Donna Dowling, PhD, RN, and Shelley Thibeau, PhD, RNC-NIC ❍ Section Editors

Original Research

Factor Structure and Psychometric

Properties of the Neonatal Eating
Assessment Tool—Bottle-Feeding
(NeoEAT—Bottle-Feeding)
Britt Frisk Pados, PhD, RN, NNP-BC; Suzanne M. Thoyre, PhD, RN, FAAN; Hayley H. Estrem, PhD, RN;
Jinhee Park, PhD, RN; Cara McComish, PhD, CCC-SLP

ABSTRACT
Background: Feeding difficulties are common in infancy. There are currently no valid and reliable parent-report measures
to assess bottle-feeding in infants younger than 7 months. The Neonatal Eating Assessment Tool (NeoEAT)—Bottle-
feeding has been developed and content validated.
Purpose: To determine the factor structure and psychometric properties of the NeoEAT—Bottle-feeding.
Methods: Parents of bottle-feeding infants younger than 7 months were invited to participate. Exploratory factor analy-
sis was used to determine factor structure. Internal consistency reliability was tested using Cronbach α. Test-retest
reliability was tested between scores on the NeoEAT—Bottle-feeding completed 2 weeks apart. Construct validity was
tested using correlations between the NeoEAT—Bottle-feeding, the Infant Gastroesophageal Reflux Questionnaire—
Revised (I-GERQ-R), and the Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Known-groups validation was
tested by comparing scores between healthy infants and infants with feeding problems.
Results: A total of 441 parents participated. Exploratory factor analysis revealed a 64-item scale with 5 factors. Internal
consistency reliability (α = .92) and test-retest reliability (r = 0.90; P < .001) were both excellent. The NeoEAT—Bottle-
feeding had construct validity with the I-GERQ-R (r = 0.74; P < .001) and IGSQ (r = 0.64; P < .001). Healthy infants scored
lower on the NeoEAT—Bottle-feeding than infants with feeding problems (P < .001), supporting known-groups validity.
Implications for Practice: The NeoEAT—Bottle-feeding is an available assessment tool for clinical practice.
Implications for Research: The NeoEAT—Bottle-feeding is a valid and reliable measure that can now be used in feeding
research.
Key Words: bottle-feeding, feeding behavior, feeding methods, infant, infant nutrition, newborn, premature,
psychometrics, surveys and questionnaires
Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

BACKGROUND AND SIGNIFICANCE includes behaviors such as refusing to feed, gagging,

It is common for infants, particularly those born
premature1 or with other medical complexity,2 to
experience difficulty with feeding. Feeding difficulty
Author Affiliations: Boston College William F. Connell School of
Nursing, Chestnut Hill, Massachusetts (Drs Pados and Park); The
University of North Carolina at Chapel Hill School of Nursing
(Dr Thoyre); University of North Carolina at Chapel Hill Center for
Developmental Sciences (Dr Estrem); and University of North Carolina
at Chapel Hill School of Medicine, Department of Allied Health
Sciences, Division of Speech and Hearing Sciences (Dr McComish).
This study was conducted at The University of North Carolina at Chapel
Hill School of Nursing.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL
citation appears in the printed text and is provided in the HTML and
PDF versions of this article on the journal’s Web site (www.advances
inneonatalcare.org).
Correspondence: Britt Frisk Pados, PhD, RN, NNP-BC, Boston College
William F. Connell School of Nursing, Maloney Hall 268, 140
Commonwealth Ave, Chestnut Hill, MA 02467 (britt.pados@bc.edu).
Copyright © 2018 by The National Association of Neonatal Nurses
DOI: 10.1097/ANC.0000000000000494
coughing, irritability, and difficulty coordinating
sucking, swallowing, and breathing. Data on the
population prevalence of feeding difficulties in
infants are not available due in part to a lack of con-
sensus on the definition of a feeding problem3 and a
lack of valid and reliable measures4 capable of dif-
ferentiating infants with feeding problems from
healthy, typically feeding infants. Infants born pre-
mature,1 with congenital heart disease,2 genetic dis-
orders,5 and congenital anomalies involving the
head, face,6 mouth,7 and gastrointestinal tract8,9 are
at particularly high risk for experiencing difficulty
with feeding. Many of these infants are cared for in
the neonatal intensive care unit (NICU). Even when
they are able to establish oral feeding prior to dis-
charge, many of them continue to have long-term
feeding problems into early childhood that require
specialty feeding treatment.10-13
Early identification of the infant who is struggling
with feeding is critical for implementation of appro-
priate therapies in order to optimize nutrition during

232 Advances in Neonatal Care • Vol. 18, No. 3 • pp. 232-242

Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.

