The Neonatal Eating Assessment Tool:

Development and Content Validation

Britt F. Pados, PhD, RN, NNP-BC
Hayley H. Estrem, PhD, RN
Suzanne M. Thoyre, PhD, RN, FAAN
Jinhee Park, PhD, RN
Cara McComish, PhD, CCC-SLP

Disclosure
The authors have no relevant
financial interest or affiliations
with any ­commercial interests
related to the subjects discussed
within this article.
No commercial support or
­sponsorship was provided for this
educational activity.
Abstract
Purpose: To develop and content validate the Neonatal Eating Assessment Tool (NeoEAT), a parent-
report measure of infant feeding.
Design: The NeoEAT was developed in three phases. Phase 1: Items were generated from a literature
review, available assessment tools, and parents’ descriptions of problematic feeding in infants.
Phase 2: Professionals rated items for relevance and clarity. Content validity indices were calculated.
Phase 3: Parent understanding was explored through cognitive interviews.
Sample: Phase 1: Descriptions of infant feeding were obtained from 12 parents of children with
diagnosed feeding problems and 29 parents of infants younger than seven months. Phase 2: Nine
professionals rated items. Phase 3: Sixteen parents of infants younger than seven months completed the
cognitive interview.
Main Outcome Variable: Content validity of the NeoEAT.
Results: Three versions were developed: NeoEAT Breastfeeding (72 items), NeoEAT Bottle Feeding
(74 items), and NeoEAT Breastfeeding and Bottle Feeding (89 items).

Keywords: feeding; breastfeeding; bottle feeding; assessment

F eeding is one of the most complex

skills required of newborns, and it is
common for young infants to experience dif-
ficulty with feeding.1–4 Difficulties include
behaviors such as feeding refusal, irritabil-
ity, difficulty latching to the breast or bottle,
lengthy feedings, coughing, choking, and
gagging. 5,6 Prevalence studies of this phe-
nomena early in infancy are lacking, but
54 percent of breastfeeding mothers report
feeding concerns at one week of life, 5 and
9–36 percent of parents report feeding dif-
ficulty in their six- to eight-week-old infants.7
Feeding problems can occur in infants who
are apparently otherwise healthy, 2 but infants
with medical complexity, particularly those
born premature4,8 and with congenital heart
Accepted for publication
June 2017.
disease,9 are at most risk. Advancements in
health care, allowing for the increasing sur-
vival of critically ill newborns, has resulted in
increasing numbers of infants experiencing
feeding difficulty.10
Early infancy is a critical time for brain
growth,11 and proper nutrition is essential
for the optimal development of the brain.
Suboptimal nutrition resulting from feeding
difficulty12 is highly problematic, especially
for infants born premature, with congenital
heart disease, or other medical complexity
that puts them at heightened risk for neu-
rodevelopmental delays. Undernourished
infants and toddlers have been found to
be less sociable, less attentive, and more
fearful and to have more negative emotional

