Journal of the Formosan Medical Association (2013) 112, 161e164

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ORIGINAL ARTICLE

Early oral-motor management on feeding

performance in premature neonates
a b b b c
Yan-Lin Liu , Yi-Ling Chen , I Cheng , Ming-I Lin , Guey-Mei Jow ,
b,c,d,
Shu-Chi Mu *

a Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial
Hospital, Taipei, Taiwan
bDepartment of Pediatrics, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
c Medical College of Fu-Jen University, New Taipei City, Taiwan
d Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan

Received 18 January 2010; received in revised form 17 May 2010; accepted 30 December 2011

KEYWORDS Background/Purpose: Poor oral-motor developments in premature infants are common. From

early intervention; the viewpoint of developmental care, most of the infants required individualized therapy. The
oral-motor specific aim of our study was to evaluate the effectiveness and impact of early intervention of
management; oral-motor management on feeding pattern and the neonatal outcomes in premature
suckingeswallowing neonates.
ebreathing Methods: The study enrolled 68 preterm infants with birth weight less than 1500 g or gesta-
movements; tional age less than 32 weeks. We tried to strengthen the sucking ability of infants with poor
very low birth weight oral-motor coordination.
Results: There were significant differences in the body weight (g) while feeding up to 45 mL
(1916 156 vs. 2003 191 g, p Z 0.002) and hospital stay (46.3 25.3 vs. 54.7 23.5 days,
p Z 0.003) between the study and control groups.
Conclusion: Abnormal brain sonography [odds ratio (OR): 2.222, p Z 0.047) and necrotizing
enterocolitis (NEC) (OR: 2.857, p Z 0.017) did affect the first trial in the study group. Early
intervention of oral-motor management in very-low-birth-weight premature infants improved
feeding performance and neonatal outcome in terms of shorter hospital days. Abnormal brain
image and NEC could interfere with the success rate of initial challenge of transitioning from
tube to oral feeding in the study group.
Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

* Corresponding author. Department of Pediatrics, Shin-Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District,
Taipei 111, Taiwan.
E-mail address: musc1006@yahoo.com.tw (S.-C. Mu).

