Article gastroenterology

Oral Feeding in the Preterm

Infant
Chantal Lau, PhD*
Objectives After completing this article, readers should be able to:

1. Describe the sequential development of sucking, swallowing, and respiration.

Author Disclosure 2. Delineate the limitation of an infant’s oral feeding skills at specific times of
Dr Lau did not development to provide realistic expectations for oral feeding performance.
disclose any financial 3. Define oral feeding success in preterm infants.
relationships relevant 4. Use the current knowledge of preterm infants’ oral motor skills to facilitate and
to this article. enhance their performance.
5. Enumerate the potential short- and long-term consequences of an infant’s oral feeding
aversion for the patient, family, and health professional.

Introduction
Oral feeding issues in preterm infants are a growing concern for neonatologists because
attainment of independent oral feeding is one of the prerequisites for hospital discharge.
With the increase in survival of infants born continuously more preterm, understanding
such issues has a certain urgency. Concerns do not pertain only to difficulties encountered
by neonatologists during the birthstay hospitalization, but also by pediatricians and
pediatric gastroenterologists who attend to long-term feeding difficulties/disorders, such
as oral feeding aversion. Indeed, greater than 40% of patients followed in feeding disorder
clinics are former preterm infants. Research over the last decade has begun to shed light on
the development of oral feeding skills in these infants as they mature, which has increased
understanding of their limited skills at varying postmenstrual ages. Such knowledge is
crucial in clinical practice insofar as expectations of these infants’ oral feeding performance
must take into account the ever-changing level of maturity of their skills.
This article focuses on the development of sucking, swallowing, and respiration (as it
pertains to oral feeding) and the coordination of these three functions. Additional factors,
separate from infant feeding skills, also are discussed because they can affect oral feeding
performance. This review examines information gathered from bottle feeding because
more extensive research has been conducted on bottle feeding than on breastfeeding.
However, in no way should bottle feeding be interpreted as favored over breastfeeding.

Readiness to Feed Orally

Clinicians look for signs of readiness to feed orally before weaning preterm infants from
tube feeding. However, such signs are ill-defined because of limited information on the
oral feeding skills necessary for infants to feed safely and successfully by mouth. At present,
it is customary for infants who have stable cardiopulmonary status to be introduced to oral
feeding around 33 to 34 weeks postmenstrual age. At this age, their sucking pattern
resembles that of term infants, ie, rhythmic alternation of suction and expression, the two
components of sucking. However, studies have shown that the mature sucking pattern is
not necessary for safe and successful oral feeding. Indeed, infants can feed orally using only
the expression component, with no suction.
It is important to recognize that adequate oral feeding in infants does not rest solely on
adequate sucking, but also on appropriate swallowing, respiration, and the coordination of
sucking, swallowing, and respiration. Furthermore, independent of such skills, it is now
acknowledged that an infant’s behavioral state and organization during feeding, the
nursery environment (eg, light, sound), and a caretaker’s approach to oral feeding can

*Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston Tex.

