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Oromotor intervention for improving oral feed readiness in preterm infants
*Corresponding author: H. K. Tejal, Department of Paediatric, AJ Institute of Medical Sciences and Hospital, Mangaluru, Karnataka, India. tejalhk15@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Suresh A, Rajan A, Tejal HK. Oromotor intervention for improving oral feed readiness in preterm infants. Karnataka Paediatr J. 2025;40:109-13. doi: 10.25259/KPJ_49_2025
Abstract
Objectives:
Early oral motor intervention – comprising oral stimulation, oral support and noninvasive nasal suctioning – may enhance oral feeding skills in preterm infants and reduce hospital stay. Preterms typically struggle to initiate oral feeding due to the immature coordination of sucking, swallowing and breathing, typically developed between 32 and 34 weeks of gestation. This study aimed to study the improvement in the Preterm Oral Feeding Readiness Assessment Scale (POFRAS) after 5 days of oro-motor intervention in preterm infants.
Material and Methods:
This interventional study was conducted in the neonatal intensive care unit (NICU) at AJ Institute of Medical Sciences, Mangalore on neonates with gestational age more than 27 + 6/7 weeks and up to 34 + 6/7 weeks. Newborns were randomly assigned to either the oro-motor intervention group or a control group receiving standard care. All preterm infants were assessed using the POFRAS scale. The intervention was done for 5 min twice a day for 5 consecutive days. Both groups were then reassessed for oral feeding readiness using the POFRAS score after the intervention.
Results:
A total of 70 infants were enrolled, with 35 in the intervention group and 35 in the control group. Nasogastric (NG) tube feeds were initiated earlier in the intervention group, with 68.6% starting on the 1st–2nd day of life as compared to 40% in the control group. Full feeds on the NG tube were achieved earlier in the intervention group. Oral feeds were initiated significantly earlier in the intervention group, with a mean initiation day of 4.7 ± 1.3 days. Newborns in the intervention group achieved full oral feeds earlier, with a mean day of 6.1 ± 1.6 days, while the control group achieved this milestone at 11.1 ± 6.2 days (P < 0.001). The improvement in POFRAS score from the first to the second assessment was significantly higher in the intervention group (2.0 ± 0.6) compared to the control group (0.7 ± 0.9, P < 0.001).
Conclusion:
These findings suggest that implementing early oro-motor intervention strategies can be beneficial in improving the clinical outcomes of preterm infants. Incorporating this simple, low-cost strategy into routine NICU care may optimise feeding outcomes and potentially reduce hospital stay.
Keywords
Feeding behaviour
Infant feeding
Non-nutritive sucking
Oral stimulation
INTRODUCTION
Advances in assisted reproductive technologies over the past three decades have increased the survival of preterm infants. However, these infants often struggle to initiate oral feeding due to the immature coordination of sucking, swallowing and breathing, typically developed between 32 and 34 weeks of gestation. Inadequate oral feeding skills can lead to feeding difficulties, longer hospital stays and increased morbidity.[1] Preterm infants, particularly those born before 34 weeks, often lack the neuromuscular development necessary for effective oral feeding, predisposing them to complications such as apnoea, bradycardia and poor weight gain.[2,3]
Early oral motor intervention (OMI), which includes nonnutritive sucking (NNS), oral stimulation and support, has shown promise in enhancing oral feeding readiness and reducing the length of hospital stay.[4,5] However, previous studies have been limited by small sample sizes and methodological constraints. The rooting and sucking reflexes, essential for effective feeding, emerge around 28 and 34 weeks of gestation, respectively. Their development plays a vital role in promoting feeding skills, brain maturation and behavioural regulation.[3]
Feeding difficulties in preterm infants are often due to underdeveloped gastrointestinal and neurological systems, making the transition from tube to oral feeding challenging. Oral stimulation has been shown to accelerate this transition by promoting neurodevelopmental growth, rhythmic mouth movements and improved feeding performance. In India, with a high incidence of preterm births, these interventions are especially critical. Moderately preterm infants, though less studied, also face feeding delays, contributing to extended hospitalisations beyond 36 weeks postmenstrual age.[4,5]
This study aims to evaluate whether implementing an oral stimulation programme in the neonatal intensive care unit (NICU) can improve sucking reflexes and promote earlier oral feeding initiation. The ultimate goal is to reduce the length of NICU stay and improve overall outcomes for preterm infants.