0929-6646/$ - see front matter Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
http://dx.doi.org/10.1016/j.jfma.2012.08.003
162
Introduction
Components of delicate oral feeding in infants include well
coordination of suckingeswallowingebreathing (SSB)
movements.1 Oral and gag reflexes develop at about 12e16
weeks. Sucking and swallowing activities are present by 28
weeks, although the coordination does develop fully until
about 32e34 weeks.1 Healthy full-term infants demonstrate
such skills at birth; however, preterm infants sometimes
have difficulty in the transition from tube to oral feeding. In
preterm infants born at less than 32 weeks’ gestation,
sucking and swallowing skills are not good enough to
sustain full oral feeds. Non-nutritive sucking is believed to
have a calming effect on infants and is commonly used as
an intervention in nurseries and neonatal intensive care
units.2 In premature babies, non-nutritive sucking power is
related to their gestational age (GA).
Sucking ability improves with increasing GA. In compar-
ison with full-term babies, the characteristics of sucking
pattern in premature infants are higher in frequency, lower
in amplitude, and weaker in power. Unstable vital signs are
common in premature babies when the feedings proceed
via either tube or oral route. The unstable vital signs
comprise development of bradycardia during sucking, and
apnea and low oxygen saturation during swallowing. These
probably occur due to poor coordination of movements,
underdeveloped cardiorespiratory system, central nervous
system, and oral musculature in premature neonates. 3e8
Both intrinsic and extrinsic factors can influence an infant’s
bottle-feeding performance. In addition to age and weight,
oral-motor skills, feeding practice, and techniques also
contribute to infants’ feeding performance. Arbitrary age (34
weeks of GA) and weight criteria (1500 g) should not be the
only indicators for oral feeding.9
Some studies concerning poor oral-motor development
in premature infants focused on strengthening of sucking
ability.10e12 From the viewpoint of developmental care, most
of the infants required individualized therapy. The specific
aim of our study was to evaluate the effectiveness and
impact of early intervention of oral-motor management on
feeding pattern and the neonatal outcomes in prema-ture
neonates.
Materials and methods
This is a case-matched control study. The criteria for the
enrollment of participants were birth weight less than 1500
g or GA less than 32 weeks. Therapists screened the
premature infants in the intermediate ward and patients
who met the inclusion criteria were invited to enter the trial.
We retrospectively selected babies with matched GA and
birth weight as the control group. The same therapist
performed the intervention. Measures were collected at the
entry to the trial, and followed by intervention of oral-motor
management. This work was supervised by the ethics
committee and institutional review board of Shin-Kong
Medical Center, and informed consents were received from
parents.
Thirty-four premature neonates (19 males) were enrolled
in our intervention group and another 34 (20 males) were
selected retrospectively as our control group. All infants
Y.-L. Liu et al.
were free of major congenital anomalies. GA was determined
by menstrual history, antenatal ultrasound, and the Ballard
13
assessment. Neonatal characteristics and morbidities were
recorded. Chronological ages were adjusted.
There were two critical periods for physical intervention
in the study group. In the first step, we assessed the oral-
motor developments of the infants as their vital signs, with
other medical conditions being stable. If oral-motor
developments of the infants were inadequate, such as poor
sucking movement, incorrect sucking posture, or weak
sucking power, strengthening intervention of five consecu-
tive sucking movements and physical therapy were applied.
If the babies had non-nutritive sucking ability and could
demonstrate five consecutive strong sucking movements,
the first step of physical therapy was applied. When the
body weight becomes more than 1650 g, nursing staff
began to try bottle-feed the infants two to three times. If
they could not finish the required amount of milk within
20e30 minutes, the second step of physical therapy started.
Physical therapy was individually intervened according to
the sucking and swallowing ability, cardiopulmonary func-
tions, and SSB coordination. When the required amount of
milk could be bottle-fed within 20 minutes by the parents or
within 20e30 minutes by nurses, we stopped the program.
The duration of each intervention was 30 minutes. All
interventional programs of oral-motor management were
performed by the same therapist.
We recorded basic data including gender, GA, birth weight,
Apgar score, ages of parents, relevant medical complications of
ventilatory support and oxygen use, bronchopulmonary
dysplasia (BPD), patent ductus arterio-sus (PDA), necrotizing
enterocolitis (NEC), apnea, feeding intolerance, and findings of
brain sonography and electro-encephalography (EEG). NEC
was classified as the presence of intramural gas on X-ray, and
perforation or evidence of intestinal necrosis at surgery or
autopsy. PDA was diagnosed by clinical signs and/or
echocardiography confirmation.
We evaluated the feeding progress that contained the
transition periods from tube to oral feeding, GA at the start
of oral feedings, body weight when feeding up to 45 mL,
increment in milk (mL/d) intake, amount of milk intake at
discharge, and the days of hospital stay. It was assumed as
an unsuccessful trial as we could not switch the feeding
route from tube to oral feeding smoothly after the first trial.
We investigated the association between an unsuc-cessful
trial and the related medical conditions.
Values are expressed as mean standard deviation (SD)
unless indicated otherwise. Independent t test was used for
statistical analysis. All factors were proceeded adjusted
logistic regression analysis, which was performed to
account for the potential confounding variables of compli-
cations in premature neonates. The study was approved by
the institutional review board. A p value of <0.05 was
considered significant. Analyses were performed using the
SPSS statistical package (SPSS Inc., Chicago, IL, USA).
Results
Sixty-eight babies (34 in study group and 34 in control
group) were recruited in our study. There were no differ-
ences with respect to GA, birth weight, Apgar score at 1
and
Oral stimulation and support in premature neonates 163