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 expression than their well-nourished peers.13 In infants with
chronic disease, such as congenital heart disease, suboptimal
nutrition contributes to morbidity, such as risk for infection
and prolonged hospitalization,14 as well as mortality.15 In
addition to direct consequences on the child’s health, feeding
difficulties during infancy can impact the developing parent–
child relationship16 as well as the child’s behavioral responses
to food and mealtime.17 If left untreated, the consequences
of feeding difficulty in infancy may have a long-lasting impact
on the child’s health and well-being.
Early assessment and implementation of therapies to
support feeding and nutrition are essential for optimization
of nutritional intake and oral feeding skill development and
for prevention of development of long-term feeding prob-
lems. In retrospective studies of young children with feeding
disorders, parents report that symptoms of feeding problems
are typically evident within three months after birth,18 but
the age at which children enter specialized feeding treat-
ment is 2.4 years.2 There is a critical period of time between
six and nine months when the typically developing infant is
exposed to many different tastes and textures of food and
develops the foundation of oral motor skills for eating solid
foods.19–21 The young infant who experiences difficulty with
early oral feeding, whether bottle feeding or breastfeeding,
and requires tube feeding or is delayed in his skill develop-
ment may miss this opportunity for exposure to different
tastes and textures. This may contribute to the development
of maladaptive feeding behaviors20 and a feeding problem
that is much more challenging to treat.
The problem with early identification is that differen-
tiation between typical feeding behaviors and problematic
feeding behaviors in infants younger than seven months is
difficult. Feeding problems are heterogeneous in nature and
may present in subtle and indistinct ways, likely relating more
to underlying contributing factors (e.g., presence of gastro-
esophageal reflux) than to any other diagnosis the child may
have (e.g., congenital heart disease).22
Parents of children who were later diagnosed with a
feeding problem have retrospectively reported that their early
concerns about feeding were dismissed by their providers.23
Often, providers take a “wait-and-see” approach while mon-
itoring growth; this time spent waiting contributes to the
delay in treatment and often misses the infant who struggles
but is able to maintain growth in the short term.
An assessment tool is needed both to guide determination
of whether an infant’s feeding difficulty necessitates refer-
ral to a specialist and to evaluate the effectiveness of feeding
interventions both clinically and through research. A tool
is needed that can be used for infants from birth to seven
months of age that is not specific to feeding method (i.e., can
be used with both bottle- and breastfeeding infants) and can
be used with both healthy, full-term infants as well as infants
with diagnoses that place them at risk for feeding difficulty.
To be useful in both clinical practice and research, an
assessment tool needs to be valid and reliable. Content
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validity refers to whether the tool measures what it is intended
to measure. 24 For example, a tool assessing infant feeding
difficulty should measure the infant’s observable behaviors
during feeding and not the impact of those behaviors on
the parent. Although the impact on the parent is important,
mixing these constructs within the same tool makes it dif-
ficult to interpret the results—is the result an indicator of the
infant’s difficulty, or an indicator of the parent’s difficulty?
These are related constructs, but they should be measured
separately to guide determination of whether intervention
should be with the infant or with the parent, or both.
Reliability refers to whether the questions within the tool
accurately and consistently measure the construct of inter-
est.24 A reliable tool should provide (1) an accurate assessment
of the infant’s feeding (e.g., a poor score indicates truly poor
feeding, whereas a good score indicates truly good feeding),
(2) a score that is consistent between reporters (e.g., scores
are similar on assessments by a mom and a dad with the same
level of involvement with feeding the same baby), and (3) a
score that is reasonably consistent over time when provided
by the same reporter (e.g., a score on an assessment com-
pleted by Mom in the morning is similar to the score by Mom
later in the day). When assessment tools are used that are not
known to be valid and reliable, clinicians cannot be sure that
the tool is measuring what they think it is measuring, nor can