Aims and objectives
Aim
The aim of the study is to evaluate the impact of OMI on feeding readiness in preterm neonates using the Preterm Oral Feeding Readiness Assessment Scale (POFRAS).
Objectives
To compare pre- and post-intervention POFRAS scores in the experimental group
To compare the POFRAS score change in the control group
To evaluate differences in feeding milestones and hospital stay between the groups.
MATERIAL AND METHODS
This hospital-based interventional study was conducted in the NICU of A.J. Institute of Medical Sciences and Research Centre, Mangalore, Dakshina Kannada, over a period of 18 months from July 2022 to January 2024.
All newborns with gestational age between 27 + 6/7 weeks and up to 34 + 6/7 weeks who were haemodynamically stable were included in the study. Infants with facial deformities (cleft lip and cleft palate) and those with major congenital anomalies were excluded from the study.
Ethical clearance
Institutional ethics committee permission was obtained vide letter number AJEC/REV/124/2022 dated 28 July 2022, and subjects were recruited for the study after obtaining written informed consent from the parents/guardians of the preterm neonates.
Methodology
The demographic and perinatal data of all included neonates, including birth weight, sex, antenatal steroid exposure, and incidence of premature rupture of membranes, were collected from maternal interviews and medical records. The newborns were randomly divided into two groups: the Oro-motor intervention group, which received structured oral motor stimulation in addition to routine NICU care, or the control group, which received routine NICU care without any OMI. Randomisation was performed consecutively based on a pre-prepared allocation list to ensure comparable group sizes.
Intervention protocol
Infants in the intervention group received oral motor stimulation twice daily for 5 consecutive days. Each session lasted approximately 5 minutes and was conducted by trained NICU personnel following a standardised 8-step protocol. It begins with cheek stretches to improve tone and mobility, followed by a lip roll and lip curl to enhance lip seal and control. Gum massage promotes oral awareness and readiness for sucking. Stimulation then targets the lateral borders of the tongue and cheek to encourage lateral movements and the mid-blade of the tongue and palate to support tongue elevation and cupping. The next step is to elicit a suck reflex through gentle stimulation and finally to support NNS, reinforcing coordinated suck-swallow-breathe patterns.[1,2]
Post-intervention assessment
After the 5 days, all infants were reassessed using the POFRAS to evaluate changes in feeding readiness.
Feeding initiation and progression
All infants were started on enteral feeding through a nasogastric (NG) tube as per unit protocol, beginning with trophic feeds and advancing gradually based on tolerance, gastric residuals and absence of abdominal distension. The volume of feeds was increased incrementally until full enteral feeds were achieved. Oral feeding was initiated once the infant demonstrated clinical stability and the capability of coordinating suck–swallow–breathe patterns. Progression from partial to full oral feeds was guided by daily assessments, with oral attempts offered before NG feeds and volumes increased as tolerated. Kangaroo Mother Care (KMC) was initiated in both groups as soon as infants were clinically stable and demonstrated readiness, and its duration was recorded in the clinical chart.
Outcomes
Primary outcomes were studied in terms of day of life when feeds were initiated, when full NG feeds were achieved, when oral feeding was initiated, when full oral feeds were achieved and changes in POFRAS scores from baseline to post-intervention. Secondary outcomes included the stay in the NICU and hospital. All the data were documented in MS Excel and documented in tabular form.
