Bottle feeding, Breastfeeding, Feeding and eating disorders of childhood, Feeding behavior, Infant, Premature.



  1. Gennattasio, Annmarie MSN, RN, NNP-BC
  2. Perri, Elizabeth A. MSN, RN, NNP-BC
  3. Baranek, Donna MSN, RN, NNP-BC
  4. Rohan, Annie PhD, RN, NNP/PNP-BC


Abstract: Oral feeding readiness is a complex concept. More evidence is needed on how to approach beginning oral feedings in premature hospitalized infants. This article provides a review of literature related to oral feeding readiness in the premature infant and strategies for promoting safe and efficient progression to full oral intake. Oral feeding readiness assessment tools, clinical pathways, and feeding advancement protocols have been developed to assist with oral feeding initiation and progression. Recognition and support of oral feeding readiness may decrease length of hospital stay and have a positive impact on reducing healthcare costs. Supporting effective cue-based oral feeding through use of rigorous assessment or evidence-based care guidelines can also optimize the hospital experience for infants and caregivers, which, in turn, can promote attachment and parent satisfaction.


Article Content

Being born preterm presents numerous challenges for the baby including neurodevelopmental immaturity, physiologic instability, and behavioral state disorganization. In this context, there are often challenges with successful beginning of oral feedings and achievement of full oral intake. More evidence is needed on when and how to start oral feedings in premature infants. Although there are some universally accepted oral feeding practices in premature infants (e.g., not in the first weeks of age for micro-premature infants; not when orally intubated), individualized oral feeding plans are needed for the majority of premature infants. A review of literature related to oral feeding readiness in preterm infants and strategies for promoting safe and efficient progression to full oral intake are presented. Several tools for assessment of feeding readiness will be examined, in addition to clinical pathways, and protocols that aid in oral feeding initiation and progression. Recognition and support of oral feeding readiness may decrease length of hospital stay (LOS) and have a positive impact on reducing healthcare costs. Supporting effective cue-based oral feeding through use of rigorous assessment or evidence-based care guidelines can optimize the hospital experience for infants and caregivers, which, in turn, can promote attachment and parent satisfaction.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Background, Prevalence, and Cost to Society

Oral feeding readiness is a complex concept. Oral feeding readiness can be defined both in terms of readiness to initiate oral feedings and readiness for any particular oral feeding event. It is affected by postmenstrual age (PMA), neurodevelopmental maturity, behavioral state organization, physiologic stability, and is both directly and indirectly influenced by caregivers and the nursery environment (Kish, 2013; McGrath & Braescu, 2004).


The process by which oral feedings are established has an impact on maternal-infant attachment and parental satisfaction. Feedings offer opportunities for infants to develop a positive interactive bond with parents that influences emotional development, social learning, and health (Als, 1986; Harding, 2009). Alternatively, feeding difficulty in preterm infants has been shown to be a considerable source of stress for parents (Zanardo et al., 2011). Initiation or advancement of oral feedings in an infant who is physiologically unstable or developmentally immature may result in poor fluid management or aspiration, behavioral distress, unstable heart rate, hypoxia during feedings, increased energy expenditure, poor weight gain, and even failure to thrive (McGrath & Braescu, 2004).


Delay in attaining full oral feedings can delay hospital discharge and considerably increase the cost of care. Phibbs and Schmitt (2006) estimated the mean economic impact of 1 week of hospitalization at 34 weeks' PMA as approximately $4,528 (reflect 2003 prices, therefore, likely much higher in 2015). For convalescing preterm infants, there are wide variations in discharge practices between institutions related largely to feeding, weight gain, and intake issues (Blackwell et al., 2005; Eichenwald et al., 2001; McCormick, Escobar, Zheng, & Richardson, 2006). Practices that improve efficient development of feeding competence in preterm infants, and thus promote earlier hospital discharge, can reduce individual hospital fees by thousands of dollars, and collectively save millions in healthcare costs.


Feeding problems are implicated as a significant factor in hospital readmissions for preterm infants. Few published studies, however, have actually examined hospital readmission rates for preterm infants. Variations in hospital discharge practices among institutions appear to have an impact on early readmission rates (Young, Korgenski, & Buchi, 2013). Regardless of individual hospital readmission rates, feeding problems account for a significant portion of early readmissions for late preterm infants (Engle, Tomashek, & Wallman, 2007; Jain & Cheng, 2006; Young et al., 2013), whereas successful breastfeeding has been found to be protective against hospital readmission among infants born at under 33 weeks' gestation (Elder, Hagan, Evans, Benninger, & French, 1999).