NeoReviews Vol.7 No.1 January 2006 e19

gastroenterology oral feeding
Figure 1. Sample tracings corresponding to each of the five defined stages of sucking.
affect the infant’s performance significantly. Such aware-
ness has grown over the last few years as a result of the
introduction of the developmental care program in
growing numbers of nurseries.
Oral Feeding Skills
Sucking
Sucking includes nutritive sucking, when milk is ingested
from a bottle or breast, and non-nutritive sucking, when
no liquid is involved (eg, pacifier). Mature nutritive
sucking is defined by the rhythmic alternation of suction
(the negative intraoral pressure that draws milk into the
mouth) and expression (the positive pressure generated
by the compression/stripping of the nipple [breast or
bottle] that ejects milk into the mouth). In a longitudinal
study conducted during bottle feeding of “healthy” in-
fants, feeders and growers, born at less than 30 weeks’
gestation (ie, who had no major medical issues), we
observed that mature sucking is attained sequentially and
characterized this progression into five primary stages
(Fig. 1). In brief, sucking begins with the emergence of
an arrhythmic expression with no suction (Stage 1). As
expression becomes rhythmic, arrhythmic suction ap-
pears (Stage 2), in time also acquiring rhythmicity (Stage
3). During these initial three stages, infants can switch
from using the expression component only to a develop-
ing alternation of suction/expression within a feeding
session. As the alternation of rhythmic suction/
e20 NeoReviews Vol.7 No.1 January 2006
expression matures, suction ampli-
tude increases along with the dura-
tion of sucking bursts (Stages 4 and
5). Such characterization of the
progression of nutritive sucking
was positively correlated not only
with postmenstrual age, as ex-
pected, but also with oral feeding
performance, as defined by the rate
of milk transfer (mL/min) and the
ability of the infants to complete
their feedings within an allocated
time (20 min).
Non-nutritive sucking, al-
though not directly implicated in
feeding, has its benefits. Studies
showed that a pacifier offered dur-
ing gavage feeding accelerated the
transition from tube to oral feeding
and enhanced weight gain, leading
to an overall shortened hospital
stay. Although non-nutritive suck-
ing enhanced gastrointestinal mo-
tility, it did not increase the levels of gastrointestinal
hormones, namely, gastrin, motilin, insulin, or insulin-
like growth factor-1. Such sucking also improved the
infant’s behavioral state and organization during oral
feeding and decreased distress and pain.
A rhythmic non-nutritive sucking pattern resembling
that of mature nutritive sucking has been used as an
indicator of readiness for oral feeding. However, this
approach is now debatable. We observed that preterm
infants who demonstrated a mature sucking pattern
when sucking on a pacifier did not necessarily do so
during bottle feeding. Figure 2 shows the non-nutritive
and nutritive sucking patterns of a preterm infant
(30 weeks’ gestation) at 43 days after birth (36.1 weeks
postmenstrual age) when taking four oral feedings per
day. He was offered the pacifier for the first 3 minutes of
the monitored session and given a bottle immediately
after. During non-nutritive sucking, he demonstrated a
mature rhythmic alternation of suction/expression (Fig.
2a), which was not maintained when offered the bottle
(Fig. 2b). Figure 3 shows the results obtained in a similar
manner from an infant (29 weeks’ gestation) at 54 days
after birth (36.4 weeks postmenstrual age) when taking
eight oral feedings per day. For this infant, the sucking
pattern was similar during non-nutritive and nutritive
sucking.
We speculated that the discrepancy observed in the
first infant reflected uncoordinated suck-swallow-
 gastroenterology oral feeding

ied bolus sizes. It also is swifter, as

evidenced by the increase in swal-
lowing rates observed as infants ma-
ture (Table 1). This may be partly
explained by the increase in in-
trabolus pressure, the lingual force
generated that propels the bolus to
the pharynx to trigger the swallow-
ing reflex. This reflex can be initi-
ated with only 0.04 mL of fluid if it
is delivered to the correct region of
the swallowing receptor nerve end-
ing located in the posterior region
of the pharynx. Thus, it would be
expected that the better the bolus
formation and the stronger the in-
trabolus pressure, the more rapidly a
swallow would be initiated. Such ob-
servations emphasize the close link
Figure 2. Sample tracing of an infant (30 weeks’ gestation) at 43 days after birth
(36.1 weeks postmenstrual age) when taking four oral feedings per day: a. non-nutritive between sucking and swallowing.
sucking on a pacifier for 3 minutes prior to b. nutritive sucking. Scale rating in Oral feeding is safe if swallowing
parentheses based on the sucking stage scale shown in Figure 1. Reprinted with occurs with the proper timing of
permission from Lau C, Kusnierczyk I. Quantitative evaluation of infant’s nonnutritive and tracheal closure to prevent tracheal
nutritive sucking. Dysphagia. 2001;16:58 – 67. Reprinted with permission from Springer- penetration/aspiration into the
Verlag Publishers. lungs. This necessitates not only

respiration during oral feeding.

During non-nutritive sucking, with
swallowing being at a minimum
(but for the infant’s own secretion),
sucking and respiration can func-
tion independently from each other
(Fig. 4a). However, when frequent
swallowing occurs, as in the case of
nutritive sucking, the sucking, swal-
lowing, and respiration need to be
closely linked to avoid aspiration
(Fig. 4b). As such, immature nutri-
tive sucking does not necessarily
reflect sucking ability, but also the
coordination of suck, swallow,
and respiration. Thus, non-
nutritive sucking is a good index
of sucking skills, but not necessar-
ily of an infant’s readiness to feed
Figure 3. Sample tracing of an infant (29 weeks’ gestation) at 54 days after birth
by mouth.
(36.4 weeks postmenstrual age) when taking eight oral feedings per day: a. non-nutritive
sucking on a pacifier for 3 minutes prior to b. nutritive sucking. Scale rating in
Swallowing parentheses based on the sucking stage scale shown in Figure 1. *ⴝchange in baseline.
With maturation, the swallowing Reprinted with permission from Lau C, Kusnierczyk I. Quantitative evaluation of infant’s
process becomes more adaptable, nonnutritive and nutritive sucking. Dysphagia. 2001;16:58 – 67. Reprinted with permis-
handling both larger and more var- sion from Springer-Verlag Publishers.