Sample size
Based on the study conducted by Chang et al., titled ‘Preterm oral feeding scale to assist in deciding initial oral feeding of preterm infants[6] in NICUs’ conducted in Chung Shan Medical University Hospital, Taichung, Taiwan, to detect difference of 19.8 (L) in neonatal oral motor assessment (NOMA) scale between groups assuming 95% confidence and 80% pooled standard deviation of 1.5, the sample for study is 31.8 approximately, 32 in each group. Further assuming a 10% attrition ratio, the final sample size estimated for the study is 35 in each group.
n = 2(Z1-α/2 + Z1-β)2 σ2/L2
Sampling technique
The purposive sampling technique was adopted to select the study subjects.
Statistical analysis
All the data collected were analysed using IBM Statistical Package for the Social Sciences Statistics for Windows, Version 22.0. Descriptive statistics, frequency analysis and percentage analysis were used to summarise the data for categorical variables. For continuous variables, mean and standard deviation were used. Chi-square test or Fisher’s exact test was used for comparison of categorical variables to find the significance as required. Significance of bivariate samples was found using the unpaired sample t-test in independent groups. The Probability value of <0.005 is considered statistically significant.
RESULTS
A total of 70 babies were included in the study, with 35 in the intervention group and 35 in the control group. The mean gestational age was comparable between the groups (intervention: 33.2 ± 1.5 weeks; control: 33.1 ± 1.2 weeks; P = 0.93), as was birth weight (intervention: 1.77 ± 0.34 kg; control: 1.91 ± 0.31 kg; P = 0.07). No statistically significant differences were observed in any of the other demographic data.
Primary outcomes
Primary outcomes as shown in Table 1, depicted that oral stimulation significantly improved early initiation and achievement of feeding milestones. Initiation of NG feeds and progression to full NG feeds occurred earlier in the intervention group. Oral feeding initiation occurred on average by day 4.7 in the intervention group versus day 9.0 in the control group, and full oral feeds were achieved earlier in the intervention group.
| Outcome | Intervention group (n=35) | Control group (n=35) | P-value |
|---|---|---|---|
| Initiation of NG feeds (days) | 2.3±0.7 | 2.9±1.2 | 0.02 |
| Full NG feeds achieved (days) | 3.7±1.1 | 5.3±1.9 | <0.001 |
| Oral feed initiation (days) | 4.7±1.3 | 9.0±3.2 | <0.001 |
| Full oral feeds achieved (days) | 6.1±1.6 | 11.1±6.2 | <0.001 |
| POFRAS score (baseline) | 28.9±1.2 | 30.2±1.1 | 0.005 |
| POFRAS score improvement | 2.0±0.6 | 0.7±0.9 | <0.001 |
NG: Nasogastric, POFRAS: Preterm oral feeding readiness assessment scale
Feeding readiness scores (POFRAS)
While the initial POFRAS scores were lower in the intervention group, the improvement over time was significantly higher, indicating a strong impact of oral stimulation on feeding readiness.
KMC
In the intervention group, 30 infants (85.7%) received KMC for ≥2 h/day, with a mean duration of 3.1 ± 0.8 h/day. In the control group, 27 infants (77.1%) received KMC for ≥2 h/day, with a mean duration of 2.4 ± 0.9 h/day.
Hospital outcomes
There was a significant reduction in the length of stay:
NICU stay: 7.0 ± 1.8 days (intervention) versus 12.7 ± 6.2 days (control); P < 0.001
Total hospital stay: 9.2 ± 1.8 days (intervention) versus 16.8 ± 7.3 days (control); P < 0.001.
Furthermore, the study found that newborns from the intervention group achieved full oral feeds by 7th to 10th day, while those from the control group by 14th to 22nd day of life, as shown in Table 2. The results are statistically significant and P < 0.001.
