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Oromotor stimulation and its application in the care of preterm neonates

Article  in  Asian Journal of Nursing Education and Research · April 2021

DOI: 10.5958/2349-2996.2021.00042.2

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 Asian Journal of Nursing Education and Research. 11(2): April - June, 2021

ISSN 2231-1149 (Print) Available online at

2349-2996 (Online) www.anvpublication.org
DOI: 10.5958/2349-2996.2021.00042.2
Asian Journal of
Vol. 11 | Issue-02|
April - June| 2021 Nursing Education and Research
Home page www.ajner.com

RESEARCH ARTICLE

Oromotor stimulation and its application in the care of preterm neonates

Suvashri Sasmal1*, Dr. Asha P. Shetty2, Dr. Bijan Saha3
1
Ph.D. Nursing Scholar, National Consortium for Ph.D. in Nursing, Indian Nursing Council
2
Professor Cum Principal, College of Nursing, AIIMS Bhubaneswar
3
Associate Professor, Department of Neonatology, IPGME & R, SSKM Hospital, Kolkata
*Corresponding Author Email: suvashri.sasmal@gmail.com
ABSTRACT:
Feeding problems are common among preterm babies due to hypotonia, immature oro-motor control, and lack of
coordination in sucking, swallowing, and breathing. Oral feeding assistance such as oromotor stimulation are
provided to improve their feeding. There is lack of prescribed frequency for application of oromotor stimulation.
In India use of oromotor stimulation in preterm neonates is not a regular practice in neonatal intensive care units
though studies have found that, it reduces duration of hospital stay, improves sucking frequency, better feeding
performance.

KEYWORDS: Preterm, oromotor stimulation, feeding difficulty, feeding assistance.

INTRODUCTION: Preterms commonly have difficulty coordinating the

Every year almost 15 million babies are born preterm
globally of which three and half million babies are born
premature (born before 37 completed weeks of
gestation) in India, accounting for almost 13% of births
in the country.1,2 Prematurity related morbidities lead to
oral feeding problems, among 30-40% of preterm
approximately. These difficulties occur due to hypotonia,
immature oro-motor control, and lack of coordination in
sucking, swallowing, and breathing. Oral-motor
function, swallowing, and breathing involve cerebral and
brainstem pathways which are critical development
during mid to late gestation and continue up to the first
year of postpartum. In the last 6-8 weeks of gestation,
one-third of brain growth occurs, thus preterm born
before 32 weeks have 35% less brain volume than term
babies.
Received on 08.09.2020 Modified on 03.10.2020
Accepted on 18.10.2020 ©A&V Publications All right reserved
Asian J. Nursing Education and Research. 2021; 11(2):169-172.
DOI: 10.5958/2349-2996.2021.00042.2
suck-swallow- breath reflex before 34 weeks postpartum
due to their neurological immaturity and other medical
issues. Studies have shown that median breastfeeding
duration among preterm babies is only 4 months and
difficulties in oromotor control persist among them even
in adolescence without any speech-sound disorder.3,5
Preterm neonates are provided assistance to improve
their feeding e.g. nonnutritive sucking (NNS), suck
training, oral support during feeds, cue-based feeding,
oromotor stimulation (OMS). Oromotor stimulation or
oral motor stimulation is part of assisting in the
development of oral feeding skills.6,13
Problems of oral feeding in preterm neonates:
Preterm neonates might face certain problems while oral
feeding is attempted such as, weak, irregular rooting
reflexes and sucking, inverted lower lips drew inward
during breastfeeding, biting pattern, increased perioral
muscle tone, hypertonic tongue.6,7 In later life, preterms
may show signs of swallowing disorders requiring
specialist's attention such as incoordination between
sucking and swallowing, weak feeding, alterations in
breathing or apnea during the meal, excessive gagging or

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 Asian Journal of Nursing Education and Research. 11(2): April - June, 2021

frequent coughing during the meal, dysphagia, marked asphyxia, intraventricular hemorrhage, or other
irritability, nasal regurgitation, and lethargy during the clinical causes.
meal, feeding time more than 30–40 min, delay in • Neonates at risk of being deprived of oral feeding
unexplained refusal of food, undernutrition, craniofacial due to various clinical co-morbidities e.g. congenital
anomalies and failure to thrive, persisting drooling heart disease at early neonatal life, severe congenital
beyond 5 years.8-10 anomalies leading to NPO status, etc.