5 minutes, and parental ages between the two groups Table 2 Feeding progress of premature neonates.
(Table 1). However, significant differences were observed in
the body weight (g) while feeding up to 45 mL (1916 156 vs. Study group Control group p
(n Z 34, (n Z 34,
2003 191 g, p Z 0.002) and hospital stay (46.3 25.3 vs. 54.7
mean SD) mean SD)
23.5 days, p Z 0.003) between the study and control
groups. Other parameters such as tran-sition periods from Days of TO transfer 1.7 3.1 1.9 2.6 0.794
tube to oral feeding, GA at the start of oral feeding (weeks), GA as the start of 35.2 1.9 35.6 2.1 0.066
increment in milk intake (mL/day), milk amount (mL/meal), oral feeding (wk) 156 191
GA (weeks) and body weight (g) at discharge were not BW (g) as feeding 1916 2003 0.002*
different (Table 2). There were 34 and 12 infants in the two up to 45 mL 0.6 0.7
periods of intervention. Increase rate of 1.2 1.5 0.069
There were no differences in perinatal and neonatal milk (mL/day) 9.2 8.8
outcomes that included the numbers of ventilatory support, Milk amount (mL/meal) 55.3 56.6 0.267
oxygen use, BPD, PDA, NEC, apnea, feeding intolerance, at discharge 2.16 2.6
abnormal brain sonography, and EEG (Table 3). GA (wk) at discharge 36.5 37.7 0.530
The clarification of unsuccessful trial was that we could BW at discharge (g) 2226 373 2316 250 0.409
not switch from tube to oral feeding smoothly on the first Hospital stay (d) 46.3 25.3 54.7 23.5 0.003*
challenge. There were 10 (10/34, 29.4%) and 18 (18/34,
* p < 0.05.
52.9%) cases with unsuccessful trial in the study and
BW Z body weight; GA Z gestational age; TO Z tube to oral
control groups, respectively. Abnormal brain sonographic
feeding.
findings (OR: 2.222, p Z 0.047) and NEC (OR: 2.857, p Z
0.017) did affect the first trial in the study group, but there
were no significant effects in the control group (Table 4).
feeding amount at discharge between these two groups.
Multiple factors might have influenced the infant’s bottle-
Discussion feeding performance. In addition to age and weight, the
conventional criteria applied here, oral-motor skills, feeding
Most full-term babies had acquired good SSB coordination practice, and feeding techniques also contributed to infants’
at birth. Feeding performances of preterm infants were feeding performance. All interventional programs of oral-
affected mostly by the postconceptional age. Infants with motor management were performed by the same therapist,
greater postconceptional age had better feeding skills.3 In thus eliminating the errors of interobservers.
our study, there were 68 (34 in the study and 34 in the
control group) sick premature infants. After our program of The suckeswallow reflex appeared at around 28e30
oral-motor massage, they were able to achieve the target of weeks of age, followed by rhythmic sucking reflex at 30e32
oral feeding up to 45 mL per meal with less body weight weeks of age and good SSB coordination at 32e35 weeks
and shorter hospital days. The oral feeding performances of of age.14e17 Arbitrary age (34 weeks’ GA) and weight criteria
study group were better than their control counterparts. As
(1500 g) should not be the only indicators for oral feeding. 9
in case of previous studies, the stimulation program
Our study supported the age of successful oral feeding
enhanced the express component of sucking, resulting in
around 35 weeks in study and control groups (35.2 1.9 vs.
better oral feeding. 4 Infants with a more organized sucking 35.6 2.1 weeks, p Z 0.066). However, we should remember
pattern reached independent oral feeding 3 days earlier that bottle feeding and intervention of physical therapy could
than infants with more chaotic patterns of suck bursts.9 Our lead to more energy expenditure. There was no significant
results study showed no significant differences in the difference in body weight at discharge
transition periods from tube to oral feeding, GA at the start
of oral feeding or at discharge, and body weight and
Table 3 Comparison of medical conditions between study
group and control group.
Table 1 Demographic characteristics of study and control
groups. Study group Control group p
Ventilator use 22/34 (65%) 26/34 (77%) 0.425
Study group Control group p
(n Z 34, (n Z 34, Oxygen use 32/34 (94%) 34/34 (100%) 0.493
mean SD) mean SD) BPD 10/34 (29%) 9/34 (27%) 1.000
PDA 8/34 (24%) 6/34 (18%) 0.765
Gender (M/F) 19/15 (56%) 20/14 (59%) 1.000 NEC 7/34 (21%) 3/34 (9%) 0.305
Gestational age (wk) 30.2 3.0 30.2 2.4 1.000 Apnea 18/34 (53%) 23/34 (68%) 0.322
Birth weight (g) 1325 226 1294 192 1.000 Feeding intolerance 17/34 (50%) 16/34 (47%) 1.000
*AS (1 min) 5.6 1.6 5.5 1.7 0.093 Abnormal brain echo 5/34 (15%) 7/34 (21%) 0.752
*AS (5 min) 7.5 1.0 7.4 1.2 0.631 Abnormal EEG 5/34 (15%) 1/34 (3%) 0.197
Paternal age (y) 32.7 6.4 34.3 4.1 0.819 2
Maternal age (y) 30.0 5.9 32.0 4.9 0.546 Statistical analysis: chi-Square (x ) test.
BPD Z bronchopulmonary dysplasia; EEG Z electroencephalo-
*Assumed as p < 0.05. graphy; NEC Z necrotizing enterocolitis; PDA Z patent ductus
AS Z Apgar score. arteriosus.
164 Y.-L. Liu et al.

Table 4 Effects of medical conditions on the successful This project was supported by a grant from Shin-Kong Wu
Ho-Su Memorial Hospital (SKH-FJU-98-20). We declare no
transition from oral-gastric tube feeding to bottle feeding.
conflicts of interest.
Study group Control group
OR p OR p
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