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The article Evidence-Based Systematic Review: Effects of Oral Motor Interventions On

Feeding and Swallowing in Preterm Infants by Arvedson, Clark, Lazarus, and Frymark (2010)
aims to examine the available evidence of the effects of oral motor intervention (OMI) on
feeding efficiency, swallowing physiology, feeding safety, pulmonary health, oral feeding, and
weight gain. In this article, OMI was defined as sensory stimulation to or actions of the lips,
jaw, tongue, soft palate, pharynx, larynx (Arvedson et al., 2010, p. 323). Furthermore, OMI
may include NNS and variations of stroking, tapping, and stretching externally on the face, or
within the oral cavity (Arvedson et al., 2010, p. 323). OMI can promote awareness of the oral
and facial structures and may be helpful in accelerating the transition to oral feeding.
Premature infants often struggle to feed orally when they are born and therefore require
intervention in order to meet their nutritional needs. Many NICUs use OMIs to help facilitate the
process from gavage feedings to independent oral feedings. Oral stimulation for example, can
decrease hypersensitivity, improve range of motion and strength, increase oral motor
organization, and activate reflex behaviors that facilitate nutritive sucking.
The research article findings reported however, that in synthesizing results from various
studies, results are mixed and as a result still inconclusive. The speech-language pathologist is
counseled instead, to consider individualizing feeding/swallowing intervention. Infant-driven
developmental care can have a significant positive effect by reducing length and cost of hospital
The article The Effect of an Early Oral Stimulation Program on Oral Feeding of Preterm
Infants by Tian-chan, Yuxia, Xiao-jing, Yun, Pin, &Yue-ue (2014) is based on a study with 72
premature infants sought to see if OMIs, specifically the pre-feeding oral stimulation program,

were a beneficial strategy to use. 36 of the infants were used as a control group and received
routine care, while the other 36 received oral stimulation in addition to routine care. The study
looked specifically at post menstrual age, total intake volume, body weight, transition time from
oral feeding to full oral feeding, and feeding efficiency.
The OMI itself consisted of three components. The first was 12 minutes of oral
stimulation followed by 3 min non-nutritive sucking and stroking of the oral structures. Tianchan et. al (2014) claimed that, The first component of the oral stimulation program may cause
a strengthening of the oral musculature, which is necessary for adequate sucking. Non-nutritive
sucking, the second component of the program, may promote more efficient engagement of
neuromuscular structures and with greater endurance.
The results of the study showed that the feeding efficiency (measured in volume intake),
weight gain rate, and hospital stay were not notably varied between the two groups. However,
post menstrual age, when independent full feedings were achieved was lower than the control
group and the transition time was significantly shorter in the experiment group than in the
control group (Tian-chan et al., 2014). It can be seen that OMIs in addition to routine care, can
help shorten the transition time between gavage feedings and oral feedings. This article supports
that OMIs can be an effective strategy used in the NICU.


The article Nonnutritive sucking for promoting physiologic stability and nutrition in
preterm infants is a meta-analysis that seeks to identify the effect of non-nutritive sucking on
preterm infants weight gain, energy intake, heart rate, oxygen saturation, length of hospital stay,
intestinal transit time, and age at full oral feeds. The article outlined both the positive and