Consensus Statements

In its 2008 policy statement, Hospital Discharge of the High-risk Neonate, the American Academy of Pediatrics (AAP) provides guidelines for hospital discharge of high-risk neonates, including the preterm neonate. The guidelines describe three physiologic competencies that are generally necessary for hospital discharge (AAP, 2008). Among these is oral feeding sufficient to support appropriate growth. Feeding dysfunction is recognized as a common unresolved medical issue that can persist after discharge and result in hospital readmission. Prior to discharge, it is therefore recommended that preterm infants establish competent feeding by breast or bottle, without cardiorespiratory compromise (AAP, 2008).


Methods for establishing competent feeding are not offered by AAP (2008); however, based on current literature, this target is not identifiable by weight or age. There is a growing body of evidence supporting systematic neurobehavioral assessment of feeding readiness in preterm infants, and active, individualized management of oral intake in this population.


Risk Factors for Oral Feeding Delay

The preterm infant has a very different neurosensory experience than the term infant prior to the initiation of oral feedings. Depending on disease severity and degree of prematurity, many preterm infants are exposed to weeks-or even months-of endotracheal intubation, gastric tube placements, nasopharyngeal suctioning, and other noxious oropharyngeal stimuli before the initiation of breast or bottle feedings. Clinical factors such as lung disease and gastroesophageal reflux, and environmental factors such as noise and maternal separation, may have an impact on the developing infant brain. These early atypical experiences are thought to alter development and modify behavior in prematurely born infants (Perlman, 2001). Intrinsic and extrinsic factors that alter development and modify behavior influence the efficacious transition to independent oral feeding in the preterm neonate.


Late-preterm infants (those born between 34.0 and <37.0 week's gestation) comprise 8.8% of all live births in the United States and are a group that is particularly vulnerable to delayed oral feeding success (Raju, Higgins, Stark, & Leveno, 2006). Late preterm infants have more difficulty establishing feeding than full-term infants, are discharged from the hospital at a younger PMA than term infants, and are likely to be separated from their mothers during hospitalization. These infants can plausibly spend fewer hospital hours being fed by their mothers than either earlier preterm or term infants. Breastfeeding initiation in late preterm infants is accordingly lower than for term infants, and possibly less than for infants born before 34 to 35 weeks' gestation (Radtke, 2011).


Neurobehavioral Assessment of Feeding Readiness

Heidelise Als' Synactive Model of Behavioral Organization provides a framework for assessing the development of the premature infant and supporting feeding progression in the NICU (Als, 1986). This model outlines opportunities for productive observation of the premature infant in order to identify the infant's increasing capacity for self-maintenance and self-regulation. According to Als, assessments related to feeding initiation and advancement should take into consideration the infant's state organization, motor skills, and autonomic regulation, as well as the infant's ability to interact with care providers. According to this theory, inordinate stress created by overzealous feeding advancement can potentially create maladaptive infant functioning and preclude the differentiation of feeding skills.


Physiologic and Developmental Considerations

An abundance of literature describes the qualitative and quantitative patterns of infant sucking. One of the earliest researchers in this field, Dr. Joyce Gryboski, characterized patterns of nutritive infant sucking and identified discrete differences between term and preterm infants (Gryboski, 1965, 1969). Other researchers have supported and refined these descriptions of infant feeding such that four major patterns have emerged (Table 1). Preterm infants demonstrate the range of these sucking patterns. More commonly than full-term infants, however, preterm infants demonstrate an immature or disorganized sucking pattern. The quality of sucking, swallowing, and breathing has been shown to be very different between preterm infants and term infants. Compared to term infants, preterm infants have diminished sucking pressure/amplitude and bolus volume, a shorter sucking cycle, lower per-minute sucking and swallowing frequency, and a preference for swallowing at certain phases of the respiratory cycle (Lau, Smith, & Schanler, 2003; Medoff-Cooper, McGrath, & Bilker, 2000). Appreciation of these various patterns remains a foundation for understanding feeding readiness and nutritive sucking in preterm infants.