| Day range to full oral feeds | Intervention group (n=35) (%) | Control group (n=35) (%) |
|---|---|---|
| 3–6 days | 22 (62.9) | 0 (0) |
| 7–10 days | 10 (28.6) | 12 (34.3) |
| 11–13 days | 3 (8.5) | 8 (22.9) |
| 14–22 days | 0 (0) | 15 (42.9) |
| Mean±SD (days) | 6.1±1.6 | 11.1±6.2 |
SD: Standard deviation
The mean day of life when the cases in the intervention group achieved full oral feeds was 6.1 ± 1.6, while that of the control group was 11.1 ± 6.2, and this difference was statistically significant (P < 0.001). The mean duration of NICU stay in the intervention group was 7.0 ± 1.8 days, while that of the control group was 12.7 ± 6.2 days, and this difference was highly statistically significant with P < 0.001. Duration of NICU stay ranged from 3 to 10 days in the intervention group as compared to longer 6–24 days in the control group. The mean duration of hospital stay in the intervention group was 9.2 ± 1.8 days as opposed to 16.8 ± 7.3 days in the control group. This was noted to be highly statistically significant (P < 0.001).
DISCUSSION
This study evaluated the impact of OMI on the feeding progression and hospital stay duration in preterm neonates. The findings demonstrate that structured oral stimulation significantly improves feeding readiness, accelerates the transition to oral feeds and reduces NICU and hospital stays.
These findings reflect the growing evidence which shows the supportive role of early OMI in improving feeding establishment in preterm infants.[6]
It is already known that the suck-swallow coordination with breathing is achieved by babies only by 32 to 34 weeks of gestation and consequently contributed to delay in initiation of feeds in a preterm infant.[2,6] It has also been reported in previous studies that the lower the birthweight or postmenstrual age, the more the delay in initiation of oral feeds.[7,8] In our study, the group in whom early OMI was done were able to initiate oral feeds on an average by day 4.7 which was significantly earlier than the control group (day 9) in spite of being the same gestational age and in fact lower in weight. Similar findings have been reported by Fucile et al. and Rocha et al., where structured stimulation protocols significantly accelerated the transition from tube to oral feeding.[9,10]
POFRAS as an instrument to quickly assess and implement for feeding readiness has already been studied by Chang et al.[11] According to the literature review, cut-off values of 28, 29, and 30 were proved to obtain the best values of POFRAS for sensitivity and specificity.[10] Both our groups however did not show a significant difference in terms of baseline POFRAS and hence just relying on a single score would not have helped in further management. However, improvement in POFRAS scores in this study supports the effectiveness of early OMI in enhancing oral feeding readiness. Lau and Smith in their study confirmed nonnutritive sucking and oral stimulation helps in maturation of the oro-motor coordination and thereby improves feeding performance, which is consistent with our results.[12] The use of structured assessment tools like POFRAS provides a simple, objective way to assess feeding readiness. This reinforces the applicability of such interventions in routine NICU care.
The impact of oro-motor intervention on clinical outcomes was notable, with infants who have undergone OMI not only initiating but establishing oral feeds by day 6.1 compared to 11.1 in controls. The majority of the babies in the intervention group established feed early in the 1st week itself as compared to the other group where the majority established feed by 2nd week. These findings align with previous reports that early stimulation shortens the duration to full oral intake.[9,10] This subsequently will shorten NICU stay as it has in our intervention group (7 vs. 12.7 days). This too mirrors outcomes from prior studies, where structured feeding interventions reduced hospitalization and improved efficiency of care.[5,13]
Other than feeding readiness, OMI may play a role in the neurodevelopment of preterm babies by supporting rhythmic mouth movements thereby improving cortical regulation of feeding behaviours.[12,14] Furthermore, the biggest advantage of these interventions are that they are simple, cost-effective, and feasible to incorporate into neonatal units, which is particularly relevant in countries like India with a high burden of preterm births.[1]
While our findings are encouraging, feeding difficulties in preterm infants may persist beyond the neonatal period. There is a need for long-term follow-up studies, such as those by Jadcherla et al.[15], which have emphasized that prematurity and comorbidities continue to influence feeding milestones and later growth, highlighting the importance of continued monitoring and intervention.
In conclusion, OMI in preterm neonates proves to be a beneficial, low-risk strategy to promote feeding efficiency, support earlier discharge and enhance clinical outcomes without altering baseline demographic variables.