a time of critical brain growth in the first year of
life14 and to prevent the development of long-term
feeding problems, which become more difficult to
treat as the negative behavioral responses to feeding
become more established. A valid and reliable assess-
ment tool can provide an objective measure of feed-
ing, help clinicians identify infants in need of referral
to specialty care, and monitor responses to interven-
tions. Valid and reliable measures are also needed
for feeding-related research. The validity and reli-
ability of an assessment tool are critical to ensure
that the tool is measuring what it is intending to
measure (ie, infant symptoms of problematic feeding
as opposed to the impact of problematic feeding on
the parent) and that the score reflects what is true
(ie, an infant with problematic feeding receives a
score that reflects that feeding is problematic).15
While human milk is considered the ideal nutri-
tion for infants, there are a variety of reasons why
most infants, particularly those with medical com-
plexity, will be offered a bottle containing either
human milk or formula in the first 6 months of life.
The Centers for Disease Control and Prevention
reports that at 6 months of life, only 24.9% of
infants are exclusively breastfed,16 and some portion
of these infants will receive human milk by bottle.
Exclusive breastfeeding rates are significantly lower
for infants born premature17,18 and with medical
complexity.19 An assessment tool for bottle-feeding
infants is needed for both clinical practice and
research on infant feeding.
LITERATURE REVIEW
A systematic review was conducted in 2015 that
reported on assessment tools available for the assess-
ment of feeding in the infant 6 months of age and
younger.4 At the time of that publication, while there
were several breastfeeding assessment tools, there
were only 2 bottle-feeding assessment tools
available—the Early Feeding Skills assessment20 and
the Neonatal Oral Motor Assessment Scale.21 The
Early Feeding Skills (EFS) Assessment and the Neo-
natal Oral Motor Assessment Scale are both assess-
ments that rely on the observations of trained clini-
cians. For the purpose of this article, an updated
review of the literature was conducted for bottle-
feeding assessment tools published since 2015 (Fig-
ure 1). This literature review revealed that currently
there are no parent-report bottle-feeding assess-
ments available. Parent-report assessments have sev-
eral unique benefits over clinician-reported assess-
ments. First, they do not require any training, which
allows for wider use of the tool, and they utilize the
parent’s knowledge of the infant’s typical behavior
over a period of time, a perspective that cannot be
gained in a short outpatient visit or a single inpatient
feeding.
Advances in Neonatal Care • Vol. 18, No. 3
Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
NeoEAT—Bottle-Feeding 233
The Neonatal Eating Assessment Tool (NeoEAT) is
the first parent-report measure of bottle-feeding.
Information about the development and content vali-
dation of the NeoEAT is available elsewhere.22 There
are 3 versions of the NeoEAT—Breastfeeding (for
exclusively breastfeeding infants),23 Bottle-feeding
(for exclusively bottle-feeding infants), and Breast
and Bottle-feeding (for infants being offered both
breast and bottle-feedings). The purpose of this study
was to determine the factor structure of the NeoEAT—
Bottle-feeding and to assess the psychometric proper-
ties of the tool, including internal consistency reliabil-
ity, temporal stability (test-retest reliability), construct
validity, and known-groups validity.
What This Study Adds
• The NeoEAT—Bottle-feeding is a valid and reliable
parent-report assessment of bottle-feeding in infants
younger than 7 months.
• The NeoEAT—Bottle-feeding can be used in clinical
practice to identify infants in need of specialty assess-
ment and monitor response to treatment.
• The NeoEAT—Bottle-feeding can be used in research
to study bottle-feeding behaviors and the effectiveness
of feeding interventions.
METHODS
Design
This was an instrument development study using
methods consistent with best practices for the devel-
opment and testing of new assessment tools.15,24
Sample
This research study was conducted using a Web-
based survey platform (Qualtrics, Provo, Utah). Par-
ents and primary caregivers (heretofore referred to
as “parents”) were invited to participate in the study
if they met the following criteria: (1) at least 18 years
of age, (2) caring for a child younger than 7 months
who was being fed by mouth (ie, infants fed exclu-
sively through a feeding tube were not included), (3)
able to read English, and (4) able to access the Inter-
net to complete the survey. If a parent had more than
1 child younger than 7 months, they were able to
participate only once and were asked to report only
on 1 child. The sample that was used for this analysis
was part of a larger study involving parents of both
bottle- and breastfeeding infants. To be included in
this analysis, the parent had to indicate that the tar-
get infant (ie, the infant they were reporting on) had
been fed by bottle in the past 7 days. Quota sampling
was used to obtain a minimum sample of target
infants within each sex and age category (0-2
months, 2-4 months, 4-6 months, and 6-7 months).
To meet the aims of this study, a minimum sample
of 5 participants per NeoEAT—Bottle-feeding item
234 Pados et al
FIGURE 1
PRISMA diagram of literature search result.
Databases searched: PubMed, CINAHL, and Web of
Science. Search terms: “assessment” and “bottle-
feeding” and (“tool” or “measure” or “scale”).
Filters used: English, Full text, Humans, Infant (birth
to 23 months), and publication between January 1,
2015, and September 11, 2017.
was needed (ie, a minimum sample of 370 partici-
pants).25 Parents were primarily recruited within the
United States, but parents from other countries who
met eligibility criteria were welcome to participate.
Given the need for a large sample, a variety of recruit-
ment strategies were used. Parents of eligible patients
from a southeastern United States tertiary care hos-
pital system who were receiving care in the primary
care outpatient clinic, outpatient feeding clinic, or
who had been discharged from the NICU were
invited to participate. Parents were also recruited
through the Feeding Challenges Registry, a registry
of parents of children with feeding difficulties main-
tained by the investigative team; Researchmatch.org,
a national health volunteer registry, supported by the
US National Institutes of Health as part of the Clini-
cal Translational Science Award program; the
research team’s Web site and Facebook page; Qual-
trics respondent panels; online parent support
groups; and an informational e-mail sent to faculty,
staff, and students at a southeastern university.
Instruments
NeoEAT—Bottle-Feeding
The NeoEAT—Bottle-feeding is a 74-item parent-
report questionnaire about infant behavior during
Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
bottle-feeding. The NeoEAT—Bottle-feeding was
developed for infants younger than 7 months and
has been content validated with both parents (n =
19) and professionals (n = 9), specifically neonatal
nurses, lactation consultants, and speech-language
pathologists.22 Seven months was chosen as the
upper age limit for the NeoEAT—Bottle-feeding
because the American Academy of Pediatrics recom-
mends the introduction of solid foods at 6 months26
and in the first month of solid food exposure, the
quantity of food taken by mouth is relatively little.
Given this, an assessment of liquid feeding is most
appropriate for infants younger than 7 months, after
which an assessment of symptoms associated with
solid-food eating may be more appropriate. A full
description of the process of development and con-
tent validation is available in a previous publica-
tion.22 The NeoEAT—Bottle-feeding is written at a
fifth-grade reading level, which is consistent with
recommendations of health-related materials being
written at less than a sixth-grade reading level.27
Items on the NeoEAT—Bottle-feeding are prefaced
by the phrase “My baby” and parents are asked to
choose the answer that best describes the frequency
with which the infant displays each behavior during
bottle-feeding. Response options are Never, Almost
Never, Sometimes, Often, Almost Always, and
Always. A sum score is calculated with a possible
range of 0 to 370.
Validation Measures
The Infant Gastroesophageal Reflux Questionnaire
Revised (IGERQ-R)28-30 and the Infant Gastrointes-
tinal Symptoms Questionnaire (IGSQ)31 were used
for construct validation of the NeoEAT—Bottle-
feeding since there are no currently available parent-
report bottle-feeding instruments available for this
purpose. These instruments were chosen because
they were expected to be associated with a subset of
items on the NeoEAT—Bottle-feeding that measure
symptoms related to gastoesophageal reflux and
gastrointestinal dysfunction.
The IGERQ-R28-30 is a 12-item parent-report
questionnaire about symptoms of gastroesophageal
reflux in the past 7 days. The IGERQ-R is scored as
a sum score (range: 0-42), with a higher score indi-
cating more symptoms of gastroesophageal reflux. It
has acceptable psychometric properties with internal
consistency reliability (Cronbach α = 0.86-0.87)
and test-retest reliability (intraclass correlation coef-
ficient = 0.85). When comparing infants with and
without gastroesophageal reflux disease, the
IGERQ-R found significant differences, supporting
known-groups validity.
The IGSQ31 is a 13-item parent-report question-
naire about infant gastrointestinal symptoms in the
past 7 days. The IGSQ is scored as a sum score
(range: 13-65), with a higher score indicating more
www.advancesinneonatalcare.org

