Evaluation of early oral stimulation by sweeping method to enhance breastfeeding in term neonates

INTRODUCTION

Medical practices continue to evolve as new evidence becomes available, making improvements in patient care and safety. This dynamic nature of healthcare means that procedures are regularly reassessed and refined. Neonatal resuscitation is no exception, with its guidelines and techniques having undergone considerable changes to reflect current research and clinical outcomes better.^[1-3]

One of the most frequently performed interventions during neonatal resuscitation has been oropharyngeal suctioning.^[1-3] Conventionally, this practice has been based on the belief that removing secretions from the newborn’s mouth and airway promotes quicker lung aeration immediately after delivery. By clearing substances such as amniotic fluid, meconium, mucus, or blood that might otherwise be inhaled, suctioning is considered to reduce the risk of aspiration and subsequent respiratory complications significantly.^[4,5]

Several studies have indicated that neonates who undergo suctioning tend to exhibit higher APGAR scores and improved oxygen saturation compared to those who do not receive this intervention.^[6] These observations historically supported the widespread inclusion of suctioning in delivery room protocols. However, emerging evidence has highlighted the potential risks associated with routine suctioning. Specifically, stimulation of the vagus nerve during the procedure can result in bradycardia, a clinically significant drop in heart rate that can complicate immediate neonatal adaptation to extrauterine life.^[7]

Recognising these risks, updated recommendations from major health organisations, including the Neonatal Resuscitation Program, now advise against routine suctioning, even in neonates born through meconium-stained amniotic fluid.^[8] This shift underscores a growing consensus that unnecessary interventions should be minimised to reduce avoidable harm and promote safer, evidence-based care.

In place of suctioning, a gentler approach – wiping – has been introduced and endorsed. Research suggests that wiping the newborn’s face, mouth, or nose at delivery is just as effective at clearing secretions while avoiding the risks linked to invasive suctioning. This method is simple, safe and free from known complications. The current Neonatal Resuscitation Program guidelines recommend gentle wiping of the face, mouth and neck instead of routine, forceful suctioning. This approach helps eliminate adverse outcomes associated with bulb-syringe suctioning, such as bradycardia, lower appearance, pulse, grimace, activity, respiration (APGAR) scores and trauma to the delicate respiratory mucosa.^[9-14]

According to these modern guidelines, suctioning of the oral cavity is now reserved exclusively for neonates who show clear evidence of airway obstruction preventing spontaneous breathing or for those who require positive pressure ventilation. Beyond the APGAR score, assessing a newborn’s ability to breastfeed effectively has become a key indicator of immediate well-being and successful adaptation. Breastfeeding within the 1^st h of life is critical, as it supports nutrition, immunity, thermoregulation and mother–infant bonding.^[10]

Routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born through clear amniotic fluid is therefore no longer recommended. Instead, suctioning immediately after birth, including the use of bulb syringes, should be limited to cases with obvious airway obstruction or those needing positive pressure ventilation. This change emphasises a more individualised approach to airway management that avoids unnecessary intervention while maintaining safety.

Given that suctioning of the oronasopharynx can cause bradycardia, apnoea and even cardiac arrhythmias through vagal stimulation,^[3] it becomes essential to balance these risks with the need to establish effective breastfeeding within the 1^st h of life,^[4] aligning with the globally promoted ten steps to successful breastfeeding.^[5]

Based on our hypothesis, a simple intervention – sweeping the oral cavity with a sterile gauze piece, fully consistent with the Neonatal Resuscitation Program Guidelines, may effectively clear residual secretions while gently stimulating oral structures. This action could enhance the neonate’s ability to latch onto the breast, supporting more effective breastfeeding right from birth. In this study, we aimed to evaluate the effectiveness of this oral cavity sweeping technique in helping neonates establish breastfeeding within 1 h of delivery.

MATERIAL AND METHODS

Method

Every neonate born after 37 completed weeks of gestation through normal vaginal delivery on odd-number dates was allocated to Group A, and every neonate born after 37 completed weeks of gestation through normal vaginal delivery on even-number dates was allocated to Group B [Figure 1].

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Figure 1:

Study design. LATCH: Latch, audible swallowing, type of nipple, comfort, hold.

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The initial steps of newborn care remained the same in both groups, i.e., to provide warmth by placing the neonate under a radiant heat warmer, and dry the neonate after which the cord is clamped and cut.

In our institution, all vigorous term neonates are routinely kept under a radiant warmer for initial assessment immediately after birth. The sweeping procedure was performed during this standard newborn evaluation period and did not delay breastfeeding initiation. All neonates, including those in the sweeping group, were put to the breast within the 1^st h of life, as per the World Health Organization recommendations. No neonate was breastfed before performing the sweep, as the procedure was conducted immediately following delivery and drying of the infant.

In Group A, after the initial steps of newborn care, sweeping of the oral cavity was done, under aseptic precautions using a gloved finger, with the help of a sterile gauze piece in a single sweep, clearing the oral cavity of all the secretions.

The sweep was performed once along the inner aspect of the cheeks, gums and palate to clear residual secretions. The procedure lasted approximately 5–10 s and was done immediately after delivery under a radiant warmer before initiating breastfeeding. Care was taken to avoid any pressure or repeated insertion into the oral cavity.

In Group B, sweeping of the oral cavity was not done after the initial steps of newborn care.

LATCH score was assessed for all the neonates of both groups for breastfeeding established within 1 h of delivery, as a part of the evaluation of the study.