The concept of feeding development and competence in preterm infants has been long considered by researchers and clinicians, and has grown to reflect infant behavior more than the volume of transferred fluid per unit of time (Briere, McGrath, Cong, & Cusson, 2014). Although a maximum amount of time needs to be designated for completion of a preterm infant feeding, there is reason to believe that longer, self-paced feedings represent optimal feeding efficiency for many preterm infants-especially those with difficult early NICU paths (Medoff-Cooper, 2000). A faster feeding with more milk consumed per minute is not likely the desirable competence standard for preterm infant feeding. Rather, we should consider framing oral feeding competence in terms of the ability to pace feeding in such a way that there is minimal physiologic cost or degradation of behavioral state. Suck-swallow coordination has been demonstrated with advancing PMA (Howe, Sheu, Hinojosa, Lin, & Holzman, 2007).

Table 1 - Click to enlarge in new windowTable 1. Patterns of Infant Nutritive Sucking

Because coordination between sucking, swallowing, and breathing is essential to achieve successful oral feeding, PMA is correlated to neurobehavioral readiness for oral feedings. As such, the introduction of oral feedings has been reserved in some nurseries for between 33 and 35 weeks' PMA. The literature suggests that this approach may be an unjustified oversimplification. Reports suggest that some infants are ready to initiate oral feedings sooner, even at 30 weeks' PMA (Kirk, Alder, & King, 2007). In addition, there appear to be some feeding factors that are more closely tied to gestational age at birth, rather than PMA (Amaizu, Shulman, Schanler, & Lau, 2008; Cunha, Barreiros, Goncalves, & Figueiredo, 2009; Medoff-Cooper et al., 2000), offering explanation for why younger-born infants have different oral feeding outcomes than older-born infants, even at a similar PMA. Gestational age, weight, and PMA should not be the defining criteria in determining oral feeding readiness. Rather, there should be consideration of the behavioral factors that contribute to effective feeding. The use of feeding readiness instruments and feeding assessment scales facilitates these evaluations, and can promote evidence-based feeding advancement processes.


Readiness Assessment Instruments

All preterm infant caregivers should be able to assess and describe feeding performance in a way that allows other caregivers to understand an infant's strengths and challenges, and provide information upon which to evaluate progression. The use of a formal readiness screening instrument to assess an infant's behavior and development has been introduced as a way to improve the accuracy of determining the appropriate time to initiate oral feedings (McGrath & Braescu, 2004). Assessment instruments also promote the use of common language to assist caregivers in effectively communicating information regarding feeding readiness and progression.


Several instruments are described in the literature to assist clinicians in measuring nutritive sucking behaviors and quantify feeding performance. Similar to other tools used by clinical nurses, the origin of feeding readiness instruments can date back a decade or more before appropriate validation studies are published. Using standard analysis methods, a recent Cochrane review of the literature identified several instruments for the assessment of feeding readiness in preterm infants (Crowe, Chang, & Wallace, 2012). These and other instruments are described below.


Preterm Infant Nipple Feeding Readiness Scale (PINFRS)

The PINFRS instrument is a 10-item scale used prior to each prospective oral feeding that awards points for gestational age, PMA, color, activity, state, cues, and tone. Based upon score, the infant being assessed will either "pass" or "fail" (McGrath & Braescu, 2004). The PINFRS tool indirectly measures feeding readiness by exploring factors related to the construct of feeding readiness. Reliability and validation studies of this instrument are still needed. The PINFRS was renamed in 2008, and has since also been referred to as the Feeding Readiness and Progression in Preterms Scale (FRAPPS) (Crowe et al., 2012).


The Early Feeding Skills Assessment (EFS)

The EFS assessment is a checklist for assessing infant readiness (Thoyre, Shaker, & Pridham, 2005). The EFS assessment is a three-section 36-item checklist for assessing infant feeding readiness, as well as for assessing tolerance of feeding and feeding recovery. It is a tool that evaluates the tolerance of feeding and for profiling the infant's developmental stage that targets specific feeding skills. Among these skills are the ability to remain engaged in feeding, the ability to organize oral-motor function, and the ability to coordinate swallowing with breathing while maintaining physiologic stability. Validation studies of this instrument are also still needed.


The "Oral Feeding Readiness" section of the EFS instrument is designed to assess whether the infant has sufficient energy for feeding, is in an optimal state, and has adequate baseline oxygen saturation. This section has five items, each with two choices. If all answers to the five items are yes, it is suggested that the caregiver attempts to feed the infant. Content validity of the EFS has been established with expert neonatal nurses and oral feeding researchers, and both intra- and interrater reliability have been found to be acceptable (Thoyre et al., 2005).


