Early Human Development (2007) 83, 293 — 305

available at www.sciencedirect.com

www.elsevier.com/locate/earlhumdev

Feeding skill performance in premature infants during

the first year
Karen Pridham a,*, Deborah Steward b,1, Suzanne Thoyre c,2
Roger Brown a,3, Lisa Brown c,2
a
University of Wisconsin-Madison School of Nursing, 600 Highland Avenue, Madison, WI, 53792, United States
b
Ohio State University College of Nursing, 1585 Neil Avenue, Columbus, Ohio, 43210, United States
c
University of North Carolina College of Nursing at Chapel Hill, Carrington Hall, NC, 27599, United States

Accepted 14 June 2006

KEYWORDS Abstract
Premature infant;
Infant feeding skills; Background: Little is known about premature infants’ feeding skill development and the
Rate of weight contribution to it of biologic and environmental conditions.
gain/day; Aims: Explore the level and variation in feeding skill performance through the first post-term
Maternal feeding year and examine the contribution to performance of infant neonatal condition and rate of
behavior; weight gain per day, maternal feeding behavior, and its interaction with neonatal condition.
Neonatal Medical Index Study design and subjects: In this longitudinal, descriptive study, data sources included
observed and videotaped in-home feeding for 45 infants b 1250 g birth weight and their mothers
(age z 17 years).
Outcome measure: Feeding skill performance (fdgskill): total number of expected skills at 1, 4,
8, and 12 months, post-term age (PTA).
Results: Feeding skill performance varied widely among infants at all four assessments. At 8 and
12 months, fdgskill indicated, for a minority of infants, delay and lack of opportunity to engage
in skills associated with new foods and new feeding modalities. Neonatal medical condition
contributed significantly to fdgskill at 1 and 4 months, but in the predicted (negative) direction
only at four months. Rate of weight gain per day contributed significantly to fdgskill at 1 and
8 months, but in the predicted direction (positive) only at one month. Maternal feeding
behavior did not contribute to fdgskill, nor did it interact with infant neonatal conditions to
affect fdgskill.

* Corresponding author. Tel.: +1 608 238 7536; fax: +1 608 263 5332.
E-mail address: kpridham@wisc.edu (K. Pridham).
1
Tel.: +1 614 292 4978.
2
Tel.: +1 919 966 8418; fax: +1 919 843 9969.
3
Tel.: +1 263 5281; fax: +1 263 5332.