Followed by which the efficacy of sweeping of the oral cavity in the establishment of breastfeeding is compared between the two groups.

RESULTS

A total of 438 term neonates were included in the study, with 219 neonates each in the intervention (oral sweeping) and control (no sweeping) groups [Figure 2].

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Figure 2:

Correlation of LATCH with oral sweeping. LATCH: Latch, audible swallowing, type of nipple, comfort, hold.

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DISCUSSION

This study demonstrated that early oral stimulation using a simple sweeping technique significantly improved LATCH scores among term neonates, indicating more effective breastfeeding initiation. The results align with growing evidence supporting oral stimulation as a beneficial intervention for enhancing feeding outcomes in neonates.

Breastfeeding is a cornerstone of neonatal nutrition and has profound short- and long-term health benefits. The World Health Organization and UNICEF advocate for initiation of breastfeeding within the 1^st h of life, which is known to reduce neonatal mortality and improve maternal–infant bonding.^[15] In our study, the average LATCH score was 8.37, indicating generally good breastfeeding performance. However, neonates who received oral sweeping had significantly higher LATCH scores, with more neonates achieving the maximum score of 10 compared to controls (63 vs. 33, respectively).

The use of the LATCH scoring system provided a structured and validated method to assess breastfeeding success.^[16] Components of the LATCH tool, such as latch quality and audible swallowing, reflect neuromuscular coordination and effective feeding. Sweeping of the oral cavity may provide mild tactile stimulation, which in turn may help in activating orofacial reflexes critical for successful latching.

Similar benefits of oral stimulation have been observed in preterm neonates. El Mashad et al. showed that pre-feeding oral stimulation significantly improved oral feeding performance and weight gain and shortened hospital stay among preterm infants.^[17] While their study focused on Neonatal Intensive Care Unit (NICU) patients, our findings extend this concept to healthy term neonates during the critical 1^st h of life.

Recent shifts in neonatal resuscitation guidelines also support the relevance of oral interventions. Traditional suctioning has been discouraged due to risks such as bradycardia and mucosal trauma from vagal stimulation.^[6] Instead, simple wiping has been promoted as an equally effective and safer alternative in vigorous neonates.^[10] In this context, our study proposes a safe enhancement – a gauze sweep – that is quick, non-invasive and may improve feeding readiness without conflicting with current resuscitation protocols.

Kelleher et al. demonstrated that wiping instead of suctioning in vigorous neonates led to fewer adverse outcomes and better overall neonatal adaptation.^[10] Our study builds on this by showing a specific feeding-related benefit from a similar but more targeted approach – sweeping the oral cavity to clear secretions and stimulate oral structures.

Structured tools such as the neonatal oral-motor assessment scale, developed by Palmer et al., and the SOMA tool, used by Yamamoto et al., have been employed to evaluate feeding readiness in preterm infants.^[18,19] Although our study did not use formal neuromotor scales, the LATCH score provided a practical proxy for feeding effectiveness. The significantly better scores in the intervention group suggest enhanced coordination of suck–swallow–breathe reflexes, which are essential for successful breastfeeding.

Furthermore, Ostadi et al. demonstrated that non-nutritive sucking combined with swallowing exercises in NICU infants improved oral feeding outcomes and reduced the duration of gavage feeding.^[20] While our study population included only term neonates, it is plausible that even mild oral stimulation in this group could strengthen orofacial reflexes and enhance coordination, leading to improved latch and feeding success.

From a public health perspective, breastfeeding promotion strategies must emphasise practical, low-cost interventions that can be implemented in resource-limited settings. The sweeping technique used in this study requires no equipment, minimal training and can be safely performed by healthcare providers or trained birth attendants. Given its simplicity and positive impact on early breastfeeding, it may be integrated into delivery room routines, especially in baby-friendly hospital initiatives (BFHI) settings.^[13]

The association between pre-delivery maternal knowledge and breastfeeding success was also significant in our study, particularly among primigravida mothers. Similar findings have been noted in studies emphasising antenatal education as a determinant of breastfeeding outcomes.^[21] This highlights the importance of combining maternal education with supportive neonatal interventions to optimise breastfeeding initiation.

CONCLUSION

This study demonstrated that early oral stimulation using a simple sweeping technique significantly improved LATCH scores among term neonates, indicating more effective breastfeeding initiation. Oral motor stimulation in the form of sweeping the oral cavity proved to be a safe, simple and low-cost intervention that can enhance breastfeeding performance from the very beginning.

In addition, our observations revealed that pre-delivery breastfeeding knowledge was poorer among primigravida mothers and among those lacking adequate family support. This underscores the importance of creating a supportive social environment and ensuring that expectant mothers receive appropriate counselling before delivery. Providing education and engaging family members can play a critical role in establishing successful breastfeeding practices.

Given these findings, we recommend considering oral cavity sweeping as part of routine newborn care for all term neonates, provided that adequate antenatal counselling has been given and family support is available to sustain breastfeeding efforts. We also suggest that this simple technique be incorporated into training programs for ASHA workers, midwives and NICU nurses to help improve neonatal nutrition and breastfeeding outcomes at the community level.

While our results are encouraging, this study was limited to term neonates delivered vaginally in a single centre and outcomes were measured only during the immediate postpartum period. Long-term breastfeeding success and generalisability to other settings remain to be established. Therefore, further research involving larger, more diverse populations and longer follow-up is needed to confirm these findings and guide broader implementation.