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Oral stimulation accelerates the transition from tube to oral feeding in preterm
infants* 1

Article  in  Journal of Pediatrics · September 2002

DOI: 10.1067/mpd.2002.125731 · Source: PubMed

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 Oral stimulation accelerates the transition from
tube to oral feeding in preterm infants
Sandra Fucile, MSc, OTR, Erika Gisel, PhD, OTR, and Chantal Lau, PhD
The effect that early oral feeding diffi-
Objective: To assess whether an oral stimulation program, before the intro- culties may have on the ability to breast/
duction of oral feeding, enhances the oral feeding performance of preterm in- bottle-feed and the duration of hospital-
fants born between 26 and 29 weeks’ gestational age. ization underscores the urgent need to
Study design: Preterm infants (n = 32) were randomized into an experimen- facilitate the development of normal
tal and control group. Infants in the experimental group received an oral oral-motor skills.2,4,5,14 Different oral
stimulation strategies have been used
stimulation program consisting of stimulation of the oral structures for 15
concomitant with the onset of oral feed-
minutes. Infants in the control group received a sham stimulation program.
ing or once oral feeding difficulties have
Both were administered once per day for 10 consecutive days, 48 hours after
become evident.15,16 Beneficial effects
discontinuation of nasal continuous positive air pressure. on the oral feeding performance of
Results: Independent oral feeding was attained significantly earlier in the ex- preterm infants were found. Leonard et
perimental group than the control group, 11 ± 4 days (mean ± SD) versus 18 al15 reported an enhanced sucking rate
± 7 days, respectively (P = .005). Overall intake and rate of milk transfer were when stroking of the cheeks was ap-
significantly greater over time in the experimental group than the control plied during an oral feeding session.
group (P = .0002 and .046, respectively). There was no difference in length of Einarsson-Backes et al16 demonstrated
hospital stay between the 2 groups. an increase in volume intake when
cheek and chin support was provided
Conclusion: An early oral stimulation program accelerates the transition to
during an oral feeding. Non-nutritive
full oral feedings in preterm infants. This was associated with greater overall
sucking accelerated the transition from
intake and rate of milk transfer observed in the experimental group when tube to independent oral feeding and
compared with the control group. (J Pediatr 2002;141:230-6) enhanced sucking maturation.17-19 Gae-
bler and Hanzlik,20 demonstrated that
infants receiving a peri- and intra-oral
Preterm infants frequently experience pital stays, and may lead to long-term stimulation just before oral feedings
oral feeding difficulties because of their feeding difficulties.3-7 Oral feeding dif-
underdeveloped cardiorespiratory sys- ficulties may include a disorganized GA Gestational age
tem, central nervous system, and oral sucking pattern, incoordination of
musculature.1-3 Oral feeding difficulties suck-swallow-breathe and an aversion scored better on the Neonatal Oral
often affect an infant’s ability to reach or hypersensitivity to touch around Motor Assessment Scale8 had greater
independent oral feeding, prolong hos- and/or in the mouth.8-13 weight gain and fewer days of hospital-
ization. Across all studies, there is con-
siderable evidence that oral stimulation
From the School of Physical and Occupational Therapy, McGill University, Montreal, PQ, Canada, and the Depart- through non-nutritive sucking or senso-
ment of Pediatrics/Neonatology, Baylor College of Medicine, Houston, Texas. rimotor input to the oral structures has
Supported by the Fonds de la Recherche en Santé du Québec graduate student scholarships beneficial effects on oral feeding perfor-
#002056 and #990522, the National Institute of Child Health and Human Development (R01-
HD28140), and the General Clinical Research Center, Baylor College of Medicine/Texas Chil-
mance when applied before or during
dren’s Hospital Clinical Research Center (M01-RR-00188), National Institutes of Health. oral feedings in medically stable
Submitted for publication July 25, 2001; revision received Mar 20, 2002; accepted Apr 10, 2002. preterm infants >30 weeks gestational
Reprint requests: Chantal Lau, PhD, Baylor College of Medicine, Department of age (GA). However, the effect of oral
Pediatrics/Neonatology, One Baylor Plaza, Houston, TX 77030. stimulation provided before the start of
Copyright © 2002, Mosby, Inc. All rights reserved. oral feedings has not been addressed in
0022-3476/2002/$35.00 + 0 9/21/125731 infants born <30 weeks GA. Given that
doi:10.1067/mpd.2002.125731 these infants are at a greater risk of en-