symptoms of gastrointestinal distress. The IGSQ
also has acceptable psychometric properties, includ-
ing internal consistency reliability (Cronbach α =
0.72), test-retest reliability (r = 0.69), and known-
groups validity supported by significant differences
found between IGSQ scores in infants with known
formula intolerance and those without.
Statistical Analysis
Data were analyzed using IBM SPSS Statistics, ver-
sion 24.0 (IBM Corp, Armonk, New York). Cases
with more than 10% missing data were excluded
from the analysis. A significance level of .05 (2-sided)
was used for all statistical testing. The specific meth-
ods for each phase of data analysis are described
separately.
Item Analysis
For each of the 74 items on the NeoEAT—Bottle-
feeding, descriptive statistics, item-total correlation,
and inter-item correlations (Pearson product-
moment correlation r) were calculated. The research
team first reviewed items that failed to correlate with
any other item at 0.3 or greater (indicating that the
item was not related to the other items) or correlated
with another item at 0.8 or greater (indicating that
those 2 items were measuring the same thing). The
research team came to a consensus about removal of
items, taking into account the constructs measured
by the remaining items on the tool.
Factor Analysis
After removing items identified in the item analysis
phase, an exploratory factor analysis was conducted
on the remaining items using principal component
analysis with varimax rotation. Initially, an eigen-
value of 1 was used to consider the possible number
of factors explained by the data. The scree plot was
then examined to determine a range of factor solu-
tions that could represent the data based on the fac-
tors extracted around the bend in the elbow on the
scree plot. For example, if the bend in the elbow on
the scree plot occurred around 5 components (ie,
5 factors extracted), then a range of possible factor
solutions of 4, 5, 6, or 7 factors was considered.
Exploratory factor analysis was used to systemati-
cally test each possible factor solution, taking into
account the total variance explained, added variance
of each factor, number of cross-loading items, and
conceptual clarity of the items in each factor. The
research team came to a consensus on the number of
factors to extract based on these data. In the final
factor solution, items that cross-loaded (ie, loaded
on more than 1 factor) at 0.3 or greater were placed
in the most appropriate factor, based on the concep-
tual fit between the item and the other items in the
factors in which it loaded. Items that cross-loaded
on more than 2 factors were considered for removal,
Advances in Neonatal Care • Vol. 18, No. 3
Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
NeoEAT—Bottle-Feeding 235
as this indicates that the item does not clearly fit
with any particular factor.24
Internal Consistency Reliability
After cross-loading items were evaluated and final
assignments were made to each factor, internal con-
sistency reliability was calculated for each factor
using Cronbach α. Item-total correlations were then
calculated and items that failed to correlate with the
total factor score at greater than 0.3 were considered
for removal. The Cronbach α for the scale (ie, fac-
tor), if the item was deleted, was also considered
when evaluating an item for removal. After final
items were removed, the items in each factor were
evaluated to determine the predominant concepts
measured by the factor. The research team came to
consensus about the concepts measured and assigned
names to the factors accordingly. After factor names
were assigned, the factors were then referred to as
subscales. Finally, Cronbach α was used to calculate
the internal consistency reliability of the full scale.
Temporal Stability
The temporal stability (ie, test-retest reliability) of
the NeoEAT—Bottle-feeding was tested using a sub-
sample of participants who completed both the time
1 and time 2 surveys. Subscale scores and total scores
were calculated at time 1 and time 2. Bivariate cor-
relations (Pearson product-moment correlation r)
were calculated between the subscale scores at time 1
and time 2 and between the total NeoEAT—Bottle-
feeding scores at time 1 and time 2.
Construct Validity
Sum scores were calculated for the IGERQ-R and
the IGSQ. Bivariate correlations (Pearson product-
moment correlation r) were calculated between the
sum score of the IGERQ-R and the subscale and
total scores on the NeoEAT—Bottle-feeding. The
same process was used to calculate bivariate correla-
tions between the IGSQ and the subscale and total
scores on the NeoEAT—Bottle-feeding.
Known-Groups Validity
Data from a series of questions in the survey were
used to categorize the target infants into 3 groups:
(1) healthy, typically feeding infants, (2) infants with
risks for atypical feeding but not a feeding problem,
and (3) infants with a feeding problem. Healthy,
typically feeding infants were defined as not having
any of the following: history of preterm birth
(<37 weeks of gestation); genetic disorder; congeni-
tal heart disease; daily prescription medication use;
developmental delay; diagnosed or undiagnosed
feeding problem; feeding tube; structural abnormal-
ity of the face, mouth, or gastrointestinal tract; or
parent-reported difficulty with breast- or bottle-
feeding. Infants with a feeding problem were defined
236 Pados et al