Premature Oral Feeding Readiness Assessment Scale (POFRAS)

This scale includes objective criteria to assess preterm infants' readiness to start breastfeeding (Fujinaga et al., 2013). Its goal is to systematically establish the adequate time to safely initiate breastfeeding in the preterm infants. It is comprised of five categories with a total of 18 items to evaluate.


The POFRAS scale was first developed to assess preterm infant readiness to start breastfeeding and is also designed to assign a "pass" or "fail" designation. This 18-item scale awards points for factors including PMA, behavioral state, tone, gag reflex, tongue and movements, and maintenance of an alert state. Each item is scored 0-2, for a maximum score of 36. In clinical validation studies of the POFRAS, the tool was demonstrated to be both sensitive and specific at a cutoff score of 30 (Fujinaga et al., 2013). See Supplemental Digital Content, Figure 1,


Neonatal Oral-Motor Assessment Scale (NOMAS)

The NOMAS tool was developed to guide the healthcare professional in making decisions about feeding advances in newborns, including gavage feedings, through the identification and quantification of oral-motor patterns (Bingham, Ashikaga, & Abbasi, 2012; Braun & Palmer, 1985). It is a 28-item checklist that includes measurement of maturational items for evaluating infant organization and pathologic items for evaluating dysfunction. Although demonstrated to have acceptable interrater reliability (Palmer, Crawley, & Blanco, 1993), recent examination found that baseline NOMAS scores were not predictive of feeding performance and that NOMAS items may not reflect key features of feeding behavior (Bingham et al., 2012).


We must continually reassess and refine our feeding practices. An ongoing need for psychometric testing for many of our clinical feeding assessment tools has been demonstrated (Briere et al., 2014). In addition, despite our increasing knowledge that oral feeding readiness and feeding success should not be measured by the historical volume-driven model, many researchers continue to include outcome measures that define feeding success as volume consumed over time rather than a multidimensional model of oral feeding readiness, progression, and success. Still other researchers focus on the attainment of full oral intake at younger ages in defining success. In keeping with the Synactive Model of Behavioral Organization, we believe that feeding success is more appropriately assessed using infant behavioral criteria, than by using volume or age measures.


Prefeeding Interventions

Adopting best feeding practices for preterm infants often requires a cultural shift in how nurses and other care providers view feeding interactions in the hospital setting. Evidence supports the view that preterm infant feeding is skilled care, and that introduction of oral feedings and transition to full oral feedings require continuous assessment and the application of evidence-based knowledge. In addition to use of valid and reliable assessment instruments, several other strategies have been associated with the efficient transition to full oral feedings.


Nonnutritive sucking (NNS) refers to the use of a pacifier, and can occur before, during, or after gavage feeding; before or after bottle/breastfeeding; or outside of feeding times (Pinelli & Symington, 2000). Although pacifier use has the potential to have an impact on breastfeeding or the incidence of oral aversion in preterm infants, there is little evidence to support this hypothesis. Preterm infants methodically exposed to NNS prior to the initiation of oral feedings have been shown to have a shorter interval for achievement of full oral feedings than infants who did not have this exposure (Bingham, Ashikaga, & Abbasi, 2010; Daley & Kennedy, 2000; Kirk et al., 2007; Pickler, Best, Reyna, Gutcher, & Wetzel, 2006; Pinelli & Symington, 2000; Shaker & Woida, 2007). Research has also shown that NNS in preterm infants has a positive impact on infant state, reduces defensive behaviors, and improves overall feeding performance (Arvedson, Clark, Lazarus, Schooling, & Frymark, 2010; Daley & Kennedy, 2000; Pickler, 2004; Pickler, Frankel, Walsh, & Thompson, 1996). A Cochrane meta-analysis of studies examining the impact of NNS in preterm infants concluded that NNS reduces hospital stay in preterm infants and facilitates transition to full oral feedings (Pinelli & Symington, 2005).


Numerous studies have demonstrated the positive impact of oral and/or perioral stimulation prior to the introduction of oral feedings. Oral and perioral stimulation interventions provide sensorimotor input to the oral and perioral structures, including the cheeks, lips, jaw, gums, and tongue through gentle application of a swab or finger. These interventions have been strongly correlated with reduced length of time to transition to full oral feedings in preterm infants, increased overall intake, and higher breastfeeding rates (Arvedson et al., 2010; Pimenta et al., 2008). In a randomized study of infants born at 26 to 29 weeks' gestation, prefeeding oral stimulation decreased time to achieve full oral feedings by more than 1 week (Fucile, Gisel, & Lau, 2002).