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THE JOURNAL OF PEDIATRICS FUCILE, GISEL, AND LAU
VOLUME 141, NUMBER 2

Table I. Oral stimulation program

Structure Stimulation steps Purpose Frequency Duration
Cheek 1. Place index finger at the base of the nose. Improve range of mo- 4 each 2 min
2. Compress the tissue, move finger toward the ear, then tion and strength of cheek
down and toward the corner of the lip (ie, C pattern). cheeks, and improve
3. Repeat for other side. lip seal.
Upper lip 1. Place index finger at the corner of the upper lip. Improve lip range of 4 1 min
2. Compress the tissue. motion and seal.
3. Move the finger away in a circular motion, from the
corner toward the center and to the other corner.
4. Reverse direction.
Lower lip 1. Place index finger at the corner of lower lip. Improve lip range of 4 1 min
2. Compress the tissue. motion and seal.
3. Move the finger away in a circular motion,from the
corner toward the center and to the other corner.
4. Reverse direction.
Upper 1. Place index finger at center of lip. Improve lip strength, 2 each 1 min
and 2. Apply sustained pressure, stretchdownward toward range of motion, and lip
lower the midline. seal
lip curl 3. Repeat for lower lip-apply sustained pressure, and
stretch upward toward the midline.
Upper gum 1. Place finger at the center of the gum, with firm Improve range of mo- 2 1 min
sustained pressure slowly move toward the back of tion of tongue, stimu-
the mouth. late swallow, and
2. Return to the center of the mouth. improve suck.
3. Repeat for opposite side.
Lower gum 1. Place finger at the center of the gum, with firm Improve range of mo- 2 1 min
sustained pressure slowly move toward the back of tion of tongue, stimu-
the mouth. late swallow, and
2. Return to the center of the mouth. improve suck.
3. Repeat for opposite side.
Internal 1. Place finger at inner corner of lips. Improve cheek range of 2 each 2 min
cheek 2. Compress the tissue, move back toward the molars motion and lip seal. cheek
and return to corner of lip.
3. Repeat for other side.
Lateral 1. Place finger at the level of the molar between the side Improve tongue range 2 each 1 min
borders blade of the tongue and the lower gum. of motion and side
of the 2. Move the finger toward midline, pushing the tongue strength
tongue towards the opposite direction.
3. Immediately move the finger all the way into the
cheek, stretching it.
Midblade 1. Place index at the center of the mouth. Improve tongue range 4 1 min
of the 2. Give sustained pressure into the hard palate for of motion and
tongue 3 seconds. strength, stimulate
3. Move the finger down to contact the center blade of swallow, and improve
the tongue. suck.
4. Displace the tongue downward with a firm pressure.
5. Immediately move the finger to contact the center
of the mouth at the hard palate.
Elicit 1. Place finger at the midline, center of the palate, Improve suck, and soft N/A 1 min
a suck gently stroke the palate to elicit a suck. palate activation.
Pacifier 1. Place pacifier in mouth. Improve suck, and soft N/A 3 min
palate activation