they be sure that it provides a true indicator of what is being
measured. For infant feeding, this may lead to an infant in
need of support not getting appropriate help or may lead to
an infant with typical feeding being referred unnecessarily for
specialized assessment and treatment, resulting in burden for
the family and the health care system.
Assessment tools also differ in terms of the intended
respondents. Generally, assessments can be completed by
either clinicians or by parents, and sometimes both. For
infants who are primarily fed by their parents, the parents
are most knowledgeable about their child’s feeding behav-
iors and are able to report on typical behavior of their child,
which may be different from a single observation of a feeding
made by a professional in an environment that is unfamiliar
to the child.25 Parent-report measures have the advantage of
being cost-effective and ideal for repeated measurements over
time. Although parent-report measures have some potential
for reporter bias, 26 this can be minimized by careful atten-
tion to development and psychometric testing.24
A search of the literature on existing assessment tools for
infant feeding, breastfeeding, and nutrition identified 21 tools
that were intended to be used with infants younger than six
months.27 Of these, only six were intended to be used with
both bottle- and breastfeeding infants. Three of these were
intended only for use with infants with specific diagnoses (the
Infant Malnutrition and Feeding Checklist for Congenital
Heart Disease, 28 the Feeding Checklist for Nonorganic
Failure to Thrive, 29 and the Infant Gastroesophageal Reflux
Questionnaire30). Of the remaining three tools, two (the
Neonatal Oral-Motor Assessment Scale31 and Nursing Child
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 Assessment Feeding Scale32) can only be used by trained
clinical observers, which is expensive and time-intensive.
The only remaining tool was the Nutrition and Feeding Risk
Identification Tool,33 which was an interview and assessment
guide for early intervention providers that does not have any
psychometric testing. Currently, there are no valid and reli-
able parent-report tools to assess feeding in infants younger
than seven months that can be used for both bottle- and
breastfeeding infants.
The purpose of this article is to present the series of three
studies that were conducted to develop and content validate
the Neonatal Eating Assessment Tool (NeoEAT), a parent-
report assessment of feeding difficulty in infants younger
than seven months.
METHODS
The NeoEAT was developed using methods in accordance
with the guidelines for scale development by DeVellis. 24
The development and content validation occurred in
three phases: phase 1—item generation, phase 2—content val-
idation by professionals, and phase 3—content validation by
parents. The methods are presented by phase of development.
Phase 1: Item Generation
Items for the NeoEAT were generated using a synthesis
research approach34 by integrating multiple types of data for
analysis, including (1) a review of the literature, (2) a review
of items on existing tools, and (3) parents’ descriptions of
problematic feeding as reported from two separate studies.
Parent descriptions were obtained through a secondary
analysis of interviews with parents of young children with a
diagnosed feeding problem and an online survey of parents
of infants younger than seven months. Specific information
will be provided about each source, followed by methods of
analysis used for the synthesis of this data.
Review of the Literature. A review of the literature
was conducted for articles related to feeding difficulty in
infants younger than six months. The databases Cumulative
Index of Nursing and Allied Health Literature (CINAHL),
PubMed, and Web of Science were searched for the following
terms: Failure to thrive [“Feed* disorder” or “Feed* diffi-
culty” or “Feed* problem”], Infantile anorexia, Oral avers*,
Dysphagia, and Enteral feeding. The search was limited to
English, full text, humans, 0–23 months of age, and publica-
tion years 2000–2015. Articles were included in the analysis
if feeding problems was the primary subject and it included a
discussion of feeding difficulty in infants younger than seven
months. Articles were excluded if they were about anorexia
nervosa or bulimia nervosa.
Articles that met inclusion and exclusion criteria were
then uploaded to Atlas.ti (Scientific Software Development
GmbH, Berlin), a software program used to code and
analyze qualitative data. Articles were coded for attributes
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of problematic feeding in infants. Attributes were defined
as words or phrases that described the characteristics of
a feeding problem (i.e., What does it look like? How is it
described by the author? How is a feeding problem diag-