negative effects non-nutritive sucking (NNS) can have on preterm infants. Twenty-one studies
were included in the review, 15 of which were randomized controlled trials.
NNS can have many positive effects on a premature infant. Firstly, it can facilitate the
development of sucking behavior. Moreover, NNS can aid digestion by promoting the secretion
of digestive enzymes. NNS is also thought to have a calming effect. Infants using a pacifier
spent less time in fussy and active states during and after tube feedings, and settled more
quickly into sleep (Pinelli & Symington, 2005, p. 2). Through this meta-analysis, Pinelli &
Symington (2005) found various significant effects of NNS. Infants using a pacifier as NNS
typically were less defensive during feeding, had a reduced time to transition between tube to
bottle feed, spent less time in crying, sleepy, drowsy states, had more time in quiet awake state,
increased intake during the first 5 minutes of feeding, improved feeding performance, less time
in fussy and active states, etc. Its not surprising then, that the most common type of
There were other findings in the study that were inconclusive and in need of more
research. No clinical significance was found on the effect of NNS on weight gain, heart rate,
oxygen saturation, intestinal transit time, stool fat, stool secretion, energy intake, gastric
emptying, and vagal tone (Pinelli & Symington, 2005, p. 6). It is important to note however, that
a lack of evidence for the latter effects does not signify that NNS is not an effective therapeutic
tool. On the contrary, it should be considered as a signal of the need for continued research on
the use of non-nutritive sucking interventions in the neonatal intensive care.
The use of NNS is not however, absolute in all areas. This review denoted a negative
impact of pacifier use. NNS has the potential of interfering with breastfeeding. Thus, it is equally
important to stress that the negative impact of NNS was not specifically addressed in any of the
studies included in this meta-analysis. This is another call for continued research.

Although there is a need for continued research, the use of NNS is very promising. It has
demonstrated to have strong clinical significance by reducing length of hospital stay, speeding
the transition from tube to bottle feeds, better bottle feed performance, etc. It is not surprising
then, that NNS is the most common type of OMI utilized in the NICU.
The article Improving preterm infant outcomes: implementing an evidence-based oral
feedingadvancement protocol in the neonatal intensive care unit by Kish (2014) critically
evaluated the implementation of an oral feeding advancement protocol in a 74-bed level III
NICU in an attempt to standardize the process of advancing oral feedings in preterm infants
through a quality improvement project. Specifically, a quasi-experimental design with a
historical control group was used. Furthermore, convenience sampling was used for this project
with inclusion criteria set at infants born at less than 35 weeks gestational age with no ongoing
oxygen requirement and considered medically stable overall. The purposes of the project were to
provide a uniform evidence-based approach for nursing practices regarding oral feeding,
illustrate the need to implement and evaluate the clinical protocol as well as establish a change in
clinical practice for offering preterm infants oral feedings. A review of the literature highlighted
the important link between nonnutritive sucking (NNS) and standardized feeding advancement
protocols with successful oral feeding. Thus, a pilot practice change using a feeding
advancement protocol, which consisted of NNS and standardized oral feeding advancement
opportunities, was initiated. Specifically, NNS was offered for 10 minutes before feedings.
During Phase 1 of the project, staff education was prominent in order to promote and ultimately
adopt the practice change by staff members. During Phase 2 of the project, preterm infants were
offered a minimum number of oral feedings within 24 hours. Infants using NNS and the
standardized oral feeding advancement protocol had a reduced time to achieving independent

oral feedings and length of stay in hospitals. Specifically, infants in the intervention group were
able to achieve exclusive oral feedings 1 day sooner than infants in the control groups and were
more likely to be discharged 3 days sooner. One of the major limitations of the study was that
staff compliance was low throughout the length of the project and NICU caregivers were not
blinded to use of the feeding advancement protocol as well as the relatively small sample size
used. In the end, future research is needed to determine what effect factors such as nursing
experience, parent involvement and amount of time spent on oral feedings may have had on
feeding outcomes. This QI project was simple to implement and could easily be replicated in
similar settings across the country.
Fucile et. al (2002) studied whether an oral stimulation program, before the introduction
of oral feeding, results in an overall successful oral feeding performance of preterm infants aged
26 and 29 weeks GA. Specifically, the researchers hypothesized that infants who received such a
pre-feeding oral stimulation program would not only achieve independent oral feeding sooner
but also would have a shortened hospital stay and would evidence an increased intake and rate of
milk transfer when compared with controls. The studys results aimed to add to existing evidence
regarding the relationship between oral stimulation and its benefits to oral feeding and provided
additional information on the effects of such oral stimulation before the start of oral feedings.
For their longitudinal study, Fucile et. al (2002) enrolled preterm infants born between 26
and 29 GA who were of appropriate size based on their GA, receiving full tube feedings and
displaying no chronic medical complications. Infants were randomized into experimental and
control groups through the use of a stratified blocked randomization method. Infants in the
experimental group received a pre-feeding oral stimulation program while infants in the control
group received a bogus stimulation program. In addition, nurses were blinded to group