NeoReviews Vol.7 No.1 January 2006 e21

gastroenterology oral feeding

Figure 4. Schematic representation of: a. the independent relationship between sucking 0.35 and 0.7 seconds, as measured
and respiration during nonnutritive sucking and b. the dependency between sucking, by intrapharyngeal pressure in term
swallowing, and respiration during nutritive sucking.
timely closure of the epiglottitis, but also of the aryepi-
glottics and vocal folds. However, penetration and aspi-
ration may occur prior to swallowing because of poor
bolus formation, during swallowing due to improper
laryngeal closure, or after swallowing when residual
pools around the valleculae and pyriform sinuses as a
result of poor pharyngeal clearance.
Respiration
Preterm infants often have respira-
tory issues, ranging from severe re-
spiratory distress syndrome, includ-
ing bronchopulmonary dysplasia,
to varying degrees of oxygen sup-
plementation early in life. How-
ever, as they mature, “healthy” pre-
term infants normally experience
decreasing episodes of oxygen de-
saturation or apnea during oral
feeding. Baseline respiratory rates
in these infants range from 40 to 60
breaths/min or 1.0 to 1.5 seconds
per respiratory cycle (inspiration/
expiration). The duration of the
swallowing event when airflow is
interrupted can range between
and preterm infants. With such re-
spiratory rates and swallow dura-
tion, little time may be left for res-
piration. In addition, during oral feeding, a number of
studies noted decreased minute ventilation, prolonged
expiration, and shortened inspiration, albeit no signifi-
cant change in tidal volume. Thus, with all the respiratory
alterations taking place, it is not surprising that some
“healthy” preterm infants incur episodes of desaturation,
apnea, or bradycardia when feeding by mouth.

Ages and Oral Feeding Characteristics of Preterm and Term

Table 1.

Infants*
Preterm Preterm
(1 to 2 oral (6 to 8 oral Term Term
feedings feedings Ad lib Ad lib Preterm Term
per day) per day) (First Week) (>2 Weeks) (Combined) (Combined)
Gestational age (wk) 26.8ⴞ2.7 — 39.1ⴞ1.1 — — —
Postnatal days (PMA) 44.6ⴞ9.8 63.6ⴞ12.5 6.5ⴞ3.3 20.6ⴞ6.5
(34.0ⴞ1.2) (36.7ⴞ1.8)
Mean bolus size (mL) 0.12ⴞ0.06 0.15ⴞ0.07 0.20ⴞ0.07 0.24ⴞ0.08 0.14ⴞ0.06a 0.22ⴞ0.07a
Sucking rate (#/min) 45ⴞ10 51ⴞ18 62ⴞ12 57ⴞ13 48ⴞ14b 59ⴞ12b
Suction Amplitude (mm Hg) ⴚ28.0ⴞ23.8 ⴚ69.2ⴞ61.0
c c,a
ⴚ130.0ⴞ34.1 ⴚ107.3ⴞ47.3 ⴚ53ⴞ54
a a
ⴚ118ⴞ42a
Swallowing rate (#/min) 41ⴞ11 49ⴞ16 56ⴞ18 55ⴞ13 45ⴞ14b 55ⴞ1b
d b,d b a
Rate of milk transfer (mL/min) 2ⴞ1 4ⴞ2 7ⴞ1 7ⴞ4 3ⴞ2 7ⴞ3a
*Mean⫾SD
PMA⫽postmenstrual age (wk)
Independent t-test, P values between symbols: aP⬍0.001; bP⬍0.01
Paired t-test, P values between symbols: cP⬍0.05; dP⬍0.01
From Lau C, Smith EO, Schanler RJ. Coordination of suck-swallow and swallow-respiration in preterm infants. Acta Paediatr. 2003;92:721–727.