as having a parent-reported feeding problem, a diag-

TABLE 1. Summary of Sex and Age
nosed feeding problem, and/or need for a feeding
tube. Only the subsample of infants who fit into Distribution of Infant Samplea
these 2 categories was used for the known-groups Sex
validation analysis. Data from infants who were at Male Female Total
risk for atypical feeding but did not have a feeding Corrected age
problem were not included in this analysis.
0-2 mo 54 50 104
Independent-samples t test for equality of means
was used to compare NeoEAT—Bottle-feeding sub- 2-4 mo 59 66 125
scale and total scores between healthy, typically 4-6 mo 63 62 125
feeding infants and infants with a feeding problem. 6-7 mo 20 22 42
Corrected age unknown 18 27 45
Procedures
Total 214 227 441
Institutional review board approval was obtained
a
Corrected age was calculated as the infant’s age on the date of
prior to commencement of the study. Parents who survey completion, adjusting for preterm birth by subtracting
met eligibility criteria were invited to participate in the number of weeks the infant was born preterm from current
a Web-based survey on infant feeding, gastroesopha- age if the infant was born prior to 37 weeks postmenstrual age.
Some parents declined to provide the infant’s date of birth and/
geal reflux symptoms, gastrointestinal symptoms, or did not answer or did not know how many weeks preterm the
and demographic characteristics. Parents were infant was born; in these cases, the corrected age was unknown.
offered a $10 gift card at the completion of the ini-
tial survey (time 1). At the end of the initial survey,
parents were asked whether they would be willing to TABLE 2. Sample Demographics
participate in a second survey 2 weeks later (time 2). Variable Frequency, n (%)
The time 2 survey was much shorter and included
Relationship to infant (n = 433)
only the items from the NeoEAT—Bottle-feeding.
The time 1 and time 2 surveys were completed 2 to Mother or mother-figure 406 (92.1)
3 weeks apart. Parents were offered a $5 gift card at Father or father-figure 21 (4.8)
the completion of the time 2 survey. Other (eg, grandparent) 6 (1.4)
Race of parent (n = 441)
RESULTS White 315 (71.4)
Black 38 (8.6)
Sample Demographics
Asian 23 (5.2)
The sample of parents who completed the time 1
survey and met the eligibility criteria for inclusion in Hispanic 28 (6.3)
this study was 441. No cases had more than 10% Multiracial 28 (6.3)
missing data, so all cases were included in the analy- Other 9 (2.0)
sis. This sample resulted in 6 participants per item,
Parent highest education (n = 441)
which exceeded the minimum goal sample of 5 par-
ticipants per item (n = 370),25 and is considered High school degree or less 99 (22.4)
good to very good for factor analysis.32 The distribu- Technical school/community 45 (10.2)
tion of target infants by age and sex categories is college
presented in Table 1. Demographics and descriptive College/university/graduate 297 (67.3)
data for the respondents and their target infants are school
presented in Tables 2 and 3. Subsamples were used Household income (n = 438)
for temporal stability, construct validity, and known-
<$20,000 42 (9.5)
groups validity. These subsamples will be described
with the respective results. $20,000 to $39,999 83 (18.9)
$40,000 to $59,999 68 (15.5)
Item Analysis $60,000 to $79,999 69 (15.8)
From the initial pool of 74 items on the NeoEAT— $80,000 to $99,999 41 (9.4)
Bottle-feeding, 5 items were found to not correlate
>$100,000 135 (30.6)
with any other item at 0.3 or greater. These 5 items
were removed. There were also 7 items that were Family type (n = 441)
found to be correlated at 0.8 or greater with at least Two-parent family 394 (89.3)
1 other item. Four of these items were removed. In Single-parent family 36 (8.2)
total, 9 items were removed during the item analysis
Other 11 (2.5)
phase.