assignment so as not to affect external validity. The time to acquire independent oral feeding was
defined as the first time an infant reached 8 oral feedings per day for 2 consecutive days or the
number of days needed to transition from complete tube feeding to independent oral feeding.
Similarly, intake and rate of milk transfer were monitored for 3 oral feeding intervals, once when
the infant was taking 1 to 2, 3 to 5 and 6 to 8 oral feedings per day. Intake was defined as the
percent volume transferred during an entire feeding session while rate of milk transfer was
defined as the volume transferred per unit time during an oral feeding session. Lastly, length of
stay was defined as the number of days from birth to discharge from the hospital. The oral
stimulation program consisted of a 15-minute stimulation program in which the first 12 minutes
involved stroking the cheeks, lips, gums, and tongue and the final 3 minutes consisted of sucking
on a pacifier. This program was administered once per day for 10 consecutive days
approximately 15 to 30 minutes before a tube feeding. The bogus stimulation program was the
same as the oral stimulation program except for the fact that the infants did not receive 15
minutes of oral stimulation.
Fucile et. al (2002) found support for their hypothesis in their quantitative experiment
that an early oral stimulation program can benefit preterm infants oral feeding skills.
Specifically, independent oral feeding was attained significantly earlier in the experimental
group who were exposed to the stimulation program than in the control group. In addition, intake
and rate of milk transfer were significantly greater in the experimental group than the control
group. However, there was no difference found in the length of hospital stay between the 2
groups as was originally anticipated by the researchers. The study is limited due to a lack of
consistent management of oral feedings by the attending physician as well as extraneous factors,
which may have contributed to the results of the experiment, which include the way, in which the

program may have developed the maturation of central and/or peripheral neural structures
leading to improved oral feeding skills. Thus, it can be concluded that an early oral stimulation
program results in a faster transition to oral feedings in preterm infants, which was also related to
greater intake and rate of milk transfer observed in these infants. According to the researchers,
such a program can be implemented easily by both nurses and parents alike, which would in turn
provide a positive relationship between preterm infants and their caregivers/parents.
Hill (2005) studied the effects of oral support and NNS on the feeding outcomes of
preterm infants. Specifically, she hypothesized that preterm infants who received a 1-week
intervention of oral support or NNS would consume a greater amount of formula during the first
5 minutes of feeding, show a decreased length in feeding time and have fewer as well as longer
sucking bursts and fewer pauses than infants who did not receive said intervention. Oral support
was defined when the researchers thumb and index fingers were used to provide support on the
infants cheeks while the third finger provided support of the mandible during the feeding.
Similarly, NNS was provided before the beginning of the scheduled feeding and infants were
allowed to suck on pacifiers for 5 minutes. The studys results aimed to add to existing evidence
regarding the relationship between oral support and NNS and its benefits to oral feeding and
provided additional information on the effects of such interventions on the positive outcome on
oral feedings.
For her longitudinal study, Hill (2005) enrolled 156 infants who were between 32 and 34
weeks GA, were at an appropriate weight for their GA, had no chronic feeding issues and had
Apgar scores of 3 or higher at 1 minute and 5 to 6 or higher at 5 minutes. The study was
conducted as a three-group repeated-observation control group quantitative design. The
experimental group, which received oral support or NNS and control groups, which received