Other research has evaluated the impact of a 5-minute oral-motor intervention that provides assisted movement to activate muscle contraction and provides movement against resistance to build strength beginning at 29 weeks PMA. Researchers found that this intervention was well tolerated and that the infants that received the intervention transitioned from their first oral feed to total oral feedings 5 days sooner than controls and were discharged almost 3 days sooner than controls (Lessen, 2011).


Prefeeding oral application of colostrum has been described as an immune-support intervention (Rodriguez, Meier, Groer, & Zeller, 2009; Rodriguez et al., 2010). Although this practice may be empirically linked to feeding achievement, there is a need for evidence to support this practice in oral feeding facilitation.


Clinical Protocols/Guidelines

Behaviorally driven feeding initiation and advancement is supported both theoretically and clinically; however, researchers have also demonstrated that protocol-driven pathways for oral feeding advancement may accelerate the transition time from tube feedings to full oral feedings (Kirk et al., 2007; Premji, McNeil, & Scotland, 2004; Simpson, Schanler, & Lau, 2002). Feeding assessment tools are now being incorporated into practical feeding initiation and advancement algorithms (Ross & Philbin, 2011). Our own proposed algorithm can be found in Figure 2.


When used in conjunction with careful neurobehavioral assessment, proponents of feeding advancement protocols suggest that they not only allow for earlier attainment of oral feedings, but can also provide increased feeding practice opportunities to augment successful discharge. Simpson et al. (2002) demonstrated a reduction in time to full oral feedings from 36.0 weeks to 34.5 weeks PMA using a feeding advancement protocol rather than use of daily physician discretion. Kirk et al. (2007) also compared time to attainment of full oral feedings between a study group of preterm infants with feeding advancement managed by nurses using a clinical pathway and a control group of preterm infants managed by physician orders. Study infants reached full oral feedings 6 days earlier than controls (Kirk et al., 2007).

Figure 2 - Click to enlarge in new windowFigure 2. General Purpose Oral Feeding Initiation and Advancement Pathway

Conclusions and Future Directions

Although technological advances have assisted us in reducing morbidity in preterm infants, efficient establishment of competent feedings remains a challenge. Delayed attainment of full oral feedings presents as an important factor preventing hospital discharge of preterm infants, and feeding issues are frequently implicated in early, unscheduled hospital readmissions for this patient population. The literature describes instruments for assessing feeding readiness and feeding quality in preterm infants, although further psychometric testing for most of these instruments is warranted.


Systematic use of NNS and oral/perioral stimulation prior to the initiation of oral feedings presents as a significant but often overlooked strategy to promote more efficient progression to full oral feedings. There is ample opportunity to explore best practices for providing these interventions. In addition, although prefeeding oral application of colostrum is an immune-support intervention and has been empirically linked with feeding achievement, further research is needed to evaluate the efficacy of this practice relative to feeding achievement.


Neonatal caregivers have a responsibility to understand the issues that have an impact on initiation of oral feedings in preterm infants and factors that influence attainment of full oral intake. Recognition and support of oral feeding readiness can optimize the hospital experience for the infant-caregiver dyad, promote parental attachment, decrease LOS, reduce hospital readmission rates, and have a positive effect on reducing healthcare costs. Although infant factors such as PMA, neurodevelopmental maturity, behavioral state, and physiologic stability have an impact on oral feeding in this population, caregiver and environmental factors are also well recognized to influence oral feeding processes and outcomes. The incorporation of valid and reliable instruments to assess feeding readiness and to quantify feeding performance, and algorithms to facilitate systematic oral feeding advancement present as important approaches for efficiently achieving the AAP (2008) goal of establishing competent feeding in the preterm infant prior to hospital discharge.


Clinical Implications


* All preterm infant caregivers should be able to assess and describe feeding performance in a way that allows other caregivers to understand an infant's strengths and challenges, and provide information upon which to evaluate progression.


* Postmenstrual age, weight, or gestational age should not be the defining criteria in determining oral feeding readiness. Rather, there should be consideration of the factors that contribute to effective feeding.


* Feeding assessment instruments should be incorporated into cue-based care to assist caretakers in considering the various factors relevant to oral feeding commencement and advancement, and promote the use of common language to assist caretakers in effectively communicating information regarding feeding readiness and progression.


* Stress created by ill-timed oral feeding advancements can create maladaptive infant feeding behaviors and impede the successful differentiation of feeding skills.


Instructions for Taking the CE Test Online Oral Feeding Readiness Assessment in Premature Infants


* Read the article. The test for this CE activity can be taken online at Tests can no longer be mailed or faxed.


