
typically based on feeding readiness cues exhibited
Copyright 2011 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
by the infant.23 In this pilot study, the physicians
ordered the first attempt for an oral feeding at the
same PMA in both groups (M  31.5 weeks). It would
not be expected that infants in either the control or
the intervention group would be eliciting clear and
measurable feeding readiness cues at this early PMA,
as preterm infants between 30 and 31 weeks do not
alert readily and may never exhibit vigorous crying.
The PMA between groups, when the infant attained
total oral feedings, was not statistically significant,
although the intervention group was an average of 4
days younger than controls when total oral feedings
were attained (3417 weeks PMA vs 3457 weeks PMA,
respectively).
Infants in the intervention group were discharged
an average of 2.6 days sooner than controls (P .541)
when 2 outliers were removed. The outliers in the
intervention group (twins) had a delay in discharge
secondary to developing gastroesophageal reflux dis-
ease around 34 weeks PMA. The development of
GERD did not occur until after the 7-day interven-
tion and completion of the feeding progression; thus,
data to analyze the number of days to total oral
feedings (hypothesis 1) were available and were still
included in those results.
Limitations
In this pilot study, a small sample size was necessary
to test the safety of doing oral stimulation on preterm
infants as young as 29 weeks PMA, as well as to test
the efficacy of the newly developed PIOMI. The
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FIGURE 4.
Feeding progression by days within each of 6 feeding phases.
length and frequency of the intervention required
careful monitoring for any adverse physiological
and/or behavioral cues. Although pilot studies often
lack power, this study did provide strong trends in
the direction of all 3 hypotheses, which lent support
for further study.
Infants behavioral state before feedings24 was not
measured and may be an interesting measure in
future studies to test whether the PIOMI modifies
behavioral state to a quiet alert state ideal for feeding.
The use of human milk versus formula in the bottle
feedings25 was not measured in this study and could
have been a confounding variable in relation to suc-
cessful feeding. The staffing patterns were not
assessed, and nurses might have decided not to do an
oral feeding (and gavage feed instead) because of the
lack of time, thus prolonging the feeding progression.
However, both groups were on the same unit, and
randomization helped control for this variable.
Recommendations for Further Study
Providing the PIOMI once per day for 7 consecutive
days beginning at 29 weeks PMA was found safe in
this study and well tolerated. Replicating this study
with a larger sample size may lead to statistical signif-
icance, rather than just trends, for the PIOMI
enhancing feeding progression and decreasing length
of stay. A larger sample size (possibly from a multi-
center trial) would also increase the likelihood of a
Advances in Neonatal Care Vol. 11, No. 2
Copyright 2011 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
Effect of the PIOMI on Feeding and Length of Stay 137
more generalizable sample, specifically regarding
racial diversity and increased homogeneity among
groups relative to gender.
It may also be of interest to initiate a series of dose-
response studies doing the PIOMI more times per
day, or for a longer period of days, even up to the day
of discharge. Infants at older PMAs were given the 15
minute BOMI for at least 10 days,8,15 while some
received oral stimulation multiple times per day.15
Evaluating the safety of more frequent oral stimula-
tion on infants as young as 29 weeks PMA would
require well-monitored, conservative increases of
oral stimulation. Tolerance would need to be care-
fully observed, and a physiological benefit to cost
ratio assessed between the benefit of additional oral
stimulation and the cost of the caloric requirement
from the increased stimulation.
An additional variable that could be studied is the
time taken to implement the PIOMI. The question of
how long each oral motor structure needs to be stim-
ulated to reach an effect has not been answered. It
may be the case that repeating movements at each
step may not be necessary, and the PIOMI can be
reduced from 5 minutes to 3 minutes or shorter,
depending on the size of the infants mouth.
Training parents to do the PIOMI would enhance
parent/infant interaction. It is safe and simple to do.
Parents providing oral stimulation would not only allow
them the much-needed opportunity to participate in the
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138 Cervantes et al
FIGURE 5.
care of their infant but also give parents the satisfaction
of possibly effecting the infants progress in an impor-
tant way. Parents providing oral stimulation throughout
the hospital stay would also lead to the opportunity for
parents to continue the intervention once home with
their infant, providing future studies demonstrate a ben-
efit to either parent or infant.
The PIOMI could be tested for safety and efficacy
on some high-risk infants, such as those who are
known poor feeders, or those (term or preterm) with
cardiac issues. For example, a similarly modified
BOMI was found to shorten the transition to full-
bottle feedings and decrease the length of stay in
term infants with congenital heart defects.26 It would
also be interesting to see whether the initial positive
effect on feeding before discharge continued after
discharge. Home follow-up could be conducted to
assess feeding success at 3, 6, and 9 months.
CONCLUSION
The newly developed PIOMI was well tolerated in
29-week PMA infants. Implementing the PIOMI
for 5 minutes per day for 7 days shows positive
trends in both feeding success and length of stay
and should be studied further in a multicenter
trial.
Copyright 2011 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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