0378-3782/$ - see front matter D 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.earlhumdev.2006.06.004
294
Conclusions: Although infant neonatal medical status and rate of weight gain per day, before or
within the span of time between assessments, accounted for some variance in feeding skill
performance within the first three assessments (1, 4, and 8 months), much remains to be
explained, including neuro- and oral—motor capacities to manage new foods and feeding
modalities and opportunities to practice feeding skills during the last half of the first year.
D 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Clinician interest in the feeding behavior of premature
infants is likely to focus on quantity of nutrient intake.
Feeding skills, in contrast, receive little attention. These
skills, in addition to their potential contribution to intake,
are significant in their own right. Feeding skills mark an
infant’s development through the first year from caregiv-
er- to predominantly self-regulated feeding. Social—emo-
tional and cognitive benefits accrue to an infant from
participation in feeding in age-expected ways. Despite
research observations [1,2] or parental report [3] that
premature infants lag behind healthy, term-born infants in
self-feeding skills, little is known, for premature infants,
about age-expected performance of feeding skills and
about factors that contribute to this performance. Knowl-
edge of feeding skills would put clinicians in a better
position to understand how premature infants function
during feeding and support researchers in designing
interventions to promote development. We took a devel-
opmental science perspective [4—6] in this study to
examine premature infants weighing b 1250 g at birth,
feeding skill performance at 1, 4, 8, and 12 months post-
term age as points of observation likely to be associated
with distinct phases of development. From this perspec-
tive, feeding skill arises from the collaboration of mother
and infant and is a function of the support the mother
offers the infant [6]. Therefore, our study included
examination of the independent and interactive contribu-
tion of infant biological and maternal feeding conditions to
feeding skill performance.
1.1. Background
Feeding skill performance. Documentation for premature
infants of developmental delay in feeding skills, for the
most part, begins with the second half of the first post-term
year when the adoption of new foods and feeding modal-
ities is expected. In one of the few observational studies to
date, Mathisen and colleagues [1] compared the oral—
motor and self-feeding skills of 20 extremely premature,
low birth-weight (ELBW) infants (i.e., birth weight less than
1000 g and born between 23 and 29 weeks gestation) at
6 months post-term age with those of 20 full-term infants at
the same age, and learned that a significantly lower
percent of the premature infants performed the skill than
full-term infants. Holditch-Davis, Miles, and Belyea [2]
observed a very low rate of self-feeding behavior at six
months post-term age among 29 very low birth-weight
(VLBW), premature infants (i.e., birth weight between 1000
and 1500 g), despite infants’ ability to bring objects to their
mouths. Description of premature infant feeding skills
K. Pridham et al.
through the first post-term year, referenced to the
spectrum of skills expected for gestation-corrected age
[7—9], is lacking.
Although a contribution of both premature infant
biologic conditions and the feeding behavior of mother
to infant feeding skill performance is supported by
research findings [10—13], we know little about the
effect, taken together, of both biologic conditions and
mother’s feeding behavior on infant feeding skill perfor-
mance through the first post-term year. Both the infant’s
medical complications in the neonatal period and current
rate of gain in weight are biologic conditions that may
make a difference in infant feeding performance. We
learned that bronchopulmonary dysplasia (BPD), examined
in the context of intervention vs. standard care, poverty,
and mothers’ symptoms of depression, had only a
marginally significant ( p b .10) effect on feeding skill
performance at eight months PTA for VLBW infants
(Pridham et al. [14]). Korner and her colleagues [15],
however, found a significant effect of medical complica-
tions on the motor and mental development of VLBW
infants using an index composed of multiple biologic
conditions, including BPD and neurologic problems (e.g.,
periventricular leukomalacia, intraventricular hemorrhage)
as well as prematurity and low birth weight [24]. An
infant’s rate of weight gain is a sign of health, vigor, and
physical robustness. A more robust infant is likely to be
more active physically, to engage in more exploratory
behavior, and to have greater stamina for participation in
feeding. Wachs [16] observed that mothers offered more
robust infants greater opportunities for autonomy, motoric
activity, and exploration than mothers offered to smaller,
same-age infants. Mothers may give more robust prema-
ture infants greater opportunities for self feeding.
A mother’s regulation of her affect and behavior during
feeding may make a difference for her infant’s participa-
tion in feeding and feeding skill learning [17]. A mother
regulates her infant’s feeding by structuring both the
feeding and the feeding environment and by responding
to an infant’s expression of need. Regulation of feeding is
also expressed through inhibition of negative affect and
disruptive behaviors (e.g., intrusiveness) and through
sensitive response. Abrupt, awkward, insensitive, or inef-
fective physical handling is one quality of maternal
behavior that may adversely affect infant feeding [18].
Mathisen and her colleagues [1] observed mothers of 6-
month-old ELBW infants having difficulties in positioning
the infant in a way that supported feeding. Maternal
feeding behavior may be influenced by perception of an
infant’s risk for medical problems [19]. How maternal
behavior contributes to infant feeding skill performance
through the first post-term year, accounting for infant
biologic conditions, is unknown.
Feeding skill performance in premature infants during the first year
1.2. Research questions and hypotheses
We addressed three questions in this study. (a) What