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 NeoEAT—Bottle-Feeding 237

items in factor 1 had item-total correlation of greater

TABLE 3. Parent-Reported Diagnoses of
than 0.3 except for the item “My baby has hard
Target Infantsa stools/poop,” which the research team had decided
Diagnosis Frequency (%) to retain. The Cronbach α for the subscale would
Diagnosed feeding problem 35 (7.9%) not increase if this item was deleted, so again, we
(n = 440) chose to retain the item. Infant Regulation (factor 2,
Current feeding tube (n = 440) 9 (2.0%) 13 items) had an internal consistency reliability of
0.93. All items had item-total correlations of greater
Preterm birth (n = 441) 79 (17.9%)
than 0.3. Energy and Physiologic Stability (factor 3,
History of necrotizing enterocolitis 4 (0.9%) 12 items) had an internal consistency reliability of
(n = 399) 0.81. Two items on factor 3 had item-total correla-
Chronic lung disease (n = 399) 7 (1.6%) tions of 0.28 each. These items were “My baby eats
more than 12 times per day (24 hours)” and “My
Structural abnormality 15 (3.4%)
baby needs help latching on to the bottle.” In both
Congenital heart disease 16 (3.6%) cases, the Cronbach α for the subscale would not
Developmental delay 4 (0.9%) increase substantially if the item were deleted, so
Genetic disorder 4 (0.9%) both items were retained. Sensory Responsiveness
(factor 4, 7 items) had an internal consistency reli-
Epilepsy 2 (0.5%)
ability of 0.70. All item-total correlations were
Other medical condition (n = 395) 12 (2.7%) greater than 0.3. Compelling Symptoms of Problem-
aMultiple conditions could be selected. n = 433 unless atic Feeding (factor 5, 5 items) had an initial internal
otherwise noted. consistency reliability of 0.55, which was below the
threshold of acceptable internal consistency reliabil-
ity of 0.7.34 One item (My baby eats fewer than
6 times per day) had an item-total correlation of
Factor Analysis
0.18. The Cronbach α for factor 5 would increase to
Exploratory factor analysis was conducted on the
0.71 (ie, above the minimum threshold) if this item
remaining 65 items of the NeoEAT—Bottle-feeding.
was deleted, so the decision was made to remove this
The sample was found to be adequate for factoring
item. The internal consistency reliability of the final
on the basis of a Kaiser-Meyer-Olkin statistic of
64-item NeoEAT—Bottle-feeding scale was excel-
0.905 and a statistically significant Bartlett’s test of
lent (Cronbach α = 0.92). Factor loadings of all
sphericity (χ2 = 14460.15, P < .001).33 Using an
remaining items ranged from 0.31 to 0.87, suggest-
eigenvalue of 1, 14 factors were initially extracted.
ing that each of the retained items contributed sig-
Upon examination of the scree plot, it was deter-
nificantly to its respective subscale.
mined that a factor solution between 4 and 7 factors
The final factor loadings for the 64-item
would be more parsimonious but still appropriately
NeoEAT—Bottle-feeding with assigned factor names
represent the data. The research team came to the
are presented in Table 4. Hereafter, the factors are
consensus, based on the methods discussed previ-
referred to as subscales. The subscale named Gastro-
ously, that the 5-factor solution best represented the
intestinal Tract Function contains items about symp-
data. The 5-factor solution explained 43.23% of the
toms of dysfunction along the gastrointestinal tract,
total variance.
from the oropharynx to the lower gastrointestinal
Using the 5-factor solution, cross-loading items
tract. In this subscale, there are items about symp-
were evaluated and 6 items were moved to a differ-
toms of aspiration, excessive gag reflex, gastro-
ent factor. One item failed to load at 0.3 or greater
esophageal reflux, and gastrointestinal dysfunction
on any factor (My baby has hard stools/poop), but
(eg, My baby gets a bloated [big or hard] tummy
the research team decided that it was an important
after eating). The subscale Infant Regulation con-
item and chose to keep it for further evaluation in
tains positively worded items that are indicative of
the next steps of analysis. No items were deleted in
an infant’s ability to self-regulate (eg, My baby is
this phase; therefore, 65 items remained. The 5 fac-
calm and relaxed when eating). The subscale Energy
tors were named on the basis of the predominant
& Physiologic Stability contains items about symp-
concepts covered within each factor, with particular
toms of cardiorespiratory dysfunction; difficulty
focus on the information gathered by the most
coordinating sucking, swallowing, and breathing;
highly loading items.
and ability to engage in and sustain the work of feed-
ing to obtain sufficient nutrition. The subscale Sen-
Reliability sory Responsiveness contains items pertaining to the
Internal Consistency Reliability infant’s particularities about feeding that may be
Gastrointestinal Tract Function (factor 1, 28 items) symptoms related to the sensory experience of feed-
had an internal consistency reliability of 0.92. All ing. For example, “My baby will only eat from a