* You will need to create a free login to your personal CE Planner account before taking online tests. Your planner will keep track of all your Lippincott Williams & Wilkins online CE activities for you.


* There is only one correct answer for each question. A passing score for this test is 13 correct answers. If you pass, you can print your certificate of earned contact hours and the answer key. If you fail, you have the option of taking the test again at no additional cost.


* For questions, contact Lippincott Williams & Wilkins: 1-800-787-8985.


Registration Deadline: April 30, 2017


Disclosure Statement:


The authors and planners have disclosed that they have no financial relationships related to this article.


Provider Accreditation:


Lippincott Williams & Wilkins, publisher of MCN, The American Journal of Maternal/Child Nursing, will award 2.5 contact hours for this continuing nursing education activity.


Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.


This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.5 contact hours. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the District of Columbia and Florida CE Broker #50-1223. Your certificate is valid in all states.




* The registration fee for this test is $24.95.



For additional continuing nursing education activities on neonatal topics, go to




Als H. (1986). A synactive model of neonatal behavioral organization: Framework for the assessment of neurobehavioral development in the premature infant and for support of infants and parents in the neonatal intensive care environment: Part I. Theoretical Framework. Physical and Occupational Therapy in Pediatrics, 6(3-4), 3-53. doi:10.1080/J006v06n03_02 [Context Link]


Amaizu N., Shulman R., Schanler R., Lau C. (2008). Maturation of oral feeding skills in preterm infants. Acta Paediatrica, 97(1), 61-67. doi:10.1111/j.1651-2227.2007.00548.x [Context Link]


American Academy of Pediatrics. (2008). Hospital discharge of the high-risk neonate. Pediatrics, 122(5), 1119-1126. doi:10.1542/peds.2008-2174 [Context Link]


Arvedson J., Clark H., Lazarus C., Schooling T., Frymark T. (2010). Evidence-based systematic review: Effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology, 19(4), 321-340. doi:10.1044/1058-0360(2010/09-0067) [Context Link]


Bingham P. M., Ashikaga T., Abbasi S. (2010). Prospective study of non-nutritive sucking and feeding skills in premature infants. Archives of Disease in Childhood - Fetal and Neonatal Edition, 95(3), F194-F200. doi:10.1136/adc.2009.164186 [Context Link]


Bingham P. M., Ashikaga T., Abbasi S. (2012). Relationship of neonatal oral motor assessment scale to feeding performance of premature infants. Journal of Neonatal Nursing, 18(1), 30-36. doi:10.1016/j.jnn.2010.09.004 [Context Link]


Blackwell M. T., Eichenwald E. C., McAlmon K., Petit K., Linton P. T., McCormick M. C., Richardson D. K. (2005). Interneonatal intensive care unit variation in growth rates and feeding practices in healthy moderately premature infants. Journal of Perinatology, 25(7), 478-485. doi:10.1038/ [Context Link]


Braun M., Palmer M. (1985). A pilot study of oral-motor dysfunction in "at risk" infants. Physical and Occupational Therapy in Pediatrics, 5, 13-26. doi:10.1080/J006v05n04-02 [Context Link]


Briere C. E., McGrath J., Cong X., Cusson R. (2014). State of the science: A contemporary review of feeding readiness in the preterm infant. Journal of Perinatal and Neonatal Nursing, 28(1), 51-58. doi:10.1097/JPN.0000000000000011 [Context Link]


Crowe L., Chang A., Wallace K. (2012). Instruments for assessing readiness to commence suck feeds in preterm infants: Effects on time to establish full oral feeding and duration of hospitalisation. Cochrane Database of Systematic Reviews, 4, CD005586. doi:10.1002/14651858.CD005586.pub2 [Context Link]


Cunha M., Barreiros J., Goncalves I., Figueiredo H. (2009). Nutritive sucking pattern-From very low birth weight preterm to term newborn. Early Human Development, 85(2), 125-130. doi:10.1016/j.earlhumdev.2008.07.003 [Context Link]


Daley H. K., Kennedy C. M. (2000). Meta analysis: Effects of interventions on premature infants feeding. Journal of Perinatal and Neonatal Nursing, 14(3), 62-77. [Context Link]


Eichenwald E. C., Blackwell M., Lloyd J. S., Tran T., Wilker R. E., Richardson D. K. (2001). Inter-neonatal intensive care unit variation in discharge timing: Influence of apnea and feeding management. Pediatrics, 108(4), 928-933. [Context Link]