e22 NeoReviews Vol.7 No.1 January 2006

 gastroenterology oral feeding

from 34 to 42 weeks postmenstrual age (Table 1). Dur-

ing this time period, there occurred a steady increase in
bolus size, sucking and swallowing rate, strength of the
suction component, and rate of milk transfer. It is of
interest that suck-swallow coordination already was at-
tained when infants were introduced to oral feeding at
approximately 34 weeks postmenstrual age.
We further explored the timing of swallows in relation
to the phases of the respiratory cycle. The schematic in
Figure 5 depicts the various phases of the respiratory
cycle when swallows may occur (swallow-respiratory in-
Figure 5. Schematic representation of swallow-respiration
terfacings). We computed the frequency of occurrence of
interfacings. Position 1: swallow (Sw) at start inspiration/end
expiration; position 2: Sw during inhalation; position 3: Sw at these potential interfacings when preterm infants were
end of inspiration/start expiration; position 4: Sw during taking one to two and six to eight oral feedings per day
exhalation; position 5: Sw interrupting inspiration; position 6: and when term infants were at 1 week and 2 to 3 weeks
Sw interrupting exhalation; position 7: Sw episodes when after birth. Table 2 shows how, with maturation, a grad-
respiration is halted (>2 sec). ual trend occurs toward swallowing at a safer phase of
respiration (ie, start of inspiration or end of expiration
Coordination of Suck, Swallow, and Respiration when airflow is minimal or stopped). Considering the
A number of studies have examined the coordination of risks involved if swallows were to occur at other phases of
sucking, swallowing, and breathing. However, they have the respiratory cycle (eg, inspiration or deglutition ap-
been primarily descriptive, focusing on the structural nea), we propose that coordination of suck-swallow-
elements (eg, tongue and perioral muscles) implicated in respiration is attained with a consistent suck-swallow ratio
the generation of sucking and swallowing. No study, to (eg, 1:1, 2:1) and a safe swallow-respiration interfacing
our knowledge, has yet defined the precise temporal (eg, start of inspiration or start of expiration).
relationship(s) for the proper coordination of suck, swal- In a recent study investigating whether an optimal
low, and respiration. Clinically, coordination is pre- bottle nipple can be identified to enhance oral feeding
sumed attained when infants take
their feedings by mouth with no Table 2. Percentage Occurrence of Swallow-
overt signs of aspiration, oxygen
desaturation, apnea, or bradycar- respiration Interfacings in Decreasing Order of
dia and demonstrate a ratio of Frequency (Only Frequency Occurrences >5%
1:1:1 or 2:2:1 suck:swallow:
breathe.
Presented)
Based on the close link be- Term Infants
tween sucking and swallowing
Preterm Infants <2 wk >2 wk
and between swallowing and res-
piration, we investigated a dif- Deglutition Apnea Deglutition Apnea Start Inspiration
ferent aspect of coordination by (53ⴞ25) (37ⴞ25) (34ⴞ20)
2 2 2
examining the relationships be- 3 Start Inspiration* 3 End Inspiration
Inhalation*
tween suck-swallow and swallow- (21ⴞ13) (36ⴞ23) (23ⴞ13)
respiration. This study was con- 2 2 2
ducted during bottle feeding in Start Inspiration*† End Inspiration* Inhalation
preterm infants who had no major (11ⴞ11) 3 (12ⴞ10) 3 (19ⴞ11)
2 2 2
medical issues and were born at
End Inspiration*# Inhalation* Deglutition Apnea
less than 30 weeks’ gestation (8ⴞ8) (9ⴞ8) (13ⴞ12)
(26.8⫾2.7 weeks) and term in-
Preterm Infants:
fants (39.1⫾1.1 weeks’ gestation) *Pⱕ0.02 vs Deglutition Apnea (@ 1 to 2 PO/d)
†
between 1 and 3 weeks after birth. Pⱕ0.05 vs Deglutition Apnea (@ 6 to 8 PO/d)
Term infants
We followed the gradual matura- *Pⱕ0.05 vs Deglutition Apnea
tion of various oral feeding skills