nosed? What makes feeding difficulty problematic or dif-
ferentiate it from normal feeding?). Articles were coded by
research assistants who were trained by the first or second
author. Twenty percent of the articles were double-coded by
one of the authors to ensure reliability.
Review of Items on Existing Tools. Existing tools were
identified through a separate literature review, which has
been published elsewhere.27 From this review, 21 assessment
tools were identified. Items from these assessment tools were
uploaded into Atlas.ti, and attributes of problematic feeding
targeted by each item were coded.
Parent Descriptions of Problematic Feeding in Infants.
Results of two separate studies conducted by this investiga-
tive team were included as sources of parent descriptions for
item generation. Because the NeoEAT is intended to be a
parent-report instrument, parent descriptions were impor-
tant as this ensured the NeoEAT covered problems identi-
fied by parents and was written in language used by parents.
First, a secondary analysis was conducted with the interview
data from 12 parents of young children with a diagnosed
feeding problem. In the original study, parents were recruited
from a feeding and dysphagia specialty clinic at a southeast-
ern regional medical center. Parents were eligible if they
were older than 18 years, English-speaking, and had a child
between six months and five years of age with a diagnosed
feeding problem. Both mother and father figures were invited
to participate in the semi-structured interviews, which were
framed within the Family Management Style Framework.35
The primary aim of the original interviews was to elicit
parent perspectives on the family management of problem-
atic feeding in their child. Interviews were transcribed in
the primary analysis. A secondary analysis of these transcrip-
tions was conducted using Atlas.ti for attributes of problem-
atic feeding identified by parents. Attributes were defined
as described previously. Because these interviews were with
parents of older children, this qualitative secondary analysis
sought specifically to identify parents’ retrospective descrip-
tions of their child’s eating when he or she was an infant.
The second source of parent descriptions was an online
survey of parents of infants younger than seven months.
Parents were recruited through online support groups and
social media sites to participate in a survey that included a
combination of selection and open text-entry questions about
experiences feeding their infants. For example, parents were
asked to describe what feeding their baby was like and to
respond to questions such as “How do you think your baby
feels when he/she eats?” If a parent indicated their child
had a feeding problem, parents were asked to describe their
feeding concerns and what the child did before, during, or
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 after feeding that was concerning. Qualitative data from the
open-text questions was coded using Atlas.ti for attributes of
problematic feeding.
Item Generation Synthesis. After initial coding of the
attributes of problematic feeding from these four sources of
data, attributes were evaluated for redundancy and dupli-
cates were removed. The attribute codes and linked quota-
tions created from each source were then combined into a
new Atlas.ti project. Directed content analysis36 was used to
identify common themes of problematic feeding in infants
younger than seven months. The research team used the
common themes to organize the attributes. Items for the
NeoEAT were developed that related to each of the attributes.
Each item began with the preface “My baby . . . ” and asked
about a behavior or feeding-related problem that could be
observed or measured by a parent with no specialized feeding
expertise (i.e., common parenting knowledge). Response
options given for each item were “Never,” “Almost Never,”
“Sometimes,” “Often,” “Almost Always,” and “Always.”
The research team used an iterative process to evaluate the
attribute-derived items and then return to the linked quota-
tions from the data to consider whether the items generated
within each common theme comprehensively assessed the
range of problematic behaviors possible in infants younger
than seven months.
At the completion of phase 1, the NeoEAT was tested
for readability to ensure that it met the health literacy stan-
dards of being written at or below a sixth-grade reading
level.37 To establish readability grade levels, a free online
program (http://www.readability-score.com) was used to
calculate the following formulas: Flesch-Kincaid, Gunning
Fog, Coleman-Liau, SMOG, Automated Readability Index,
Spache Score, and Dale-Chall Score. The average of all of
these scores was used to determine the readability grade level.
Phase 2: Content Validation by Professionals