neither oral support nor NNS consistently for each feeding, were randomly assigned and
measures of the dependent variables were repeated before the intervention, immediately after the
7-day intervention and at a 1-week follow-up. These included amount of formula taken in 5
minutes, length of feeding, number of sucks, number of bursts, number of sucking bursts and
pauses and length of pauses. Instruments were used to evaluate the sucking rate and rhythm
during feeding, which was connected to wire connectors so as to register electroconductive
waves by a computer program. Once a feeding session was complete, the researcher recorded the
amount of formula taken and the amount of time needed to complete the feeding.
Hill (2005) found support for her hypothesis in her quantitative design. Specifically, the
experimental groups consumed more formula during the first 5 minutes of feeding and
completed feedings sooner than the control group. In fact, the oral support group consumed more
formula than the NNS group and required less time in the total feeding than the NNS group. In
addition, the experimental groups had a decreased number of bursts and increased length of
bursts at the 1-week follow-up. The oral support group also produced fewer and shorter pauses
during sucking. Thus, infants who received oral support and NNS had a decreased length of time
in completing their feedings, which proved beneficial to the preterm infants. Both of these
interventions were found to have immediate and continuing effects on the amount of formula
taken. The effects on sucking patterns are mixed with continuing effects noted on the number
and length of bursts after the use of oral support and NNS but not immediately after the


In the article Instruments for assessing readiness to commence suck feeds in preterm
infants: effects on time to establish full oral feeding and duration of hospitalization by Linda
Crowe, Anne Chang, and Karen Wallace the purpose of the intervention review was to identify
the effect of utilizing a feeding readiness instrument. Instruments that can aid neonatal care
providers determine preterm infants readiness to commence feeding include the Feeding
Readiness and Progression in Preterms Scale (FRAPPS), the Neonatal Oral Motor Assessment
Scale, and the Early Feeding Skill (EFS).
The implementation of an instrument to assess oral feeding readiness has many benefits
for both the providers and the infants. A screening instrument can reduce staff time required and
other costs and possible detrimental effects such as introducing oral feeds when infants are not
ready or withholding oral feeding (Crowe et al, 2016, p. 3). These benefits should be weighed
against the cost of an instrument, given its positive effects in improving the accuracy of
determining the transition to suck feeds.
Unfortunately, these tools are not readily accessible for speech-language pathologists. As
a result, speech-language pathologists often have to rely on informal measures such as
observation, gestational age, weight, and behavioral cues to decide when to transition to oral
feeding. Determining readiness to suck is not a feasible task and should not be taken lightly. If
the infant is introduced to oral feeding prematurely, the infant may be at risk of developing
1) aspiration pneumonia, 2) readmission to the neonatal intensive care unit (NICU), 3) fatigue,
4) increased energy expenditure, 5) hypoxia, 6) bradycardia, and 7) deglution apnoea (Crowe et
al., 2016, p. 2). Factors that can influence safe feeding also includes neurobehavioral maturation,
physiologic stability, and control of tone. Moreover, successful feeding is circumscribed by

adequate development of the structures of the upper airway including the lips, palate, jaw,
tongue, pharynx, larynx, and oesophagus (Crowe et al., 2016, p. 3). Lastly, it is important to
consider individuality that may account for differences between preterm infants.
This meta-analysis determined that is a need for further research to demonstrate the
clinical benefit of using standardized assessment protocols. No studies were found to compared
instruments to one another or to an absence of instrument. Perhaps the best approach is a holistic
one, in which all information and resources available (i.e. standardized feeding readiness
protocol, behavioral cues, weight, gestational cues) is paired will clinical and family values to
collectively form efficient and effective evidence-based practice (EBP).
The study The Effects of Non-Nutritive Sucking and Pre-Feeding Oral Stimulation on
Time to Achieve Independent Oral Feeding for Preterm Infants by Asadollahpour, et al.
observed various oral stimulation techniques that facilitate oral feeding in preterm infants and
promote independent oral feeding. Of all the techniques, non- nutritive sucking (NNS) and prefeeding oral stimulation were among the most popular. The researchers developed a study that
would observe the interventions of NNS and pre- feeding oral stimulation and evaluate their
efficacy based on feeding performance, weight gain, and length of hospital stay.
The infants studied were preterm from 26 to 32 weeks of gestational age, fed through a
tube and their birth weight was between 1,000 to 2,000 grams. For the NNS intervention, the
speech therapist stroked the palate for 5 minutes to elicit a suck and introduced the little finger to
the infants oral cavity, gently stroking the palate to elicit a suck. Pre- feeding oral stimulation
consisted of stroking the cheeks, gums, and tongue once a day for three minutes and nonnutritive sucking for 15 minutes. The control group was given a sham intervention that consisted