expected oral—motor, hand—mouth—eye (manual), head—
trunk (postural), and communicative—social feeding skills
are observed in VLBW premature infants at 1, 4, 8, and
12 months, post-term age? (b) What do infant biologic
conditions, indexed by both neonatal medical status and
rate of weight gain per day, and maternal regulation of
affect and behavior during feeding contribute to feeding
skill performance at each of these four ages? (c) How do
infant biologic conditions and maternal feeding behavior
interact to affect feeding skill performance at each of the
four ages?
2. Methods
This longitudinal, descriptive study used data collected in a
randomized trial of an intervention to aid mothers in feeding
their VLBW infants. Because infants in the intervention and
comparison groups did not significantly differ on feeding
skill performance [14], the data for the two groups were
pooled. The study was approved by the institutional review
boards of the academic institution and the participating
hospitals.
All infant ages are referred to or reported in this study
as post-term age, i.e., for the premature infants, the
number of days or months computed from the date of
reaching 40 weeks post-conceptional age. This age was
determined by the most reliable information available,
either the mother’s menstrual dates, prenatally by ultra-
sound examination, or by the neonatologist’s post-birth
examination.
2.1. Participants
Mothers and their prematurely born infants were recruited
from 1995 to 1997 during the infant’s stay at one of three
neonatal intensive care units (NICUs) in a mid-western US
city. Inclusion criteria for infants were: (a) birth weight less
than 1250 g and appropriate for gestational age (i.e.,
greater than the 10th percentile) as determined by the
growth graph of Lubchenco et al. [20] and the gestational
age criteria of Ballard et al. [21]; and (b) at the time of
recruitment, no medical conditions that interfere with oral
intake of nutrients. Only the most severely ill infant of a
multiple birth was included. The birth weight criterion
established a population of higher-risk VLBW infants.
Inclusion criteria for mothers were: (a) age 17 years old or
older; (b) the infant’s primary caregiver; and (c) English-
speaking. Mothers who had multiple births were recruited to
the study. However, the infant of a multiple birth with the
longest length of hospital stay was the only infant included
in the study. Of the 80 eligible families, 57 (71.25%) agreed
to participate.
After mothers and fathers, if available, had signed the
study consent form, mothers were interviewed about their
plans for infant feeding and reported attribute and demo-
graphic data. Data about the infant’s birth and medical
complications were obtained from the infant’s hospital
record by a trained chart auditor. All other data for this
295
study were collected in the home at 1, 4, 8, and 12 months
by research nurses. Training for data collection included
laboratory scoring of video-taped feeding skills and in-home
mentoring. Data-collection quality was monitored on ap-
proximately every fifth to tenth home visit, depending on
the experience and performance of the data collector. In all,
two trained observers concurrently coded feeding skills at
20 home visits.
During each of the four visits, the infant was weighed
prior to a feeding that was initiated by the mother at a time
she determined to be appropriate. Mothers were requested
to feed their infants as they would usually feed. The entire
feeding was video-taped for later, laboratory-coding of
maternal feeding behavior by one of two coders who were
uninformed about infant or maternal characteristics. To
assure full visibility, infant feeding skills were coded during
the observed feeding.
2.2. Data collection instruments and measures
2.2.1. Neonatal Medical Index
The Neonatal Medical Index [15], designed to assess the
severity of the infant’s medical complications during the
initial hospital stay, was one of the variables we used to
estimate infant biologic condition in this study. Infants were
classified with the NMI ordinal scale, which ranges from 1
(i.e., freedom from medical complications) to 5 (i.e.,
occurrence of the most serious medical problems.) Birth
weight and medical complications (e.g., respiratory dis-
tress, assisted ventilation and or supplemental oxygen,
patent ductus arteriosus requiring medical treatment or
major surgery, apnea and bradycardia, hyperbilirubinemia,
meningitis, seizures, Grade III or IV intraventricular or
periventirular hemorrhage, periventricular leukomalacia)
prior to hospital discharge were included in the classifica-
tion algorithm. Predictive validity was supported, for VLBW
infants, by the significant contribution of the NMI score to
the Bayley Motor Development Index at 12 months and to
the Bayley Mental and Motor Development Indices at
24 months as well as to the Stanford Binet Intelligence
Scale at 36 months [15].
2.2.2. Rate of weight gain per day
To obtain infant weight at 1-, 4-, 8-, and 12-month
assessments and to compute the rate of gain prior to each
assessment, the infant was weighed nude on a portable
digital electronic scale (Hopkins Medical Products, Balti-
more, MD) that dynamically integrates fluctuating weight to
the nearest 10 g. Weight was repeatedly assessed until two
readings agreed within 10 g. The average of these two
readings was recorded. Rate of weight gain per day
(rwtgain) was determined by dividing the amount of gain
between assessments by the number of days spanned. The
rate of weight gain/day prior to one month was computed by
subtracting the infant’s hospital discharge weight from the
one-month weight, and dividing by the number of days from
discharge to the visit date.
2.2.3. Child Feeding Skills Checklist
The Child Feeding Skills (CFS) Checklist was developed to
assess, primarily from observation, skills of infants born at
term or prematurely at 1, 4, 8, and 12 months [22]. The
296
CSF items were drawn from Gesell and Ilg’s [7] list of skills,
except for two items concerning skill in taking non-milk
foods that were drawn from Morris and Klein’s [9] clinical
observations. Gesell and Ilg [7] gave each item a beginning
age or age period. We selected for non-overlapping
assessments at 1, 4, 8, and 12 months items that could