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 FUCILE, GISEL, AND LAU
Table II. Subject characteristics
Experimental (n = 16) Control (n = 16)
GA distribution
26/27 weeks’ GA 6 6
28/29 weeks’ GA 10 10
GA (wk) 28.2 ± 1.3* 28.1 ± 1.1
(26.4–29.9)† (26.0-29.7)
Birth weight (g) 1044 ± 260 959 ± 244
(740-1500)† (560-1300)
Gender distribution
Male 7 6
Female 9 10
*Means ± SD.
†Range.
‡Number of infants scoring <7.
countering oral feeding difficulties than grades III and IV, necrotizing enterocol-
older preterm infants, this study was itis,21 and congenital anomalies (eg, oral,
initiated to assess the effects of an early heart, etc). The Institutional Review
oral stimulation program on the oral Board for Human Subject Research of
feeding performance. The oral stimula- Baylor College of Medicine and Affiliat-
tion program was administered before ed Hospitals approved the research pro-
the introduction of oral feeding because tocol. Written consent to participate was
the goal was to enhance the maturation obtained from parents before infants
of oral motor skills before the potential were entered into the study.
development of oral feeding difficulties.
Specifically, this study addressed Procedures
whether infants who received the All infants were randomized into the
prefeeding oral stimulation program control or experimental groups by using
would attain independent oral feeding a stratified blocked randomization
sooner, would have a shortened hospital method with a block size of 4. Stratifi-
stay, and would demonstrate enhanced cation on GA (26-27 vs 28-29 weeks
overall intake and rate of milk transfer GA) was used to ensure that the 2
when compared with controls. groups had similar gestational age dis-
tribution.
METHODS Infants in the experimental group re-
ceived a prefeeding oral stimulation
Subjects program (described later), and infants
Preterm infants (n = 32; 19 females) in the control group received the sham
completed the study. All were recruited stimulation program. Both interven-
from the Neonatal Intensive Care Unit tions were started 48 hours after dis-
at Texas Children’s Hospital, Houston. continuation of nasal continuous
Infants were enrolled if they were (1) positive airway pressure. The program
born between 26 to 29 weeks’ GA as de- was not administered if infants were
termined by obstetric ultrasonogram disturbed 30 minutes before the inter-
and clinical examination, (2) of appro- vention (eg, ophthalmologic examina-
priate size for their GA, (3) receiving tion), and it was stopped if infants
full tube feedings (120 kcal/kg/day), and were medically unstable and/or had
(4) had no chronic medical complica- any episodes of oxygen desaturations
tions, such as bronchopulmonary dys- and/or apnea/ bradycardia during the
plasia, intraventricular hemorrhage intervention. Both groups were moni-
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THE JOURNAL OF PEDIATRICS
AUGUST 2002
tored from the time of entry into the
study until their discharge from the
hospital. The initiation and advance-
ment of oral feedings was left to the
discretion of the attending physician.
Nurses were responsible for feeding
infants in their customary fashion with
nipples routinely used in the nursery.
Both were blinded to group assign-
ment. The outcome variables (de-
scribed later) were measured at
specific times throughout the study.
Time to attainment of independent oral
feeding was defined as the first time an
infant reached 8 oral feedings per day
for 2 consecutive days. Overall intake
and rate of milk transfer were moni-
tored 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.
Interventions
The prefeeding oral stimulation pro-
gram consisted of a 15-minute stimula-
tion program, whereby the first 12
minutes involved stroking the cheeks,
lips, gums, and tongue, and the final 3
minutes consisted of sucking on a pacifi-
er routinely used in the nursery (Table
I). The infants were positioned supine in
the isolette. This program was based on
Beckman’s principles.22 The program
was administered once per day for 10
consecutive days, 15 to 30 minutes be-
fore a tube feeding. A screen was placed
around the infant’s isolette so as to blind
the caretakers and family members to
group assignment. The sham stimulation
program was identical to the prefeeding
oral stimulation program, with the ex-
ception that infants did not receive the
15 minutes of oral stimulation.
Outcome Measures
Time to attainment of independent oral
feeding was defined as the number of
days necessary to make the transition
from complete tube feeding to indepen-
dent (8) oral feeding. In addition, the
number of days to reach one and 4 suc-
cessful oral feedings per day was also
recorded. Success was defined as the
completion of the entire feeding without
THE JOURNAL OF PEDIATRICS FUCILE, GISEL, AND LAU
VOLUME 141, NUMBER 2