What is oromotor stimulation? Effect of oromotor stimulation among preterm

It is a scientific, sequential measure in which patterned neonates:
stimulation is provided to perioral and intraoral muscular Prolonged oral feeding difficulties increases medical
structures for strengthening them, thus facilitating costs, feeding aversion, and increases maternal stress
normal physiologic feeding patterns. leading to poor maternal and infant reunion. But there is
no direct tool to measure the oral feeding readiness
History of oromotor stimulation: among preterms and research is needed in this area to
• 1970's: Speech-Language Pathologists started establish an evidence base for the clinical utility of
working with the occupational therapist, instruments and implementing the use of them to assess
physiotherapist, and other professionals. The clinical feeding readiness in the preterm infant population. 11-12
idea of utilizing oral motor therapy in schools,
hospitals, and clinics started in this decade through Existing literature shows that oromotor stimulation,
the exchange of ideas. when administered to the preterm neonates they reach,
• In 1977 a three days conference was conducted on first oral feeding earlier, have improved sucking
"Oral-motor function and dysfunction in children", frequency, better feeding performance in terms of overall
which was perhaps the beginning of oral-motor intake and rate of milk transfer, shorter transition to
therapy. independent oral feeding, better daily weight gain,
• 1993 onwards research articles by the speech- earlier transition from spoon-feeding to breastfeeding, a
language pathologists and occupational therapists shorter duration of hospital stay, , better score in Infanib
came in the area of oral motor therapy in preterm (the instrument used for assessment of early motor
neonates were published. development) than the control group.13-16
• In 2008, the first attempt was made by a nurse, Dr.
Brenda Knoll Lessen to apply the oromotor therapy Prereqisites for oromotor stimulation of preterm
in the care of preterm neonates. babies:
There is no single standardized procedure for providing
Purpose of oromotor stimulation: oromotor stimulation to neonates. Various schools of
Oromotor stimulation when provided to preterm at least thought are present with varying practices. But initially,
5-15 minutes before feeding, before applying any method it should be considered that,
• Stretches, improves the tone and length of facial the neonate is placed in a supine or side-lying position
muscles. and has to be performed at least 10-20 mins before
• Improves flexion of the lips for mouth closure and feeding, so that 14-19
aspiration of food doesn't occur due to
puckering. gag reflex. The pre-requisites for prefeeding
• Stimulation to the tongue changes the movement of oromotor stimulation for preterms are as follows,
the tongue. • Adequate information must be provided to the
• Reduces pauses in sucking thus improves the parents regarding the application of oromotor
frequency of sucking. therapy, its benefits, and its adverse reactions if any.
Oromotor stimulation when applied by parents
• Increases rate and volume of intake during feeds.
(following a training programme) it tend to be
• Reduces transition time to exclusive breastfeeding.
effective as shown in the studies.23
• Continuous monitoring of vital signs to be done
Indications of oromotor stimulation in neonates:
throughout the procedure especially of oxygen
The literature shows that oromotor stimulation can be
saturation , heart rate (so that apneic spells can be
provided to,
identified earlier).
• Preterm neonates born at the gestational age of <29
• Gloved fingers should be used to prevent the spread
weeks and it can be until and unless effective oral
infection to the baby even when providing non-
feeding is achieved,
nutritive sucking.
• Neonates showing dysfunctional sucking,
• If the baby doesn't tolerate the therapy then
swallowing, and breathing coordination irrespective
immediately discontinue it. The signs of intolerance
of their gestational age
to oromotor therapy are periods of apnea inbetween
• Neonates with existing brain damage due to birth
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 Asian Journal of Nursing Education and Research. 11(2): April - June, 2021

therapy, the baby seems to be drowsy, crying because Other methods of providing oromotor stimulation in
of discomfort. neonates:
• There is no fixed dose of administration for this NTrainer, is an FDA approved method of providing
therapy but existing literature shows, that oromotor oromotor stimulation in neonates other than manual
stimulation is effective whether it is applied once a methods. Patterned frequency-modulated oro-
day or 6 time a days.11-14 Before application of somatosensory stimulation is delivered via the NTrainer
oromotor stimulation the administrator of therapy System through a pacifier interface. NTrainer has a
must undergo a training programme and obtain pneumatic stimulator which generates a series of
permission from the respective copyright owner. frequency modulated pulses (0 to 16 Hz) patterned as 6-
cycle bursts followed by 2-second pause periods, which
Strategies for providing oromotor stimulation: transforms the pacifier into a pulsating nipple
Oromotor stimulation is currently, provided through stimulating the oral facial nerves. Studies have shown
manual application in neonatal intensive care units. The that, NTrainer is effective in reducing time to achieve
protocol is still at the evolving stage and it lacks any full oral feeds and duration of hospitalization even in 29-
fixed frequency of application. Though PIOMI 30 weeks subgroup.20
(Premature Infant Oromotor Intervention) has been
developed in 2008 based on scientific evidence. DISCUSSION:
Feeding a preterm baby to meet his/her body
Dr. Brenda Leessen, has adopted the PIOMI from the requirements is a challenge for health care professionals.
Beckman Oral Motor Intervention (BOMI). The BOMI Physiological immaturity makes a pretmature baby
is a 15 minutes oral motor intervention for infants, vulnerable for developing feeding difficulties. Oromotor
children, and adults with developmental delays having stimulation is a method of choice for enhancing feeding
feeding difficulties. BOMI is redesigned for use in ability among them. It can be provided manually by a
premature neonates considering their physiological trained health care provider or a parent. Stimulation can
requirement, safety and tolerance. PIOMI is an assisted also be provided through mechanical methods such as
movement of 5 minutes duration, provided to activate NT Trainer. In all cases continuous monitoring of vital
muscle contraction and provides movement against signs is mandatory to identify any sign of intolerance
resistance to build strength in the oral cavity. The target and the procedure should be applied consistently to
areas of the mouth include cheeks, lips, gums, tongue, achieve desirable results.
and palate. It is provided using a gloved finger in the
mouths of premature infants of at least 29 weeks post- Although prefeeding oromotor stimulation is a rapidly
menstrual age (PMA) and can be provided by any direct growing field of interest, most of the studies are done
care provider of neonates. In the following section only on haemodynamically stable preterm babies.14-20,23
(Table 1) depicts the complete steps of the procedure.14 There is still limited number of studies conducted in
India on oromotor stimulation.15-16,23 It’s effect on
preterms with medical complications are till unrevealed.
Thus further research studies are required in this area.