be first observed within the infant’s first five weeks for the
1-month assessment, weeks 8—24 for the 4-month assess-
ment, 28—36 weeks for the 8-month assessment, and 40—
52 weeks for the 12-month assessment. In the count of
feeding skills, six CFS items were included at one month,
21 at four months, 31 at eight months, and 22 at twelve
months.
A count of skills observed or reliably reported by the
mother as having been performed, if the data collector
could not observe performance, was obtained for each
assessment. This count (fdgskill) reflects the perspective
of Fischer, Bullock, Rotenberg, and Raya [6] concerning the
contribution of opportunity to skill and represents the
feeding skills performed and not the skills an infant could
perform given the opportunity. Discharge from the special
care nursery was contingent on suckling or sucking with
effective extraction of milk. Because all of the infants
performed this feeding skill at one month, it was not
included in the one-month skill count. Four of the CFS
items (i.e., grasps and draws bottle to mouth, hands close
on bottle, holds bottle, and tips bottle adaptively) are
applicable only to bottle-feeding infants. These skills were
included in the total count of performed skills because all
of the infants in the sample were bottle fed at four
months when these behaviors are expected. Skills related
to taking food from a spoon that Gesell and Ilg [7]
identified in their sample as early as 20 weeks were not
included in the CFS count at four-months because pedia-
tricians were, in general, advising mothers to begin spoon
feeding later. At eight and twelve months, the observer
recorded each spoon-feeding, finger-feeding, and cup-
drinking skill and table-food handling skill that the infant
had not experienced or had an opportunity to learn. If this
were the case, the infant was assumed not to have the
skill, and the skill was reported as not performed. For
each infant without experience or opportunity, we dis-
cussed with the mother her perspective on the infant’s
ability to perform the skill and were informed that she did
not believe the infant could manage the skill. The
communication—social skills primarily concerned age-spe-
cific vocal or behavioral cues of hunger and of satiety.
These skills were not included in the skill count because
the infant’s feeder could over-ride their expression,
confounding observance of performance.
Inter-rater agreement for approximately 10% of the
observed feedings averaged 87% (range 83% to 91%) for
the observed/not observed score for each item. Using
data collected on developmental measures for the
larger study, concurrent validity of the measure of
expected feeding skills performed (fdgskill) was sup-
ported by the correlation of eight-month fdgskill with
the eight-month score on the Bayley Infant Neurodeve-
lopmental Screener [23] and by the correlation of the
12-month fdgskill measure with the 12-month Motor
Development Index [24], respectively r = .54, p b .001 and
r = .49, p b .01.
K. Pridham et al.
2.2.4. Maternal regulation of feeding behavior and affect
We used an observation instrument, the Parent—Child Early
Relational Assessment (PCERA) [25] to rate the quality of
maternal regulation of feeding behavior and affect (mrab).
The PCERA scales were derived from theoretical and empir-
ical studies and confirmed by factor analysis on feeding data
from a sample (n = 379) of mothers and their healthy, four-
month-old term infants [18,26]. The 14-item mrab scale
includes items to assess on five-point ordinal scales the
following concepts: (a) structuring a feeding and mediating
the environment to support feeding; (b) responding sensi-
tively to infant needs and preferences; (c) responding
flexibly; and (d) expressing little or no negative feelings,
intrusiveness, abrupt or rough physical handling of the infant,
or contingent responding to infant behavior that had a
negative meaning for the mother. The low end of the scale
for each item indicates less well regulated affect or behavior
and the high end of the scale indicates regulated, well-
structured feeding behavior, absence of negative affect,
presence of positive affect, or positive interactive behavior.
Scores may be defined categorically as follows: (a) 1 or 2, area
of concern; (b) 3, area of some concern; (c) 4 or 5, area of
strength. Items were rated from the second 5 min of
videotaped feeding interaction. A feeding is generally
established and mothers and infants comfortable with and
inattentive to the video taping within about five minutes [26].
The PCERA has been used with both mothers of term and
premature infants who were near term or post term [18,27—
29,14]. Validity, both discriminant and concurrent, has been
demonstrated with women and children from a broad
spectrum of the population, including African-American
women and children [27]. Coders were trained to at least
80% reliability, using the three category criterion. To maintain
inter-rater equivalency of coding, drift sessions were held
every two weeks. In all, 20% of the total number of tapes was
rated by two raters. Tapes with low coding agreement were
discussed to obtain consensus on scale codes. Inter-rater
agreement was 85% on average. The Kappa statistic averaged
.66 (SD = .23), signifying substantial agreement [30]. The
internal consistency reliability of the mrab items ranged from
.81 to .91 across the four assessments.
3. Results
3.1. Sample description
Of the families recruited to the study, 45 (78.9%) completed
at least one observation of feeding skills, and 43 (75%)
finished the study at the infant’s 12th month. All of the 14
families that did not complete the study left it before the
infant was four months. Although we obtained weight data
for 44 infants at one month, we could observe infant feeding
skills for only 41 of these infants, primarily due to problems
in scheduling the observation with the family. Feeding skills
were observed for 39 infants at four months, 40 infants at
eight months, and 38 infants at twelve months.
3.2. Data collection procedure
Maternal, family, and infant attributes are described in Table
1. Most infants had two parents living in the home.
Approximately two-thirds of the mothers were married or
Feeding skill performance in premature infants during the first year 297