Elder D. E., Hagan R., Evans S. F., Benninger H. R., French N. P. (1999). Hospital admissions in the first year of life in very preterm infants. Journal of Paediatrics and Child Health, 35(2), 145-150. [Context Link]


Engle W. A., Tomashek K. M., Wallman C. (2007). "Late-preterm" infants: A population at risk. Pediatrics, 120(6), 1390-1401. doi:10.1542/peds.2007-2952 [Context Link]


Fucile S., Gisel E., Lau C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in preterm infants. Journal of Pediatrics, 141(2), 230-236. doi:10.1067/mpd.2002.125731 [Context Link]


Fujinaga C. I., de Moraes S. A., Zamberlan-Amorim N. E., Castral T. C., de Almeida e Silva A., Scochi C. G. (2013). Clinical validation of the Preterm Oral Feeding Readiness Assessment Scale. Revista Latino-Americana de Enfermagem, 21 Spec No, 140-145. doi:10.1590/S0104-11692013000700018 [Context Link]


Fujinaga C. I., Zamberlan N. E., Rodarte M. D., Scochi C. G. (2007). Reliability of an instrument to assess the readiness of preterm infants for oral feeding. Pro Fono, 19(2), 143-150.


Gryboski J. D. (1965). The swallowing mechanism of the neonate. I. Esophageal and gastric motility. Pediatrics, 35(3), 445-452. [Context Link]


Gryboski J. D. (1969). Suck and swallow in the premature infant. Pediatrics, 43(1), 96-102. [Context Link]


Harding C. (2009). An evaluation of the benefits of non-nutritive sucking for premature infants as described in the literature. Archives of Disease in Childhood, 94(8), 636-640. doi:10.1136/adc.2008.144204 [Context Link]


Howe T. H., Sheu C. F., Hinojosa J., Lin J., Holzman I. R. (2007). Multiple factors related to bottle-feeding performance in preterm infants. Nursing Research, 56(5), 307-311. doi:10.1097/01.NNR.0000289498.99542.dd [Context Link]


Jain S., Cheng J. (2006). Emergency department visits and rehospitalizations in late preterm infants. Clinics in Perinatology, 33(4), 935-945; abstract xi. doi:10.1016/j.clp.2006.09.007 [Context Link]


Kirk A. T., Alder S. C., King J. D. (2007). Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology, 27(9), 572-578. doi:10.1038/ [Context Link]


Kish M. Z. (2013). Oral feeding readiness in preterm infants: A concept analysis. Advances in Neonatal Care, 13(4), 230-237. doi:10.1097/ANC.0b013e318281e04e [Context Link]


Lau C., Smith E. O., Schanler R. J. (2003). Coordination of suck-swallow and swallow respiration in preterm infants. Acta Paediatrica, 92(6), 721-727. [Context Link]


Lessen B. S. (2011). Effect of the premature infant oral motor intervention on feeding progression and length of stay in preterm infants. Advances in Neonatal Care, 11(2), 129-139. doi:10.1097/ANC.0b013e3182115a2a [Context Link]


McCormick M. C., Escobar G. J., Zheng Z., Richardson D. K. (2006). Place of birth and variations in management of late preterm ("near-term") infants. Seminars in Perinatology, 30(1), 44-47. doi:10.1053/j.semperi.2006.01.012 [Context Link]


McGrath J. M., Braescu A. V. (2004). State of the science: Feeding readiness in the preterm infant. Journal of Perinatal and Neonatal Nursing, 18(4), 353-368; quiz 369-370. [Context Link]


Medoff-Cooper B. (2000). Multi-system approach to the assessment of successful feeding. Acta Paediatrica, 89(4), 393-394. [Context Link]


Medoff-Cooper B., McGrath J. M., Bilker W. (2000). Nutritive sucking and neurobehavioral development in preterm infants from 34 weeks PCA to term. MCN: The American Journal of Maternal/Child Nursing, 25(2), 64-70. [Context Link]


Palmer M. M., Crawley K., Blanco I. A. (1993). Neonatal Oral-Motor Assessment scale: A reliability study. Journal of Perinatology, 13(1), 28-35. [Context Link]


Perlman J. M. (2001). Neurobehavioral deficits in premature graduates of intensive care-potential medical and neonatal environmental risk factors. Pediatrics, 108(6), 1339-1348. [Context Link]