of the speech therapist putter her hands in the incubator for 15 minutes without touching the
It was found that infants participating in the NNS and pre- feeding stimulation groups
were feeding independently 7.55 and 6.07 days sooner than infants in the control group. This
study, along with others, confirmed the benefits of oral stimuli techniques. But it was found that
NNS was more beneficial than pre- feeding oral stimulation because NNS improved weight gain
at the time of discharge. It was stated by Asadollahpour, et al. In general newborns in NNS and
pre- feeding oral stimulation groups were discharged sooner than those in control groups.
Which provides some concrete evidence that non- nutritive sucking can be a beneficial
intervention, but the sample size was not big enough to provide statistical evidence in favor of
the oral stimulation programs.

Institutions vary on their approach to infant care in the NICU. Some hospitals include
formal assessments, whereas others use general guidelines to reduce infant stress. In the article
Distilling the evidence on developmental care: a systematic review by Amanda Symington and
Janet Pinelli (2002) was to pin point whether developmental care can reduce adverse outcomes
faced by preterm infants. Core elements of developmental care encompasses a plethora of efforts
to minimize infant stress This meta-analysis focused on the outcomes of positioning/ swaddling
(to create an environment similar to the intra-uterine experience), modification of external
stimuli, clustering of nursing care activities, and individualized developmental care.
Their result findings pertaining to feeding can be summarized as following: infants under
a Newborn Individualized Developmental Care and Assessment Program (NIDCAP) had

significantly less tube feeding days and a shorter hospital stay. No evidence was found of the
effect of tactile stimulation on the ability to achieve full or partial nipple feedings. Infants
receiving tactile stimulation had a significantly shorter length of stay in the hospital. Auditory
and visual stimulation created significant changes in the feeding time and weight gain,
vestibular/ auditory, and tactile stimulation resulted in improved Nursing Child Assessment
Feeding Scale scores and better behavioral states. Lastly, there was some evidence of
individualized developmental care intervention on improving neurodevelopment. Individualized
intervention is without a doubt a gold standard given its positive effects on feeding and overall

Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010). Evidence-based
systematic review: effects of oral motor interventions on feeding and swallowing in
preterm infants. American Journal of speech-language pathology, 19(4), 321-340.
Asadollahpour, F., Yadegari, F., Soleimani, F., & Khalesi, N. (2015). The Effects of Non
Nutritive Sucking and Pre-Feeding Oral Stimulation on Time to Achieve Independent
Oral Feeding for Preterm Infants. Iranian Journal of Pediatrics, 25(3), 1-5.
Crowe, L., Chang, A., & Wallace, K. (2012). Instruments for assessing readiness to commence
suck feeds in preterm infants: effects on time to establish full oral feeding and duration of
hospitalisation. The Cochrane Library.
Fucile, S., Gisel, E., & Lau, C. (2002). Oral stimulation accelerates the transition from tube to
oral feeding in preterm infants. Journal of Pediatrics, 141, 230236.
Hill, A. S. (2005). The effects of nonnutritive sucking and oral support on the feeding efficiency
of preterm infants. Newborn and Infant Nursing Reviews, 5, 133141.

Kish MZ. (2014). Improving preterm infant outcomes: implementing an evidence-based oral
feedingadvancement protocol in the neonatal intensive care unit. Adv Neonatal Care,
(14), 34635.
Lyu, T. C., Zhang, Y. X., Hu, X. J., Cao, Y., Ren, P., & Wang, Y. J. (2014). The effect of an
early oral stimulation program on oral feeding of preterm infants. International Journal
of Nursing Sciences, 1(1), 42-47.
Pinelli, J., & Symington, A. J. (2005). Nonnutritive sucking for promoting physiologic stability
and nutrition in preterm infants. The Cochrane Library.
Symington, A., & Pinelli, J.M. (2002). Distilling the evidence on developmental care: a
systematic review. Advances in Neonatal Care: Official Journal of the National
Association of Neonatal Nurses 2(4), 198-221.