Table 1 Demographic and attribute data was breastfed at the one-month assessment. All other
infants were bottle fed at the 1-, 4-, 8-, and 12-month
Mean (SD) Range
assessments. Post-term age in days averaged 40.2 (SD = 21.4)
Maternal and family data for the first (1 month) assessment; 131.0 (SD = 26.7) for the
Mother’s age (years) 25.67 18— 37 second (4 month) assessment; 249.1 (SD = 20.9) for the third
(5.30) (8 month) assessment, and 375.1 (SD = 17.6) for the fourth
Mother’s education (years) 13.04 8—21 (12 month) assessment.
(2.62) Although the infants, on average, performed two-thirds
Number Percent of the expected skills in the set of skills included in the Child
Parents’ marital status: married 14 31.1 Feeding Skills Assessment at one month, by 12 months, the
Partnered, living together 16 35.6 average percent of skills performed had dropped to 54% of
Partnered, not living together 12 26.7 the expected skills (see Table 2). The probability of
Single, not living with a partner 2 4.4 performing less than 60% of the expected feeding skills at
Separated, divorced 1 2.2 a specific age, conditional on performance of less than 60%
Poverty statusa 29 64.4 of the expected feeding skills at the previous assessment,
Race/ethnicity: African American 27 60.0 was 41.7% at 4 months, 45.0% at 8 months, and 64.3% at
Euro-American 15 33.3 12 months. The variation in performance of the set of skills
Asian 1 2.2 assessed was wide, particularly at one month (M = 67.07%,
Latina 2 4.4 SD = 25.41; at four months, M = 56.78%, SD = 17.29; at eight
months, M = 65.56%, SD = 18.41; at 12 months, M = 54.39%,
Infant data SD = 18.45). Descriptive statistics for the number of skills
Birth weight (g) 876.58 530—1240 performed in relation to the set of skills assessed are shown
(205.90) in Table 3.
Gestational age (weeks) 26.37 23—30 At one month, on average, infants performed four of
(1.93) the six oral—motor and communication—social feeding
Days on assisted ventilation 27.80 0—83 skills included in the set expected at one month, PTA
(23.40) (see Table 2). At this age, almost all (93%) of the infants
Hospital days (special care) 82.73 35—158 demonstrated coordinated sucking and swallowing with
(27.43) breathing by swallowing liquids without choking. About
Number Percent 75% of the infants performed skills that are signs of an
Male gender 22 48.9 infant’s active participation in feeding (e.g., signaling
readiness for food with jaw excursion; sucking or mouthing
Neonatal Medical Index (NMI) b when placed in a feeding position). Only 51% of the infants
Rating = 1 0 mouthed or sucked their fists, a feeding readiness signal
Rating = 2 1 2.2 that has a wide age span for performance. We may have
Rating = 3 13 28.9 assessed this skill too early for the infants in our sample to
Rating = 4 7 15.6 demonstrate. About 75% of the infants engaged in looking
Rating = 5 24 53.3 at the mother’s face for more than a moment, a skill that
Note. N = 45. supports feeding alertness and maintenance. However, only
a
Estimated income below the poverty line, using U.S. about half of the infants communicated distress when
Census Bureau data specific to the time families were enrolled interrupted in feeding.
in the study (http://www.census.gov/hhes/poverty/threshld/ At four months, the infants, on average, performed
thresh98.html). approximately 12 of the 21 expected skills. About 77% of
b
A rating of 5 represents the most serious medical
the infants returned to feeding after brief socializing with
complications.
the mother, indicating ability to maintain and regain focus
living with a partner and 64% had a family income below the on the feeding task. All but 14% of the infants signaled
poverty level, determined by federal guidelines [31]. One- readiness to feed by opening the mouth and poising it to
third of the mothers were Euro-American; 60% were African receive the nipple. About 67 to 75% of the infants brought a
American. Although mothers averaged about 13 years of hand to the mouth or followed the bottle with the eyes at
education, the range in education years was 8 to 21. The least once during feeding, indicating engagement in the
infants, on average, were extremely low birth weight, and the feeding. However, except for keeping hands open for most
majority had high ratings (i.e., 4 or 5) of severity of medical of the feeding, demonstrated by about 70% of the infants,
complications on the Neonatal Medical Index. Twenty (44.4%) only about one-third of the infants performed skills involving
of the infants had a Grade I or II intraventricular hemorrhage hands, mouth, and perhaps eyes (e.g., making a hand-to-
(IVH). Although none of the infants had an IVH graded III or IV, mouth movement as the nipple is removed, closing in with
six infants had a diagnosis of periventricular leukomalacia. both hands to grasp objects held near). These skills are
precursors of skills in finger-feeding and in participating in
3.3. Performance of feeding skills through the first year, bottle feeding and, eventually, cup drinking. The skill of
post-term age maintaining a midline head position when the body is in
midline, performed by about 85% of the infants, and the skill
The feeding skills observed were almost entirely in the of sitting supported, performed by about 64% of the infants,
context of bottle- rather than breast-feeding. One infant contribute to an infant’s accepting food from a spoon.
298 K. Pridham et al.