NeoReviews Vol.7 No.1 January 2006 e23

gastroenterology oral feeding
performance, we observed that “healthy” preterm infants
(⬍30 weeks’ gestation) can alter their sucking pattern
depending on the flow rate of the bottle nipples used.
From these results, we speculated that infants can modify
their sucking skills to maintain a rate of milk transfer that
they can handle safely or that is compatible with the level
of suck-swallow-breathe coordination they have at-
tained. Because the studied infants were “healthy” and
medically stable, we hypothesize that their ability to
modify specific sucking variables to maintain appropriate
flow rates requires the integrity of afferent sensory feed-
back to the sucking, swallowing, and respiratory centers
in the brainstem. This concept is supported by the work
of Finan and Barlow, who speculated that the sucking
motor pattern of infants is under the control of a central
pattern generator that adapts to changing environmental
conditions via afferent sensory feedback. Craig and Lee
have proposed a similar theory, with the existence of an
intrinsic tau-guide acting as a common process linking
various forms of timing events within the motor function
(eg, the control of sucking pressure in infants). Under
such conditions, oral feeding can be successful if the
infants are allowed to regulate their own milk flow.
Infant’s Condition(s)
Medical Condition(s)
Oral feeding safety and success is not solely dependent on
an infant’s oral feeding skills. Indeed, it may be disrupted
by fluid penetration or aspiration into the larynx caused
by unrelated factors, such as gastrointestinal immaturity
or the infant’s behavioral state and organization at the
time of the feedings. Fluid backflow into the larynx may
occur not only as a result of pooling at the level of the
valleculae and pyriform sinuses resulting from poor pha-
ryngeal clearance, but also as a result of improper timing
of the relaxation or constriction of the upper or lower
esophageal sphincters, gastroesophageal reflux, im-
proper esophageal motility, or delayed gastric emptying.
Because these different aspects of gastrointestinal imma-
turity are addressed in other articles in this issue, only the
infant’s behavioral state and organization and environ-
mental factors are discussed here.
Behavioral State and Organization
The National Neonatal Individualized Developmental
Care and Assessment Program (NIDCAP) distinguishes
six levels of state organization: quiet sleep, active sleep,
drowsiness, quiet alert, active alert, and crying/fussing.
Based on this classification, the optimal states for oral
feeding appear to be drowsiness and quiet and active
e24 NeoReviews Vol.7 No.1 January 2006
alert. However, due to their immaturity, one of the
characteristics of preterm infants is their inability to reg-
ulate their states. Because they spend most of their time
transitioning from one state to another, some infants
cannot feed by mouth for extended periods of time.
Neurobehavioral studies have proposed that an orga-
nized pattern of state regulation is a good indicator of an
infant’s ability to cope with his or her environment,
particularly that of a neonatal intensive care unit. As a
result, improvement in state regulation is interpreted as
evidence of central nervous system maturation and can
be key to an infant’s ability to orally feed successfully for
an extended period of time.
Behavioral organization is identified by the calmness,
relaxation, and regular breathing that an infant exhibits
at a particular time. Not necessarily linked to a particular
behavioral state, this condition needs to be taken into
account when feeding infants. Feeding therapists com-
monly identify infants as organized when their bodies are
gently flexed, their arms are folded toward midline,
hands are placed under the chin, and there are no facial
adverse expressions (eg, grimace). It is under these cir-
cumstances that oral feeding is best achieved, likely be-
cause infants, in the absence of any additional stimula-
tion, can focus on the task at hand. Thus, behavioral state
and organization can affect significantly the ability of a
preterm infant to feed by mouth.
Developmental Care Program
Given the type of stimulations that preterm infants expe-
rience in nurseries, debate has arisen regarding the ap-
propriate stimulations that such infants should receive.
Caretakers have long recognized different types of sen-
sory stimulations. Some provided during routine nursing
care are aversive (eg, venipuncture, heelsticks, suction-
ing) and “impersonal” (eg, regular diaper changes, tem-
perature monitoring, positioning). Others, often pro-
vided by parents, are calming and soothing (eg, holding,
stroking, or rubbing). To address these issues, two dif-
ferent approaches are taken. The first reduces or limits
the aversive stimulations occurring in nurseries and the
second provides additional stimulations that benefit the
infants.
The establishment of developmental care programs
primarily led by nursing staff focuses on the first ap-
proach. For example, effort is made to cluster care or to
carry out painful procedures within a specific time of the
day rather than throughout the day. The light in nurser-
ies is dimmed, isolette covers are used to reduce back-
ground light and noise, and containment methods (eg,
swaddling) are used as calming interventions. The sec-