Table 1 Sequence of Premature Infant Oromotor Intervention

8 steps Purpose Duration
Cheek Improve range of motion and strength of cheeks, and improve lip seal. 30 sec
Lip roll Improve lip range of motion and seal. 30 sec
Lip curl or Lip stretch Improve lip strength, range of motion, and seal. 30 sec
Gum massage Improve range of motion of tongue, stimulate swallow, and improve suck. 30 sec
Lateral borders of tongue/ cheek Improve tongue range of motion and strength. 15 sec
Midblade of tongue/ palate Improved tongue range of motion and strength, and improve suck. 30 sec
Elicit a suck Improve suck, and soft palate activation. 15 sec
Support for non- nutritive sucking Improve suck, and soft palate activation. 2
Min

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 Asian Journal of Nursing Education and Research. 11(2): April - June, 2021
CONCLUSION:
In India use of oromotor stimulation in neonates is not a
regular practice in neonatal intensive care units. Even
only It is currently a growing field of interest for
researchers to develop a protocol for improving oral
13.
skills in preterm babies. Oromotor stimulation is a major
assistance that promotes earlier transitions to oral
feeding and latching to breast, reduces hospital stay
among preterm neonates. Most of the neonatal intensive
14.
care units of India practices only non-nutritive sucking to
enhance oral motor function but they lack regular
practice of oromotor stimulation. Thus, based on existing
evidence base oromotor stimulation should be actively
15.
incorporated in regular neonatal care.
REFERENCES:
1. Lee ACC, Blencowe H, Lawn JE. Small babies, big numbers:
global estimates of preterm birth. The Lancet Global Health. 2019
Jan; 7(1): Available from:
https://www.thelancet.com/journals/langlo/article/PIIS2214109X
(18)30484-4/fulltext. Accessed on 2020; 08; 25,
2. March of Dimes, PMNCH, Save the Children, WHO. Born Too
Soon: The Global Action Report on Preterm Birth. Eds, Howson
CP, Kinney MV, Lawn JE. Geneva: World Health Organization,
2012.
3. Lau C. Development of infant oral feeding skills: what do we
know? Am J Clin Nutr: 2016; 06: 103, 616-21.
4. Baker M, Villela LD, Gomes S, Tovar MC, Moreira ML.
Breastfeeding of preterm newborn infants following hospital
discharge: follow-up during the first year of life. Ciencia and
Saúde Coletiva, 2018; 04: 23(7): 2403-12, Available from:
http://www.scielo.br/scielo.php?pid=S1413, Accessed on July 30,
2020
5. Northam GB, Morgan AT, Fitzsimmons S, Baldeweg T and
Liégeois FJ. Corticobulbar tract injury, oromotor impairment and
language plasticity in adolescents born preterm. Hum. Neurosci:
2019 Feb; 13 (45): 1-7. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/30837853. Accessed on
Aug 27, 2020
6. Manno CJ, Fox C, Eicher PS, Kerwin ME. Early oral motor
intervention for pediatric feeding problems: what when and how.
JEIBI: 2005 Fall; 2(3): 145-54. Available from:
https://files.eric.ed.gov/fulltext/EJ846764.pdf. Accessed on Aug 9,
2020
7. https://pdfs.semanticscholar.org/90d4/576e2bbc27adc4ab8f90c825
ddb89f12de12.pdf. Accessed on Oct 9, 2019
8. Zaidi I, Thayath MN, Singh S, Sinha A. Preterm birth: a primary
etiological factor for delayed oral growth and development.
IJCPD: 2015 Sep; 8(3): 215-19. Available from:
https://pdfs.semanticscholar.org/f0ab/f9bb6cd1213f27ebdda2dc40
cbe19240f375.pdf. Accessed on July 29, 2020
9. Pedroza RMS, López LFC, Gómez KER. Description of oral-
motor development from birth to six years of age. Rev. Fac. Med:
2014 Aug; 62(4): 593-604. Available from:
http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120
-00112014000400012. Accessed on July 29, 2020
10. Sanches MTC. Clinical management of oral disorders in
breastfeeding. Jornal de Pediatria J Pediatr: 2004 Sep; 80(5): 155-
62. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/15583766. Accessed on
Aug 27, 2020
11. Pados BF, Park J, Estrem H, Awotwi A. Assessment tools for
evaluation of oral feeding in infants younger than 6 months. Adv
Neonatal Care. 2016 April; 16 (2): 143–50. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4781663/.
Accessed on Aug 30, 2020.
12. Crowe L, Chang A, Wallace K. Instruments for assessing
172
View publication stats
readiness to commence suck feeds in preterm infants: effects on
time to establish full oral feeding and duration of
hospitalisation. Cochrane Database Syst Rev. 2016; 2016(8): 1-22.
Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/27552522/.
Accessed on Aug 30, 2020.
Dodrill P. Feeding difficulties in preterm infants. ICAN: Infant,
Child, and Adolescent Nutrition: 2011 Dec; 3(6): 324-29.
Available from:
https://www.researchgate.net/publication/254080967_Feeding_Dif
ficulties_in_Preterm_Infants. Accessed on July 28, 2020
Ghomia H, Yadegarib F, Soleimania F, Lessen BK, Noroozid M,
Mazourie A. The effects of premature infant oral motor
intervention (PIOMI) on oral feeding of preterm infants: A
randomized clinical trial. Int J. Pedia Otor: 2019 Feb; 120 (4): 202-
9.
Thakkar PA, Rohit HR, Das RR, Thakkar UP, Singh A. Effect of
oral stimulation on feeding performance and weight gain in
preterm neonates: a randomised controlled trial, Paediatrics and
International Child Health. 2018 Sep; 1-6. Available from:
https://doi.org/10.1080/20469047.2018.1435172. Accessed on
Aug 27, 2020
16. Arora K. et al. Prefeeding oromotor stimulation program for
improving oromotor function in preterm infants – a randomized
controlled trial. Indian Pediatrics. 2018 Aug; 55(1): 675-78
17. Hasanah O, Novayelinda R, Deli H. The effect of oromuscular
stimulation on neonate latch score. Enferm Clin. 2019 Feb; 29(1):
46-48. Available from:
https://www.researchgate.net/publication/330858665_The_effect_
of_oromuscular_stimulation_on_neonate_latch_score. Accessed
on Apr 2, 2020
18. Khalessi N, Nazi S, Shariat M, Saboteh M, Farahani Z. The effects
of pre-feeding oral stimulations and non-nutritive sucking on
physical growth and independent oral feeding of preterm infants.
Iran J Pediatr. 2015 June; 25(3): 1-5
19. Yang C. et al. Clinical significance of oral motor intervention on
the prognosis of early premature infant. Chin Crit Care Med. 2019
Feb;31(2): 150-54. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/30827300. Accessed on
Aug 8, 2020
20. Song D, Jegatheesan P, Nafday S, Ahmad KA, Nedrelow J,
Wearden M, et al. Patterned frequency-modulated oral stimulation
in preterm infants: A multicenter randomized controlled trial.
PLoS ONE. 2019 Feb; 14(2): 1-15. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/30817764. Accessed on
Aug 3, 2020
21. Kirk et al. Health, nutrition, and development of children born
preterm and low birth weight in rural Rwanda: a cross-sectional
study. BMC Pediatrics: 2017 July; 17(3): 191-95. Available from:
https://www.researchgate.net/publication/321088718_Health_nutri
tion_and_development_of_children_born_preterm_and_low_birth
_weight_in_rural_Rwanda_A_cross-sectional_study. Accessed on
July 28, 2020
22. Freitas BAC, Lima LM, Valente CFL, Priore SE, Sylvia FC.
Duration of breastfeeding in preterm infants followed at a
secondary referral service. Rev Paul Pediatr: 2016 Mar; 34(2):
189-196. Available from: https://docksci.com/duration-of-
breastfeeding-in-preterm-infants-followed-at-a-secondary-referral-
se_5a245d99d64ab20a5ec13061.html. Accessed on July 27, 2020
23. Topkar P, Metgud D, Machakanur V. Effect of follow-up home
based oromotor stimulation on breastfeeding performance in
preterm low-birth-weight infants: A randomized control trial.
Indian J Health Sci Biomed Res: 2019; 12: 85-90