The initial set of items generated from phase 1 were then
presented to a multidisciplinary panel of professionals in infant
feeding to be evaluated for clarity and relevance. Professionals
were defined for this purpose as a clinician or researcher
with expertise in infant feeding. Because the NeoEAT is
intended to be used for evaluation of both breastfeeding and
bottle feeding, efforts were made to ensure adequate sam-
pling of professionals who provide support to infants who
are both breastfeeding and bottle feeding. Professionals were
recruited through convenience and snowball sampling and
were invited to participate in an anonymous online survey.
Professionals were encouraged to be forthcoming with opin-
ions, good or bad, to make the NeoEAT clinically relevant
and useful. The survey was done anonymously to encour-
age professionals to share their honest opinions. They were
presented with items developed for the NeoEAT and asked
to rate the items on a 4-point ordinal scale for clarity and
relevance, with “1” indicating low relevance/clarity and “4”
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indicating high relevance/clarity. Professionals were also
asked to provide suggestions for rewording and additional
items that were missed.
Content validity indices (CVI) were calculated at the item
level and scale level for both clarity and relevance.38 Item-level
CVI was calculated as the proportion of professionals who
rated the item as moderately or highly (rated 3 or 4 on the
4-point scale) clear (I-CVI-C) and moderately or highly rele-
vant (I-CVI-R). Scale-level CVI was calculated as the average
of the item-level CVI for clarity (S-CVI-C) and relevance
(S-CVI-R). Lynn’s guidelines38 were used to determine the
acceptable limits for CVI based on the number of profes-
sionals rating each item. Items that fell below the acceptable
limit were considered for revision or deletion by the research
team. Additional suggestions provided by the professionals
were considered in decisions made by team consensus for
revising, deleting, and/or adding items. The research team
critically evaluated items with a goal of reducing the NeoEAT
to a comprehensive, yet succinct, set of questions. Readability
testing was again conducted at the completion of phase 2.
Phase 3: Content Validation by Parents
The NeoEAT has been intentionally developed as a
parent-report assessment tool. Thus, it is critical that the
items be written in language understandable by parents and
that the items assess behaviors that are observable or measur-
able by parents with no expertise in feeding. After revisions
were made to the NeoEAT in phase 2, cognitive interviews
were conducted with parents of infants younger than seven
months. Cognitive interviewing is used to determine how
intended respondents understand items and how they make
decisions about selecting response options to items.39
Parents were invited to participate in an online survey
that consisted of demographic questions and the NeoEAT.
In addition to responding to the NeoEAT items, parents
had the option to flag items that they found confusing, dif-
ficult to answer, or otherwise problematic. After complet-
ing the survey, parents were contacted to set up a phone
interview. A combination of think aloud and verbal probing
was used during the interview to elicit information about
parent understanding of items, probe specific words/phrases
the research team had identified as potentially problematic
(e.g., parent understanding of the word latch), and gather
suggestions. The interviewer first reviewed items that the
parents had flagged as problematic and then went through all
other items, asking the parent to explain what they thought
the item meant or rephrase the item using their own words.
Interviews were audio recorded, transcribed, and checked
for accuracy by a second team member. A matrix table with
paraphrased responses was created with each item in a dif-
ferent column and each participant in a different row. The
research team conducted an item-by-item analysis and came
to a consensus about whether to revise, delete, add, or split
items. After revisions were made in phase 3, readability was
again tested.
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 RESULTS
Phase 1: Item Generation
Review of the Literature. The results of the review of the
literature are presented in a Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) diagram
(Figure 1). Qualitative coding was conducted on 56 articles.
Fifty-three attributes were identified from the literature.
Review of Items on Existing Tools. From the existing
21 tools, 81 attributes of problematic feeding were identified.
Parent Descriptions of Problematic Feeding in Infants.
The secondary analysis of interview data from parents
of young children included 12 interviews, representing
9 families.40 The child age at the time of the interview ranged