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238 Pados et al

TABLE 4. Factor Loadings for Principal Component Analysis With Varimax Rotation of the
NeoEAT—Bottle-Feedinga
Factor
Subscale NeoEAT—Bottle-Feeding Item (Each Item Begins With “My baby…”) Loadings
Gastrointestinal Tract spits up in between feedings. 0.69
Function 28 items seems uncomfortable after feeding. 0.68
Cronbach α = 0.92 throws up in between feedings. 0.65
spits up during feeding. 0.62
throws up during feeding. 0.61
is uncomfortable if laid flat after eating. 0.59
becomes upset during feeding (whines, cries, gets fussy). 0.59
becomes stiff/rigid during or after eating. 0.58
chokes or coughs during eating. 0.56
sounds gurgly or like they need to cough or clear their throat during or 0.56
after eating.
is very gassy. 0.55
coughs or chokes on saliva/spit when not eating. 0.54
coughs in between feedings. 0.52
gets a bloated (big or hard) tummy after eating. 0.49
needs to be burped more than once before the end of feeding. 0.49
gags in between feedings when there is nothing in his/her mouth. 0.48
turns red in face, may cry with stooling/pooping. 0.47
arches back during or after eating. 0.46
tilts head back during or after eating. 0.44
drools milk out of the side of the mouth when feeding. 0.44
gets watery eyes when eating. 0.41
gets a stuffy nose when eating. 0.41
gets red color around eyes or face when eating. 0.40
sweats/gets clammy when eating. 0.40
gets the hiccups. 0.40
gags on the bottle nipple. 0.36
gags on a pacifier or toys put in mouth. 0.33
has hard stools/poop. 0.25
Infant Regulation 13 items eats enough to have at least 5 wet diapers per day (24 hours). 0.87
Cronbach α = 0.93 enjoys eating. 0.86
is satisfied after eating. 0.84
sucks strong enough to get milk from the bottle. 0.83
lets me know when he/she is hungry or thirsty. 0.80
is calm and relaxed when eating. 0.78
opens mouth to accept the bottle. 0.78
is easy to console when upset (for example, stops crying when held or 0.76
offered a pacifier).
roots when hungry (for example, sucks on fist, smacks lips, looks for 0.73
breast/bottle)
lets me know when he/she is done eating. 0.67
likes to put fingers and/or toys in mouth. 0.59
stools/poops at least once per day (24 hours). 0.57
sleeps well lying flat on his/her back. 0.42
Energy & Physiologic gets exhausted during eating and is not able to finish. 0.71
Stability 12 items breathes faster or harder when eating. 0.63
Cronbach α = 0.81 is exhausted after eating. 0.62
needs to rest during eating to catch his/her breath. 0.62
can only suck a few times before needing to take a break. 0.59
needs to be encouraged to keep eating (such as, by touching or talking). 0.57
holds breath when eating. 0.52
takes more than 30 minutes to eat (including rest/burping periods). 0.48
needs help latching on to the bottle. 0.31
wants to eat again within an hour after feeding. 0.38
eats more than 12 times per day (24 hours). 0.35
gulps when eating (swallows loudly). 0.31
(continues)

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 NeoEAT—Bottle-Feeding 239

TABLE 4. Factor Loadings for Principal Component Analysis With Varimax Rotation of the
NeoEAT—Bottle-Feedinga (Continued )
Factor
Subscale NeoEAT—Bottle-Feeding Item (Each Item Begins With “My baby…”) Loadings
Sensory Responsiveness will only eat if food (milk/formula/baby food) is a certain temperature. 0.67
7 items Cronbach will only take the bottle from specific people (such as, by mom). 0.67
α = 0.7 will only eat from a specific kind of bottle/nipple. 0.59
will only eat if fed in a certain way (for example, in a certain chair, or 0.57
held upright).
needs a calm environment during feeding. 0.51
eats best when very sleepy or asleep. 0.31
refuses the bottle before having eaten enough (such as, turns head, 0.42
pushes bottle away, pushes nipple out of mouth with tongue).
Compelling Symptoms needs tube feedings. 0.55
of Problematic Feeding gets pale or blue color around lips when eating. 0.47
4 items Cronbach has blood or mucous in stool/poop. 0.44
α = 0.71 has milk come out of nose when eating. 0.38
aThe Cronbach α for the full scale (64 items) was 0.92.