any occurrence of oxygen desaturation Table III. Oral feeding milestones

and/or apnea/bradycardia. Overall intake *P
was defined as the percent volume trans- Experimental Control value
ferred during an entire feeding session Introduction to oral feeding
over the prescribed volume to be taken. PMA (wk) 34.6 ± 1.7† 34.5 ± 1.5 .880
The number of infants who took all their DOL (d) 46 ± 17 46 ± 16 .950
prescribed volume by mouth within the Weight (g) 1666 ± 270 1598 ± 289 .500
allotted time was recorded. Rate of milk 1 oral feeding/day
transfer was defined as the volume trans- No. days 2±2 6±5 .010
ferred per unit time (mL/min) during an PMA (wk) 34.8 ± 1.8 35.4 ± 1.6 .390
oral feeding session. Length of stay was DOL (d) 47 ± 18 51 ± 16 .541
defined as the number of days from birth Weight (g) 1700 ± 294 1735 ± 353 .767
to discharge from the hospital. Delay in 4 oral feedings/day
hospital discharge was defined as infants No. days 8±4 13 ± 6 .019
who remained in the hospital for >7 days PMA (wks) 35.7 ± 1.8 36.3 ± 1.6 .261
from the time they achieved independent DOL (d) 53 ± 18 58 ± 17 .473
oral feeding. Seven days was selected be- Weight (g) 1859 ± 328 1936 ± 427 .572
cause it was considered a sufficient 8 oral feedings/day
amount of time to plan discharge for No. days 11 ± 4 18 ± 7 .005
medically stable infants. The following PMA (wk) 36.1 ± 1.8 36.9 ± 1.8 .193
covariates were recorded: number of in- DOL (d) 57 ± 18 62 ± 17 .364
fants who received breast feedings Weight (g) 1928 ± 343 2043 ± 461 .431
throughout the study; gastric residuals, PMA, Postmenstrual age; DOL, days of life; No. days, number of days from introduction to 1, 4, or
oxygen requirement, episodes of oxygen 8 oral feedings per day.
desaturations and/or apnea/bradycardia *Independent t test.
†Means ± SD.
at the 3 monitored feeding sessions; and
behavioral state of the infant at the start,
at 5 minutes, and at the end of the feed-
ing sessions by using the Preterm Infant’s
Behavior State Scale from the Newborn RESULTS life, and weight at each of these 3 mile-
Individualized Developmental Care and stones (all tests P ≥ .193).
Assessment Program.23 Both groups were comparable with Figure, A, illustrates overall intake
regard to baseline characteristics (Table expressed as a percent of volume pre-
Statistical Analyses II). All covariates were equally distrib- scribed. There was no time by group
An independent t test was used to de- uted between the 2 groups (all tests interaction (P = .798). Significant
termine the effect of the prefeeding oral P ≥ .132). differences in overall transfer over
stimulation versus the sham stimulation As a first step, attainment of inde- time (P = .014) and between groups
program on time to achieve the defined pendent oral feeding, overall intake, (P = .0002) were found with the ex-
oral feeding milestones (ie, 1, 4 and 8 suc- and rate of milk transfer were stratified perimental group, demonstrating bet-
cessful oral feedings/day) and length of by GA: 26 to 27 and 28 to 29 weeks ter overall intake than the controls. A
stay. An unbalanced repeated measures GA. Because no difference was noted larger number of experimental in-
analysis was used to determine the effect between groups, all data were pooled. fants attained 100% overall intake at
of the intervention on overall intake and The results of the oral feeding mile- 1 to 2 oral feedings per day than the
rate of milk transfer. A Fisher exact test stones are presented in Table III. The control group, n = 11 versus n = 2, re-
was used to compare the number of in- 2 groups were introduced to oral feed- spectively (P = .003). Rate of milk
fants achieving 100% overall intake at the ings at similar postmenstrual ages, transfer is illustrated in Figure, B.
3 time milestones. Significance was de- days of life, and weights. Infants in the The time by group interaction was
fined at the 0.05 level using a type I error experimental group achieved one (P = not significant (P = .805). However,
of 0.05 and a power of 0.80. A sample size .01), 4 (P = .02), and 8 (P = .005) suc- time (P = .0001) and group (P = .046)
of 32 was calculated on the basis of the cessful oral feedings significantly faster effects were significant with the ex-
primary outcome, time to attainment of than the controls. There was no signifi- perimental group showing higher
independent oral feeding, which averages cant difference between the 2 groups rates of milk transfer than the control
14 ± 8 days.12 in regard to postmenstrual age, days of group.

233
 FUCILE, GISEL, AND LAU THE JOURNAL OF PEDIATRICS
AUGUST 2002

From the 160 stimulation programs

that were administered, 7 were delayed
or halted. Four sessions were delayed
because the infants were disturbed 30
minutes before the program, 2 sessions
were delayed because infants were
medically unstable, and one session was
halted because the infant had an
episode of bradycardia, which resolved
spontaneously.
The length of hospital stay for the
experimental group was 65 ± 16 days
and 70 ± 22 days for the control
group. Although the experimental
group was discharged an average of 5
days sooner, the difference was not
significant (P = .459). Discharge of
infants who achieved full oral feeding
was delayed for medical reasons (ie,
infection, unstable respiratory status,
and body weight <2000 g) and social
reasons (ie, caretakers not available,
twins who were not ready to be dis-
charged at the same time).