FIGURE 1  ■  PRISMA diagram of literature review results.

Records idenfied Records idenfied Records idenfied

in PubMed search in CINAHL search in Web of Science
(n  3,326) (n  136) search (n  59)
Idenficaon

Records remaining aer duplicates removed

(n  3,463)
Screening

Abstracts screened Records excluded for

(n  3,463) improper topic and abstracts
(n  3,330)

Full-text arcles assessed Full-text arcles excluded, with reasons

Eligibility

for eligibility (n  77)

(n  133) 15 Parcipants 6 mo
58 Feeding behavior not primary topic
2 Age of subjects not defined
2 Focus on maternal feeding
Full-text arcles included behaviors/skill, not infant eang
in phase 1: item behaviors
Included

generaon -
review of the literature
(n  56)

Abbreviations: PRISMA 5 Preferred Reporting Items for Systematic Reviews and Meta-Analyses; CINAHL 5 Cumulative Index of Nursing and
Allied Health Literature.

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 from 14 months to 4.5 years (mean 2.3 y). Although all chil-
dren were diagnosed with a feeding problem and were at risk
for feeding tube placement, at the time of the survey, all chil-
dren were eating exclusively by mouth. Annual household
incomes ranged from $20,000 to $29,000 to .$100,000.
Parents identified their children as being White (n 5 5) and
multiracial (Black/White [n 5 1], Hispanic/White [n 5 2],
and Native American/White [n 5 1]).40 From this secondary
analysis, 45 attributes of problematic feeding in early infancy
were identified.
The online survey included 29 parents (28 mothers and
1 father) who were 25–40 years of age and ranged in educa-
tion from completion of high school to a graduate degree.
All parents were currently living in two-parent households.
Household income ranged from ,$30,000 to .$100,000
annually. Parents described themselves as White (n 5 24),
Black (n 5 1), Asian (n 5 1), and multiracial (White/Black/
Hispanic [n 5 1], Indian/American Indian or Alaskan Native
[n 5 1], and White/Hispanic [n 5 1]). Parents reported
their infants as being on average 3.1 months of age (range
0.4–6.6 mo) and being primarily born at full term with no
medical diagnoses (n 5 23). Six of the parents reported
having an infant with some degree of medical complexity,
including five born preterm (as early as 27 weeks’ gestation),
one having tetralogy of Fallot, and one having congenital
diaphragmatic hernia. At the time of the survey, 19 infants
were being breastfed, 5 were being fed breast milk in a bottle,
and 5 were exclusively fed formula by bottle. From the quali-
tative data of this online survey, 60 attributes of problematic
feeding were identified.
Item Generation Synthesis. A total of 239 attributes
were coded within the four sources of data. After duplicate
attributes were removed, there were 118 unique attributes of
problematic feeding in infants younger than seven months.
Directed content analysis resulted in organization of the
attributes into the following common themes: (1) growth/
nourishment, (2) readiness/arousal, (3) oral phase/suck and
latch, (4) pharyngeal phase/swallowing, (5) gastroesopha-
geal/gastrointestinal symptoms, (6) behavior during feeding,
(7) alterations made to feeding, (8) physiologic stress symp-
toms, (9) general stress cues/discomfort, (10) mother–infant
dyadic symptoms, (11) foundational motor skills for feeding,
(12) sensory symptoms, (13) flexibility with different feeding
TABLE 1  ■  Example of Item Generation Process
Original Data Attribute Coded
Literature: “gagging” Gagging and/or retching
Feeding tool data: “During feeds:
coughing, choking, or gagging.”
Interview data: “We have a gagger.”
Survey data: “She fights taking her bottles,
spits them out, sometimes gags.”
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methods, and (14) infant regulation (e.g., sleep). From the
118 attributes within these 14 common themes, 126 items
were generated for the initial version of the NeoEAT. In most
cases, an attribute resulted in the generation of a single item,
but in some cases, an attribute (e.g., gagging) resulted in the
generation of two unique items (e.g., “My baby gags on the
bottle or breast.” and “My baby gags on a pacifier or toys
he/she puts in mouth.”). An example of the item generation
process, including the original data element, coded attribute,
common theme, and resulting item, is provided in Table 1.
Readability testing at the completion of phase 1 revealed a
reading grade level of 5.4, which was acceptable.
Phase 2: Content Validation by Professionals
Items generated for the NeoEAT were reviewed by nine
professionals with expertise in pediatric feeding, including
four nurses (two of whom were lactation consultants), one
nurse practitioner, and four speech-language pathologists.
All reviewers had a current clinical inpatient practice, and
five also practiced in an outpatient setting. Three of the pro-
fessionals were involved in research, and five were involved
in training other professionals or students. Given that there
were more than six professionals, Lynn’s guidelines suggest
an acceptable CVI limit of .78.38 The scale level CVI was
acceptable for both clarity (S-CVI-C 5 .90) and relevance
(S-CVI-R 5 .93).41 Of the 126 items reviewed, 19 items
had an I-CVI ,.78. Twelve items had I-CVI-C ,.78, four
had I-CVI-R ,.78, and three fell below .78 for both clarity
and relevance. As a result of considering the CVI data and
qualitative data provided by professionals, the research team
evaluated all items and made decisions to retain 57 items as
written, revise 38 items, delete 31 items, and add 2 items. One
example of insightful professional feedback was to reword
items that included both bottle feeding and breastfeeding
with breastfeeding at the forefront (i.e., written first) to be
more breastfeeding-friendly. At the end of phase 2, there
were 97 items on the NeoEAT with an acceptable reading
grade level of 5.3.
Phase 3: Content Validation by Parents
There were 19 parents who completed the online survey