specific kind of bottle/nipple” and “My baby eats .001). The results of the independent-samples t tests
best when very sleepy or asleep.” Finally, the sub- comparing the NeoEAT—Bottle-feeding subscale
scale named Compelling Symptoms of Problematic scores between healthy, typically feeding infants and
Feeding contains 4 items that would be compelling infants with a feeding problem are presented in
indicators of a feeding problem (eg, My baby has Figure 2. The subscale Infant Regulation was not
blood or mucous in stool/poop). found to be significantly different between healthy,
typically feeding infants and infants with a feeding
Temporal Stability (Test-Retest Reliability) problem (Figure 2). Upon closer inspection of these
There were 72 parents who completed both time 1 data, it was found that the subscale scores for Infant
and time 2 surveys, which represented 16.3% of the Regulation were significantly different (P < .05)
total sample. The time 1 and time 2 NeoEAT— between the 2 groups for all ages except the 6- to
Bottle-feeding total scores were strongly correlated 7-month age category (Table 6). There were only 25
(r = 0.90, P < .001). All of the time 1 and time 2 infants 6 to 7 months of age who were included in the
subscale scores were also strongly correlated
(r = 0.70-0.86, P < .001).
TABLE 5. Correlation Between the
Validity NeoEAT—Bottle-Feeding, IGERQ-R, and
IGSQ (n = 380)a
Construct Validity
There were 380 parents who completed the IGERQ-R IGSQ Sum
NeoEAT-Bottle-Feeding Sum Score Score
NeoEAT—Bottle-feeding, IGERQ-R, and IGSQ.
The NeoEAT—Bottle-feeding total score was Total score 0.74b 0.64b
strongly correlated with the sum scores of the Subscale scores
IGERQ-R (r = 0.74, P < .001) and moderately cor- Gastrointestinal Tract 0.73b 0.65b
related with the sum score of the IGSQ (r = 0.64, P Function
< .001). The full results of the correlations between Infant Regulation 0.50b 0.43b
the NeoEAT—Bottle-feeding subscales and the
Energy & Physiologic 0.57 b
0.48b
IGERQ-R and IGSQ are presented in Table 5.
Stability
Known-Groups Validity Sensory Responsiveness 0.33b 0.26b
The subsample that was used for known-groups vali- Compelling Symptoms of 0.35b 0.24b
dation included 193 healthy, typically feeding infants, Problematic Feeding
and 94 infants with a feeding problem. The Abbreviations: IGERQ-R, Infant Gastroesophageal Reflux
NeoEAT—Bottle-feeding total score was signifi- Questionnaire—Revised; IGSQ, Infant Gastrointestinal
Symptoms Questionnaire; NeoEAT, Neonatal Eating Assessment
cantly lower (ie, fewer symptoms of problematic Tool.
feeding) in healthy, typically feeding infants (M = aPearson correlation’s product-moment correlations are

66.6, SD = 25.6) than in infants with a feeding prob- presented as an r value.

bThe correlation was statistically significant (2-tailed) at P < .001.
lem (M = 103.1, SD = 37.9; t137.42= −8.47, P <

Advances in Neonatal Care • Vol. 18, No. 3

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240 Pados et al

FIGURE 2

Comparison of NeoEAT—Bottle-feeding scores of healthy, typically feeding infants, and

infants with feeding problems. aP < .01. NeoEAT indicates Neonatal Eating Assessment Tool.

known-groups analysis (19 healthy, typically feeding from the NeoEAT—Bottle-feeding, it can be used
infants and 6 infants with a feeding problem). with all infants younger than 7 months, including
otherwise healthy infants who are having difficulty
DISCUSSION with feeding.

The results of this study support the validity and reli-
ability of the NeoEAT—Bottle-feeding as a parent-
report assessment of bottle-feeding in infants
younger than 7 months. The lack of statistical sig-
nificance in the known-groups validation for the
Infant Regulation subscale was likely due to the
small sample size in the 6- to 7-month age group.
Further testing with a larger sample should be done
to ensure known-groups validation for the Infant
Regulation subscale. Although infants who have
received care in a NICU are most likely to benefit
Implications for Practice
The NeoEAT—Bottle-feeding now provides clini-
cians with an objective assessment of the bottle-
feeding infant that does not require specialized train-
ing on the part of the clinician, is inexpensive to
administer, and utilizes the primary caregiver (ie, the
parent) as the expert on the infant’s typical feeding.
The NeoEAT—Bottle-feeding is intended to be com-
pleted by a parent or a caregiver and shared with a
clinician who can use it in combination with their
clinical assessment to guide decision making. The

TABLE 6. “Infant Regulation” Subscale Results by Known Groupsa

Healthy, Typically Feeding Problem t Test for Equality of 95% CI
Age Category Feeding (M ± SD) (M ± SD) Means (Lower, Upper)
0-2 mo (n = 70) 14.93 ± 5.86 18.81 ± 7.61 t68 = −2.39; P = .02b −7.11 to −0.63
2-4 mo (n = 79) 11.78 ± 5.1 18.94 ± 8.5 t48.36 = −4.31; P < .001c −10.49 to −3.82
4-6 mo (n = 79) 11.81 ± 6.59 20.77 ± 11.82 t26.2 = −3.36; P = .002 c −14.44 to −3.49
6-7 mo (n = 25) 12.16 ± 7.85 17.67 ± 12.34 t6.33 = −1.03; P = .34 c
−18.44 to −7.42
Abbreviation: CI, confidence interval.
aLevene’s test of equality of means was used to determine whether equal variances should be assumed when interpreting the t test for

equality of means.
bEqual variances assumed.

cEqual variances not assumed.