Table 2 Feeding skill performance for four assessments during the first year, post-term age, by skill category
Infant post-term age (approximate) na Number of infants Percent of infants Post-term age or age period
at Assessment/Category of Skill performing skill performing skill of expected performanceb
1 month, post-term age
Oral—motor skills
Swallows liquids, no choking or coughing 41 38 92.7 Term (40 weeks)
Begins sucking/mouthing when in 40 30 75 Term—9 wks
feeding position
Moves jaw as mouth opens, signaling 40 30 75 4—12 wks
readiness for food
Mouths or sucks fist 40 17 42.5 Term—16 wks
Communication—social skills
Indicates distress when feeding 41 21 51.2 2 wks
is interrupted
Looks at caregiver’s face for more than 39 29 74.4 5 wks
a moment

4 months, post-term age

Oral—motor skills
Opens mouth and poises it to 38 33 86.8 16 wks
receive nipple
Does not choke with milk from bottle 38 28 73.7 16 wks
or breast
Hand—mouth—eye skills
Brings hand to mouth 38 28 73.7 16—24 wks
Grasps and draws bottle to mouth, 39 10 25.6 20—26 wks
usually with assistance
Hands close on bottle 37 18 48.6 20 wks
Hands are open for most of feeding 36 25 69.4 8 wks
Hand to mouth movement as nipple 38 10 26.3 16—24 wks
is removed
Regards hand 38 10 26.3 12—16 wks
Reaches for object on sight and grasps it 39 17 43.6 24 wks
Closes in with both hands to grasp 39 15 38.5 20 wks
objects held near
Looks at object in hand 38 19 50 20 wks
Head and trunk skills
Flexes neck towards breast or bottle 39 18 46.2 20—23 wks
when seen
Follows bottle with eyes at least 37 25 67.6 12 wks
once during feeding
Maintains midline head position 39 33 84.6 16 wks
when body is in midline
Turns head to sound as if to look at 39 36 92.3 24 wks
what is going on
Sits supported 39 25 64.1 16 wks
Communication—social skills
Regards breast or bottle eagerly 39 26 66.7 10 wks
Occasionally looks at caregiver’s 38 20 51.3 8 wks
face and smiles
Returns to feeding after brief 39 30 76.9 12 wks
socializing with caregiver
Regards caregiver’s face for a 38 24 63.2 8 wks
prolonged time
Coos 36 26 72.2 12 wks

8 months, post-term age

Oral—motor skills
Removes food quickly from spoon 41 32 78.0 28 wks
Uses upper lip to remove food from spoon 41 20 70.7 32 wks
Feeding skill performance in premature infants during the first year 299

Table 2 (continued)
Infant post-term age (approximate) na Number of infants Percent of infants Post-term age or age period
at Assessment/Category of Skill performing skill performing skill of expected performanceb
8 months, post-term age
Oral—motor skills
Draws in lower lip to remove food 40 27 65.9 28—32 wks
from spoon
Smacks tongue against palate 40 13 31.7 28—36 wks
Swallows solids; seldom chokes 41 39 95.1 28 wks
Takes pureed foods from spoon 40 36 87.8 27 wksc
Manipulates textured/lumpy foods 40 22 53.7 36 wksc
in mouth
Does up and down chewing 41 32 78.0 27 wks
Does rotary chewing 41 12 29.3 32 wks
Keeps lips closed while chewing, some 40 31 77.5 25 wks
of the time
Takes sips of liquid from a cup 40 23 56.1 28 wks
Takes one or two swallows from a cup 41 20 48.8 32 wks
Drinks from cup without choking 41 25 61.0 32 wks
Lips close on bottle nipple with little 41 34 82.9 28 wks
loss of liquid
Hand—mouth—eye skills
Hands reach for food 41 34 82.9 32 wks
Feeds self crackers, larger pieces of 41 24 58.5 28 wks
finger food
Helps with spoon 41 21 51.2 28 wks
Drinks from cup with caregiver control 41 19 46.3 32 wks
Holds bottle by self 41 28 68.3 28 wks
Adaptively tips bottle as it empties 40 23 57.5 32 wks
Uses inferior scissors grasp 40 25 62.5 32 wks
Grasps, brings food to mouth, and mouths 41 39 95.1 26 wks
or bites it
Voluntarily releases and re-secures 40 32 80.0 28 wks
food/object
Transfers food/object held in one hand 41 34 82.9 28 wks
to another
Head and trunk skills
Brings head forward to receive spoon 41 24 58.5 32 wks
Sits alone (unsupported) 41 29 70.7 32 wks
Balances trunk while manipulating 41 25 61.0 28—32 wks
food/object with hands
Communication—social skills
Vocalizes impatience or eagerness as sees 41 21 51.2 28—36 wks
caregiver preparing meal
Vocalizes eagerness as regards bottle, dish, 41 29 70.7 28—34 wks
or cup when placed in chair
Explores food with hands 41 24 58.5 32 wks
Vocalizes da-da or similar syllables 41 24 58.5 36 wks