Limitations and recommendations
The drawback of this study is its relatively small sample size and single-centric nature. This may limit the broader applicability of the results. The study additionally focuses on only immediate short-term outcomes. Blinding of caregivers was not feasible, which might have influenced feeding progression. Nutritional intake variables such as the source of milk and fortification practices were also not standardised across both groups. To build on these findings, future research should include larger, multi-centre randomised controlled trials, implement standardised protocols for early intervention and employ blinding to reduce observer bias.
CONCLUSION
This study demonstrates that early intervention in neonatal care significantly enhances outcomes in preterm infants. Specifically, the intervention group showed earlier initiation and achievement of full NG and oral feeds, leading to shorter durations of NICU and hospital stays. The mean gestational age at delivery, mode of delivery, gender distribution and birth weight were similar between the intervention and control groups, indicating no significant differences. However, the intervention group exhibited substantial improvements in the POFRAS scores from the first to the final assessment, underscoring the effectiveness of the early intervention approach in promoting better feeding readiness and overall neonatal health. These findings suggest that implementing early intervention strategies can be beneficial in improving the clinical outcomes of preterm infants.
Ethical approval:
The research/study was approved by the Institutional Review Board at AJ Institute of Medical Sciences, number AJEC/REV/124/2022, dated 28 July 2022.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Global, regional, and national estimates of levels of preterm birth in 2014: A systematic review and modelling analysis. Lancet Glob Health. 2019;7:e37-46.
- [CrossRef] [PubMed] [Google Scholar]
- Development of suck and swallow mechanisms in infants. Ann Nutr Metab. 2015;66:7-14.
- [CrossRef] [PubMed] [Google Scholar]
- Physiology of aerodigestive development and implications for feeding. J Pediatr Gastroenterol Nutr. 2017;65:184-95.
- [Google Scholar]
- Maturation of oral feeding skills in preterm infants. Acta Paediatr. 2008;97:61-7.
- [CrossRef] [PubMed] [Google Scholar]
- Feeding interventions for infants and children with dysphagia. Semin Speech Lang. 2013;34:254-69.
- [Google Scholar]
- Preterm oral feeding scale to assist in deciding initial oral feeding of preterm infants in neonatal intensive care units. Pediatr Neonatol. 2022;63:269-75.
- [CrossRef] [PubMed] [Google Scholar]
- Exploring factors related to oral feeding progression in premature infants. Adv Neonatal Care. 2013;13:288-94.
- [CrossRef] [PubMed] [Google Scholar]
- Factors influencing independent oral feeding in preterm infants. J Neonatal Perinatal Med. 2015;8:15-21.
- [CrossRef] [PubMed] [Google Scholar]
- Oral stimulation accelerates the transition from tube to oral feeding in preterm infants. J Pediatr. 2002;141:230-6.
- [CrossRef] [PubMed] [Google Scholar]
- A randomized study of the efficacy of sensory-motor-oral stimulation and non-nutritive sucking in very low birthweight infants. Early Hum Dev. 2007;83:385-8.
- [CrossRef] [PubMed] [Google Scholar]
- Clinical validation of the preterm oral feeding readiness assessment scale in Taiwan. J Pediatr Nurs. 2021;59:e84-92.
- [CrossRef] [PubMed] [Google Scholar]
- A novel approach to assess oral feeding skills of preterm infants. Neonatology. 2011;100:64-70.
- [CrossRef] [PubMed] [Google Scholar]
- The effects of Premature Infant Oral Motor Intervention (PIOMI) on oral feeding of preterm infants: A randomized clinical trial. Int J Pediatr Otorhinolaryngol. 2019;120:202-9.
- [CrossRef] [PubMed] [Google Scholar]
- Relationship of neonatal oral motor assessment scale to feeding performance of premature infants. Dev Med Child Neurol. 2012;54:888-92.
- [CrossRef] [PubMed] [Google Scholar]
- Impact of prematurity and co-morbidities on feeding milestones in neonates: A Retrospective study. J Perinatol. 2010;30:201-8.
- [CrossRef] [PubMed] [Google Scholar]