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 NeoEAT—Bottle-Feeding 241

Summary of Recommendations for Practice and Research

What we know:
What needs to be studied:
What we can do today:
The NeoEAT—Bottle-feeding:
• Is a valid and reliable parent-report assessment of feeding in the bottle-fed infant.
• Has 5 subscales that measure Gastrointestinal Tract Function, Infant Regulation,
Energy & Physiologic Stability, Sensory Responsiveness, and Compelling Symp-
toms of Problematic Feeding.
• Differentiated infants with a feeding problem from healthy, typically feeding
infants.
• Norm-referencing needs to be done to establish a scoring system for the
NeoEAT—Bottle-feeding.
• A shorter, screening version of the tool needs to be created to identify infants
who would benefit from the full version of the NeoEAT—Bottle-feeding.
• The NeoEAT—Bottle-feeding can be used to study the development of feeding in
infants at risk for feeding problems to better understand factors contributing to
long-term feeding problems.
• Primary care providers and neonatal follow-up clinic providers can use the
NeoEAT—Bottle-feeding as part of the clinical assessment to identify infants in
need of referral to a specialist.
• Feeding specialists can use the NeoEAT—Bottle-feeding as part of the initial
assessment to identify potential underlying factors contributing to problematic
feeding to tailor interventions.
• Researchers can use the NeoEAT—Bottle-feeding as a valid and reliable measure
to study bottle-feeding in infants up to 7 months of age.

NeoEAT—Bottle-feeding will enhance clinical care
of infants by facilitating earlier referral to feeding
specialty care and promote improved long-term out-
comes related to feeding and nutrition.
In the inpatient setting, we anticipate that the
NeoEAT—Bottle-feeding may be used in the NICU
and in other inpatient settings to improve communi-
cation about feeding between parents and clinicians
and to guide feeding education. It may also be used
to identify infants in need of inpatient specialty feed-
ing services or referral to outpatient services at dis-
charge. In the outpatient setting, we anticipate that
the NeoEAT—Bottle-feeding will be useful to pri-
mary care clinicians and neonatal follow-up clinics to
identify infants with problematic feeding who are in
need of referral to a specialist. Feeding specialists
may use the NeoEAT—Bottle-feeding as part of the
initial assessment, in combination with their clinical
assessment, to identify underlying mechanisms for
the feeding problem and target interventions appro-
priately. The tool may also be used to evaluate effec-
tiveness of interventions and guide tailoring of treat-
ment plans.
Implications for Future Research
The NeoEAT—Bottle-feeding provides researchers
with a valid and reliable measure of feeding in the
bottle-fed infant that is inexpensive to administer
and can be completed in hard copy form or by online
survey. This will facilitate a variety of research stud-
ies, including longitudinal research on feeding devel-
opment in infants at risk for problematic feeding. In
combination with the other versions of the NeoEAT,23
the Pediatric Eating Assessment Tool (PediEAT)35-37
and the Child Oral and Motor Proficiency Scale
(ChOMPS),38-40 this set of valid and reliable tools
allows for the seamless measurement of feeding in
infants from birth to 7 years of age.
Limitations
The demographic characteristics of the sample were
a limitation of this study. Despite our varied recruit-
ment strategies, the sample in this study was pre-
dominantly white, highly educated, and had a
household income of more than $60,000 per year.
Further testing of the NeoEAT—Bottle-feeding with
a more diverse sample would strengthen the evi-
dence of its validity across a wider population.
Future Directions
The next step in the development of the NeoEAT—
Bottle-feeding will be to conduct a norm-referencing
study with a large sample of healthy, typically devel-
oping and typically eating infants to establish the
range of typical behavior and create a scoring system
based on the age of the infant. In addition, item
response theory will be used to identify approxi-
mately 10 of the most important questions that can
be used as a screening version of the NeoEAT—
Bottle-feeding. The full version of the tool is 64 items,
which is a lengthy assessment. The NeoEAT-Bottle-
feeding screener will be best used as a quick evalua-
tion that can identify infants in need of more thor-
ough evaluation with the full version. Additional
testing of the NeoEAT—Bottle-feeding may include
evaluation of the tool’s validity compared with a clini-
cian assessment, the sensitivity of the tool for detect-
ing change in clinical status, and testing of the tool
with infants up to 12 months of age who are still
bottle-feeding.

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242 Pados et al
Acknowledgment
This work was supported by the Small Grants Pro-
gram of the National Association of Neonatal
Nurses (NANN) (awarded to Britt Frisk Pados).
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