12 months, post-term age

Oral—motor skills
Controls bite of soft solids or crunchy foods 38 28 73.7 52 wks
Manipulates food with definite 39 35 89.7 44 wks
chewing movements
Actively closes lips on spoon 39 31 79.5 52 wks
Uses tongue to lick morsels of food off 37 10 27.0 40 wks
lower lip
Uses upper or lower lip to clean food off 39 23 59.0 52 wks
the other lip
Eats mashed table foods 39 18 46.2 44 wks
Eats foods that vary in consistency 39 29 74.4 52 wks
(continued on next page)
300 K. Pridham et al.

Table 2 (continued)
Infant post-term age (approximate) na Number of infants Percent of infants Post-term age or age period
at Assessment/Category of Skill performing skill performing skill of expected performanceb
12 months, post-term age
Oral—motor skills
Adaptively approximates lips to rim or 39 26 66.7 40 wks
spout of cup
Does not spill from corners of mouth as 39 14 35.9 40—44 wks
drinks from cup
Continuously drinks 4—5 or more swallows 39 11 28.2 40 wks
from a cup
Does not drool 39 26 66.7 52 wks
Hand—mouth—eye skills
Finger feeds small pieces of food with a 39 28 71.8 46—48 wks
refined/ neat pincer grasp
Reaches for spoon 39 29 74.4 40 wks
Gets food into mouth with spoon, may 39 12 30.8 44 wks
grasp with pronated hand
Uses spoon independently; no spills 39 1 2.6 52 wks
Pokes at nipple or food with index finger 38 28 73.7 44 wks
Rubs spoon back and forth on tray 39 17 43.6 50 wks
Uses cup independently with two hands, 38 10 26.3 52 wks
spilling less than half
Grasps bottle or cup and brings to mouth 39 15 35.9 40 wks
Voluntary hand to mouth movements 38 32 84.2 40 wks
Communication—social skills
Vocalizes eagerness or fusses impatiently if 39 33 84.6 44—48 wks
caregiver is slow or presents an other than
wanted food
a
Number of infants participating in an observed feeding.
b
Derived from Gesell and Ilg [7] except as noted.
c
Derived from Morris and Klein [9].

At eight months, on average, infants performed 20 of
the 31 skills assessed. At least two-thirds of the infants
performed finger-feeding skills (e.g., hands reach for food;
voluntarily releases and re-secures food or an object;
transfers food or an object held in one hand to another;
grasps and brings food to the mouth; and mouths or bites it)
and spoon-feeding skills (e.g., removes food quickly from
the spoon; uses upper lip to remove food from the spoon;
draws in the lower lip to remove food from the spoon). Up
to 60% of the infants demonstrated skills for cup drinking
and for managing textured or lumpy foods. For cup
drinking, these skills included taking one or two swallows
from a cup, drinking from a cup without choking, and
drinking from a cup with caregiver control. For managing
textured or lumpy foods, the demonstrated skills included
manipulating the food in the mouth, rotary chewing, and
self-feeding crackers and larger pieces of finger food. At
least 50—60% of the infants were showing signs of becoming
independent in bottle feeding in skills they performed
(e.g., adaptively tips the bottle as it empties) and
progressing towards self-spoon feeding (e.g., helps with
spoon). However, approximately 30% of the infants did not
sit unsupported, and almost 40% did not balance the trunk
while manipulating food or an object with their hands, both
skills that are important for managing food that is a
progression to table food and for independently bottle or
spoon feeding. Five of the infants (12.5%) had not had an
opportunity to take pureed food from a spoon. Sixteen of
the infants, almost 40% of the infants observed, had not
had an opportunity to self-feed crackers, and 12 infants
(30% of those observed) had had no opportunity to take sips
from a cup.
At the 12-month assessment, on average, infants per-
formed 11 of the 21 expected skills. At least 70% of the
infants demonstrated feeding skills needed for eating table
foods (e.g., controls bite of soft solids or crunchy foods,
manipulates food with definite chewing movements, eats
foods that vary in consistency, finger feeds small pieces of
food with a refined/neat pincer grasp. Advancement in
spoon feeding skill was demonstrated in actively closing the
lips on a spoon, for almost 80% of the babies, and in
reaching for the spoon, for just under 75% of the babies. Of
the approximately 75% of the infants who were given a
spoon, either with food on it or to dip into food, less than
one-third were skilled enough to get food into the mouth
with it. Infants, in the range of 25—40%, performed more
sophisticated cup drinking and spoon feeding skills (e.g.,
drinks from a cup without spilling from the corners of the
mouth; continuously drinks 4—5 or more swallows from a
cup; grasps bottle or cup and brings it to the mouth; gets
food into the mouth with a spoon, perhaps grasped with a
pronated hand). Only one infant, however, used a spoon
Feeding skill performance in premature infants during the first year 301