Phibbs C. S., Schmitt S. K. (2006). Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants. Early Human Development, 82(2), 85-95. doi:10.1016/j.earlhumdev.2006.01.001 [Context Link]


Pickler R. H. (2004). A model of feeding readiness for preterm infants. Neonatal Intensive Care, 17(4), 31-36. [Context Link]


Pickler R. H., Best A. M., Reyna B. A., Gutcher G., Wetzel P. A. (2006). Predictors of nutritive sucking in preterm infants. Journal of Perinatology, 26(11), 693-699. doi:10.1038/ [Context Link]


Pickler R. H., Frankel H. B., Walsh K. M., Thompson N. M. (1996). Effects of nonnutritive sucking on behavioral organization and feeding performance in preterm infants. Nursing Research, 45(3), 132-135. [Context Link]


Pimenta H. P., Moreira M. E., Rocha A. D., Gomes S. C. Jr., Pinto L. W., Lucena S. L. (2008). Effects of non-nutritive sucking and oral stimulation on breastfeeding rates for preterm, low birth weight infants: A randomized clinical trial. Jornal de Pediatria, 84(5), 423-427. doi:10.2223/JPED.1839 [Context Link]


Pinelli J., Symington A. (2000). How rewarding can a pacifier be? A systematic review of nonnutritive sucking in preterm infants. Neonatal Network, 19(8), 41-48. doi:10.1891/0730-0832.19.8.41 [Context Link]


Pinelli J., Symington A. (2005). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database of Systematic Reviews, (4), CD001071. doi:10.1002/14651858.CD001071.pub2 [Context Link]


Premji S. S., McNeil D. A., Scotland J. (2004). Regional neonatal oral feeding protocol: Changing the ethos of feeding preterm infants. Journal of Perinatal and Neonatal Nursing, 18(4), 371-384. [Context Link]


Radtke J. V. (2011). The paradox of breastfeeding-associated morbidity among late preterm infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 40(1), 9-24. doi:10.1111/j.1552-6909.2010.01211.x [Context Link]


Raju T. N., Higgins R. D., Stark A. R., Leveno K. J. (2006). Optimizing care and outcome for late-preterm (near-term) infants: A summary of the workshop sponsored by the National Institute of Child Health and Human Development. Pediatrics, 118(3), 1207-1214. doi:10.1542/peds.2006-0018 [Context Link]


Rodriguez N. A., Meier P. P., Groer M. W., Zeller J. M. (2009). Oropharyngeal administration of colostrum to extremely low birth weight infants: Theoretical perspectives. Journal of Perinatology, 29(1), 1-7. doi:10.1038/jp.2008.130 [Context Link]


Rodriguez N. A., Meier P. P., Groer M. W., Zeller J. M., Engstrom J. L., Fogg L. (2010). A pilot study to determine the safety and feasibility of oropharyngeal administration of own mother's colostrum to extremely low-birth-weight infants. Advances in Neonatal Care, 10(4), 206-212. doi:10.1097/ANC.0b013e3181e94133 [Context Link]


Ross E. S., Philbin M. K. (2011). Supporting oral feeding in fragile infants: An evidence-based method for quality bottle-feedings of preterm, ill, and fragile infants. Journal of Perinatal and Neonatal Nursing, 25(4), 349-357; quiz 358-359. doi:10.1097/JPN.0b013e318234ac7a [Context Link]


Shaker C. S., Woida A. M. (2007). An evidence-based approach to nipple feeding in a level III NICU: Nurse autonomy, developmental care, and teamwork. Neonatal Network, 26(2), 77-83. doi:10.1891/0730-0832.26.2.77 [Context Link]


Simpson C., Schanler R. J., Lau C. (2002). Early introduction of oral feeding in preterm infants. Pediatrics, 110(3), 517-522. [Context Link]


Thoyre S. M., Shaker C. S., Pridham K. F. (2005). The early feeding skills assessment for preterm infants. Neonatal Network, 24(3), 7-16. doi:10.1891/0730-0832.24.3.7 [Context Link]


Young P. C., Korgenski K., Buchi K. F. (2013). Early readmission of newborns in a large health care system. Pediatrics, 131(5), e1538-e1544. doi:10.1542/peds.2012-2634 [Context Link]


Zanardo V., Gambina I., Begley C., Litta P., Cosmi E., Giustardi A., Trevisanuto D. (2011). Psychological distress and early lactation performance in mothers of late preterm infants. Early Human Development, 87(4), 321-323. doi:10.1016/j.earlhumdev.2011.01.035 [Context Link]