DISCUSSION
The average hospital stay of infants
born <30 weeks’ GA is 11 to 12 weeks.6
During this period, oral-motor stimula-
tion consists primarily of necessary med-
ical procedures (eg, placement of
endotracheal tube, nasal continuous pos-
itive airway pressure, naso- or orogastric
tubes, and/or suctioning of airways).
With the exception of the unstructured
provision of a pacifier, little attention is
placed on preparing the infants for oral
feeding. With the increased survival of
infants <30 weeks’ GA and the knowl-
edge that these infants are at greater risk
for having feeding difficulties,1-3 it is im-
portant to assess whether an early oral
stimulation can also benefit this popula-
tion of infants.
Results from this study support the
hypothesis that a prefeeding oral stimu-
lation program can benefit preterm in-
fants’ oral feeding performances.
Infants in both groups were introduced
Figure. Overal intake (A) and rate of milk transfer (B). Means ± SD of the (●) experimental to oral feeding at similar postmenstrual
group and (■) the control group. ages, days of life, and weights. Howev-

234
THE JOURNAL OF PEDIATRICS
VOLUME 141, NUMBER 2
er, the experimental group attained oral
feeding milestones (ie, 1, 4, and 8 oral
feedings) faster than their control coun-
terparts. This observation corroborates
similar studies conducted on older
preterm infants.17-20
There was no significant difference in
postmenstrual age, days of life, and
weights between either groups at each
of the oral feeding milestones. In this
study, the management of oral feedings
was left to the discretion of the attend-
ing physician. Although there are gen-
eral guidelines for the management of
oral feedings, there is no specific proto-
col for initiating and advancing oral
feedings at the participating institution.
Some practitioners advanced the num-
ber of daily oral feedings only if infants
finished all their feedings by mouth
and/or demonstrated an adequate daily
weight gain. Therefore, the large vari-
ance observed in these measures likely
reflected the varied practice of individ-
ual clinicians.
Because both groups were similar
in baseline characteristics, number of
breast-feeding sessions received,
amount of gastric residuals, oxygen
requirement, number of episodes of
oxygen desaturations and/or apnea/
bradycardia, and behavioral state, it is
unlikely that infants from the experi-
mental group achieved oral feeding
milestones faster because they were
“healthier” and/or more mature than
their counterparts. The more rapid
transition to independent oral feeding
in the experimental group was associ-
ated with better oral feeding perfor-
mance (ie, greater overall intake and
rate of milk transfer). When intro-
duced to oral feeding, infants who re-
ceived the intervention were successful
at oral feeding sooner than the con-
trols. Such enhanced oral feeding per-
formance observed in the experimental
group may be the result of several fac-
tors. Stroking of the oral structures,
the first component of the oral stimula-
tion program, may have strengthened
the oral musculature necessary for ad-
equate sucking. Nonnutritive sucking,
the second component of the program,
may have allowed infants to engage
these neuromuscular structures more
efficiently and with greater endurance.
The program, as a whole, may have en-
hanced the maturation of central
and/or peripheral neural structures,
leading to improved sucking skills and
coordination of suck-swallow-breathe.
The observations made in this study
introduce the concept that maturation
of sucking may be dependent not only
on physiologic maturation but also
learning experiences.12,25-26 As such,
the notion of training infants to im-
prove their sucking skills is conceiv-
able.
Although the experimental infants
were discharged 5 days earlier, there
was no significant difference, contrary
to other studies,16-19 in length of stay at
the hospital between the 2 groups. This
was an unexpected finding. It was an-
ticipated that experimental infants
would be discharged earlier because
they achieved independent oral feeding
significantly earlier than the control in-
fants. There are specific criteria to dis-
charge infants from the hospital.
However, there is no set time to initiate
discharge planning. This likely was an
added confounding variable in the cur-
rent study.
The model of family-centered devel-
opmental care is emerging in many
neonatal intensive care units. This ap-
proach encourages parents to become
more involved in the clinical care and
discharge planning of their infants. In
view of the benefits provided by the
pre-feeding oral stimulation program,
it is proposed that the use of such an
intervention may be implemented in
neonatal developmental care plans be-
cause it is safe and simple. Both nurs-
es and parents can be taught to
provide the program. Such application
would not only enhance the oral feed-
ing performance of preterm infants,
but also provide an increased opportu-
nity for caretakers/parents to interact
with their infants in a positive mean-
ingful manner.
FUCILE, GISEL, AND LAU
We thank all the nurses at Texas Children’s
Hospital, C. Sheel, MD, and C. Simpson, MD,
for their assistance in the collection of the data;
M. Abrahamovicz, PhD, E. O. Smith, PhD,
and K. Fraley for statistical assistance; and
the physical medicine and rehabilitation staff
at Texas Children’s Hospital for their support.
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