portion of phase 3. Of these, 16 parents participated in a
phone interview; the remaining 3 parents did not respond
to three attempts to schedule an interview. The parents who
Common Theme Items Generated
Pharyngeal phase/swallowing 1. My baby gags on the bottle or breast.
2. My baby gags on a pacifier or toys he
or she puts in mouth.
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 participated in the interviews were between 18 and 45 years TABLE 2  ■  Readability Results for NeoEAT Versions After Phase 3
of age, ranged in education from community college to NeoEAT
graduate school, were primarily in two-parent households Breastfeeding
(n 5 15), and had incomes ranging from ,$20,000 to NeoEAT NeoEAT and Bottle
.$100,000. Parents described themselves as White (n 5 Breastfeeding Bottle feeding feeding
12), Black (n 5 2), and multiracial (White/Black [n 5 1] Flesch-Kincaid 3.4 3.5 3.8
and White/Native Hawaiian or Pacific Islander [n 5 1]). The Gunning-Fog 5 4.9 5.4
mean age of the children at time of the interview was 3.6 Coleman-Liau 10.2 10.2 10.5
months (range 5 0.6–6.7 mo). Seven parents indicated that
SMOG 6.6 6.6 7
their infants had problematic feeding, six reported that their
infants were feeding well, and three parents had concerns Automated 3.6 3.4 3.9
Readability
about feeding but were not sure if their child’s feeding was Index
problematic. There were six infants with no medical diag- Spache Score 2.9 2.9 2.8
noses. Six of the infants had a tongue- or lip-tie, one had
Dale-Chall Score 3.7 3.6 3.7
seizures, five had a food allergy, six had gastroesophageal
reflux, and three were born premature. At the time of the Average 5.1 5.0 5.3
readability
study, one infant was exclusively breastfeeding, three were
exclusively bottle feeding, seven were both breastfeeding Abbreviation: NeoEAT 5 Neonatal Eating Assessment Tool.
and bottle feeding, and five were offered some combination
of breastfeeding and/or bottle feeding and baby food (e.g.,
baby cereal or pureed food). DISCUSSION
After reviewing the cognitive interview data, the research In this article, we have presented the rigorous measure-
team came to a consensus to retain 49 items as written, ment development approach that was taken to develop the
revise 28 items, delete 20 items, and add 12 items. Several NeoEAT as a valid parent-report tool for the assessment of
parents indicated that their infant was both breastfeeding breastfeeding and bottle feeding in infants younger than
and bottle feeding and that their responses to feeding seven months. The method used for item generation in
were different between these feeding methods. In these phase 1 of this research was an innovative method of synthe-
instances, it was difficult for parents to respond to a ques- sizing information from published literature, currently avail-
tion such as “My baby latches on to the breast or bottle.” able tools, qualitative interview data, and qualitative survey
For example, one parent described that their child was data to capture a broad range of attributes of problematic
always able to latch on to the bottle but was not able to latch feeding. These attributes of problematic feeding were then
to the breast. In response to this feedback, items that asked used to generate a comprehensive set of items addressing the
about both breastfeeding and bottle feeding were separated range of feeding behaviors seen in infants from birth to seven
into two questions. In addition, some questions were identi- months of age.
fied as only being relevant to certain feeding methods. For The NeoEAT is a comprehensive parent-report assessment
example, the question “My baby will only eat from a specific tool that can be used by a range of professionals for several
kind of bottle/nipple” was only applicable if the baby was purposes. It may be used by primary care providers or neo-
being offered a bottle. Given this feedback, the NeoEAT natal follow-up clinics to identify infants in need of specialty
was separated into three versions based on feeding methods: feeding assessment and treatment. It may be used by feeding
NeoEAT Breastfeeding (i.e., for exclusively breastfeeding specialists or inpatient care teams as part of the initial assess-
infants), NeoEAT Bottle Feeding (i.e., for exclusively bottle- ment and for the evaluation of response to feeding therapies.
feeding infants), and NeoEAT Breastfeeding and Bottle Finally, the NeoEAT may be used by researchers as a validated
Feeding (i.e., for infants being offered both breastfeeding assessment of feeding in the infant. We have intentionally
and bottle feeding). involved clinicians, researchers, and parents in the develop-
At the end of phase 3, 62 items remained that were ment of the NeoEAT to ensure that it is useful and relevant
common to all infants. Ten items were only applicable to for clinicians and researchers and that it is understandable
infants who were being breastfed, 12 items were only appli- and acceptable to parents, the intended respondents.
cable to bottle-feeding infants, and 5 items were only appli- The NeoEAT is an important addition to the literature
cable to infants who were being offered both breastfeeding and to clinical practice because it will allow for earlier iden-
and bottle feeding. The NeoEAT Breastfeeding version has tification and treatment of young infants, which will ideally
72 items and has a reading grade level of 5.1. The NeoEAT optimize nutrition and skill development and prevent long-
Bottle Feeding version has 74 items and has a reading level of term effects of malnourishment in the early months of life.
5.0. The NeoEAT Breastfeeding and Bottle Feeding version Early identification and treatment of infants experiencing
has the complete set of 89 items and has a reading grade level difficulty with feeding may also help to prevent long-term
of 5.3. Full readability results are available in Table 2. feeding problems, which require extensive treatment and are