Table 3. Facts and Recommendations for Oral Feeding of Preterm Infants
Facts
Completing a feeding is not always a sign of success.
Sucking is not only a reflection of sucking ability, but also
of the level of suck-swallow-respiration coordination.
With certain medical condition(s), infants may feed by
mouth.
An infant’s behavioral state and organization must be
appropriate for oral feeding.
Infant’s facial cues and body language are their means of
communication
Nursery surroundings can impede oral feeding.
There is a high occurrence of oral feeding aversion
ond approach focuses on providing supplemental stimu-
lations to counterbalance the negative effect(s) of the
immediate adversities and the developmental deficits as-
sociated with prematurity, such as skin-to-skin holding.
Caretaker’s Oral Feeding Approach
Currently, when infants are deemed ready to feed orally,
an important sign of success is completion of their feed-
ings (ie, the ability to take the volume prescribed within
an allotted period of time), which is key to advancement
of oral feeding and earlier attainment of independent oral
feeding. Under such pressure, caretakers often inappro-
priately “encourage” infants to finish their feeding no
matter what the consequences (eg, choking, fatigue,
emesis). We speculate that the high occurrence of oral
feeding aversion observed in nurseries and following
discharge may result from such technique. Conse-
quently, we have proposed a developmental oral feeding
approach that, most importantly, takes into consider-
ation the limitations of these infants. In brief, infants are
advanced in their daily oral feedings only if they do not
demonstrate any adverse events or aversive behavior.
Completion of feedings is not a requirement for advance-
gastroenterology oral feeding
Recommendations
● Do not push infant to finish a feeding.
—A mature sucking pattern is not necessary for safe
and successful oral feeding.
—Infants may adjust their sucking to balance for
appropriate flow rate.
● But, they should not be pushed to finish a feeding.
● Shorten the feeding duration with observed changes
in behavioral state, organization, and fatigue.
● Help the infant to regain an appropriate state and/or
reorganize.
—If achievable, proceed with feeding.
—If not, stop feeding.
● Watch continuously the infant’s cues for indicators of
appropriate initiation, maintenance, or halting of oral
feeding.
● Optimize environmental surroundings:
—Reduce light and sound.
—Maintain consistent containment and temperature
and supported flexed posture.
● Allow infants to feed at their own pace and rest if
necessary.
● Respect their cues.
● Stop oral feeding and tube feed remainder, if
necessary.
● Oral feeding must be a positive experience.
ment. Under such a program, caretakers must become
cognizant of all aspects of their patient’s limitations and
“adjust” their feeding approach accordingly. Table 3
shows some of the facts and recommendations we pro-
pose.
Summary
From our studies on nutritive sucking, we observed that
the mature sucking pattern is not necessary for safe and
successful oral feeding. Readiness to feed orally should
not be based only on sucking skills, but rather on the
coordination of sucking, swallowing, and respiration.
Because the various skills implicated in oral feeding ma-
ture at different times, it is speculated that neurologically
intact “healthy” infants can coordinate these three func-
tions if allowed to regulate and control their own feed-
ing. In addition, oral feeding performance does not
depend only on oral motor skills but also on the infant
behavioral state and organization and his or her environ-
ment. It is essential, therefore, that all these factors be
taken into consideration when weaning an infant from
tube feeding.
NeoReviews Vol.7 No.1 January 2006 e25
gastroenterology oral feeding
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 gastroenterology oral feeding

NeoReviews Quiz
5. For preterm infants, readiness to feed orally depends on the maturation of sucking, swallowing, and
respiration and the coordination of these activities. Of the following, the postmenstrual age at which
preterm infants who have stable cardiopulmonary status and no neurologic abnormalities are likely to be
introduced to oral feeding is closest to:
A. 28 weeks.
B. 30 weeks.
C. 32 weeks.
D. 34 weeks.
E. 36 weeks.

6. Sucking includes a nutritive component in which milk is ingested from the breast or the bottle and a non-
nutritive component in which no milk intake is involved. Of the following, the most accurate statement
regarding non-nutritive sucking in preterm infants is that it:
A. Enhances the infant’s behavioral state and organization.
B. Increases the circulating levels of gastrointestinal hormones.
C. Is a good index of the infant’s readiness to feed by mouth.
D. Retards gastrointestinal motility.
E. Slows the transition from gavage to oral feeding.

NeoReviews Vol.7 No.1 January 2006 e27