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 costly to families and the health care system. For research
purposes, the NeoEAT will allow for testing of the effective-
ness of commonly used clinical therapies and development
of tailored treatment programs based on underlying feeding
behaviors. Finally, the NeoEAT could be used in epidemio-
logic studies of the prevalence of feeding problems in young
infants to establish the need for future research and funding.
The NeoEAT, in combination with the Pediatric Eating
Assessment Tool (PediEAT),6 will allow for the seamless
assessment of feeding difficulties in infants and young chil-
dren from birth to seven years of age.
Limitations
In the item generation phase, a secondary analysis was con-
ducted on interviews with parents of older children who had
been diagnosed with a feeding problem. In the secondary
analysis, the previously transcribed interviews were coded for
attributes of problematic feeding that parents described early
in their child’s life. One limitation was that it was a secondary
analysis and parents were not specifically asked to describe
their child’s early feeding for this specific purpose. Another
limitation was that it was the parent’s retrospective memory
of their child’s behavior several years prior. The accuracy of
parents’ memory of events during highly stressful times can
be variable. The final limitation of the data used for item gen-
eration was that online sources were used for recruitment to
the parent survey (e.g., online parent support groups). There
are inherent limitations to data collected online, particularly
around participants’ self-identifying as meeting eligibility
criteria, in this case having an infant younger than seven
months. Given the limitations of retrospective, secondary
data and data from online sources, these data were combined
with multiple other sources (i.e., literature and other tools) to
generate items. The items then went through the described
content validation processes where more reliable sources (i.e.,
known professionals and parents on the telephone with a
research team member) were used to revise the items.
Future Development
Psychometric testing of the three versions of the NeoEAT
is underway and will provide information about the internal
consistency reliability, test–retest reliability, and factor struc-
ture. The NeoEAT is currently a comprehensive but lengthy
assessment. The psychometric testing process will reduce
the item number by eliminating highly correlated items and
items that fail to provide essential information about prob-
lematic feeding. Item response theory will then be used to
further reduce items to create a short version of the NeoEAT.
Although the full version is likely to be most useful for
research purposes, the short version may be useful in clinical
practice. The NeoEAT will also be tested with a large sample
of healthy, apparently typically developing infants to estab-
lish norm-referencing and cutoff scores. Construct validity
against a clinician-report assessment will be conducted in the
future.
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ACKNOWLEDGMENTS
These studies were funded by the American Nurses
Foundation through a grant from the Academy of Neonatal
Nursing and the Foundation for Neonatal Research and
Education. We would like to thank the families, clinicians,
and researchers who contributed to these studies. We would
also like to acknowledge the research assistants who contrib-
uted to these studies, including Brooke Jones, Marie Payne,
Megan Przybyla, Anna Osetek Ross, and Ya Ke (Grace) Wu.
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About the Authors
Dr. Britt Pados, PhD, RN, NNP-BC, is an assistant professor in
the Connell School of Nursing at Boston College. Her background is
as a neonatal nurse and neonatal nurse practitioner. Her research
interests include feeding in medically fragile infants, particularly
those born prematurely and those with congenital heart disease. She
is also interested in measurement of feeding difficulty throughout
childhood.
Dr. Hayley Estrem, PhD, RN, is a postdoctoral fellow with the
Center for Developmental Science at The University of North Carolina
at Chapel Hill. Her research interests include measure development,
feeding treatment program evaluation, and family management
of feeding disorder for children in late infancy and early childhood,
particularly those who may need surgical feeding tube placement. Her
research has been on the concept of feeding problems as available in the
literature, how parents perceive feeding problems, and a description
of how families manage caring for children with clinically significant
feeding difficulty.
Dr. Suzanne Thoyre, PhD, RN, FAAN, is a professor at The
University of North Carolina at Chapel Hill School of Nursing. She
has an extensive background as a neonatal nurse. Her research and
continuing education activities focus on helping nurses and families
partner more effectively with infants and young children as they learn
how to eat.
Dr. Jinhee Park, PhD, RN, is an assistant professor in the Connell
School of Nursing at Boston College, Massachusetts. Her research inter-
ests include feeding difficulties in medically fragile infants, especially
those who are born prematurely, and early feeding intervention sup-
ports. Her clinical background is as a neonatal nurse in South Korea.
Dr. Cara McComish, PhD, CCC-SLP, is a speech-language patholo-
gist and an assistant professor at The University of North Carolina at
Chapel Hill in the Division of Speech and Hearing Sciences within the
Department of Allied Health Sciences in the School of Medicine. Her
teaching and research interests include assessment and interventions
for communication and feeding difficulties in infants and young chil-
dren, early intervention supports and services, and early identification
of autism spectrum disorders.
For further information, please contact:
Britt F. Pados, PhD, RN, NNP-BC
Boston College
School of Nursing, Maloney Hall 268
Chestnut Hill, MA 02467
E-mail: britt.pados@bc.edu
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