Table 3 Descriptive statistics for continuous variables included in the model of feeding skill performance at 1, 4, 8, and 12
months, post-term age
Variable/PTA n Mean Standard deviation Min Max
a
fdgskill
1 month 41 4.02 1.52 1 6
4 months 39 11.92 3.63 4 20
8 months 40 20.32 5.71 5 28
12 months 38 11.42 3.87 1 17

mrab b
1 month 37 3.81 .41 2.93 4.36
4 months 39 3.52 .54 1.93 4.43
8 months 36 3.40 .59 2.14 4.36
12 months 40 3.37 .56 2.14 4.36

rwtgain c, g/day
NICU discharge to 44 29.96 12.02 8.05 54.28
1 month
Males 22 30.65 12.70 8.05 53.28
Females 22 29.27 11.55 11.67 51.50
1 to 4 months 35 22.33 7.46 4.79 33.49
Males 19 23.31 7.25 4.79 33.49
Females 16 21.17 7.78 5.14 21.17
4 to 8 months 38 14.04 3.76 7.46 25.68
Males 21 14.65 4.20 7.67 25.68
Females 17 13.29 3.09 7.46 18.20
8 to 12 months 41 9.50 4.23 2.76 23/4
Males 21 10.29 4.17 4.50 23.40
Females 20 8.67 4.23 2.76 15.55
Note. n refers to the number of observations made for the variable at a specific post-term age (PTA).
a
Number of feeding skills in the age-expected set of skills performed at least one time during feeding. The number of skills assessed at
each assessment was as follows: (a) 6 at 1 month; (b) 21 at 4 months; (c) 31 at 8 months; and (d) 21 at 12 months.
b
Mothers’ regulation of affect and behavior, rated on a 1—5 scale, 5 = adaptive feeding behavior and affect.
c
Rate of weight gain.

independently. Eight percent of the infants had not had an
opportunity to hold and take a bite of soft solid or crunchy
food, 51% had not had an opportunity to take mashed table
foods, and 23% had not had an opportunity to take foods
that vary in consistency. Almost 13% of the infants had not
had an opportunity to drink continuously (4—5 swallows)
from a cup.
3.4. The contribution of infant biologic conditions and
maternal behavior to feeding skill
Descriptive statistics for the infant and maternal conditions
explored as predictors of infant feeding skills are shown in
Table 3. Mothers, on the whole, had scores on regulation of
affect and behavior during feeding that ranged from within
an area of concern (b 3) to within an area of strength (N 4).
The rate of weight gain/day for female infants was not
significantly ( p N .05) lower than for male infants, and was,
on average, between the 10th and 90th percentiles for both
genders, using Fomon’s [32] tables of weight increments for
infants born at term. At one month PTA, 19.5% of the infants
assessed had daily weight increments below the 10th
percentile. The weight increment assessment at 4, 8, and
12 months PTA showed, respectively, 31.4%, 13.2%, and
31.7% of infants below the 10th percentile in daily weight
gain.
We used fixed occasions repeated measures regression
analysis [33—35] for the four assessments to explore the
contribution to feeding skills performance (fdgskill) of
infant biological conditions (NMI and rwtgain), maternal
regulation of affect and behavior during feeding (mrab), and
the interaction of NMI and mrab. This type of regression
analysis builds four simultaneous regressions and models the
correlation among fdgskill variables for the four assess-
ments. The regression is structured as a hierarchical,
marginal model that uses all of the data that are available
at any one time and permits assessment of differences
between times. For this analysis, fdgskill was log trans-
formed due to the positively skewed count data. We used a
hierarchical multivariate Poisson distribution [36,37] with
the Dispersion Phi measure to correct for over-dispersion in
8- and 12-month models [38].
Results of the fixed occasions repeated measures regres-
sion analysis of feeding skill performance at 1, 4, 8, and
12 months are shown in Table 4. At one month, both the
infant’s NMI score and rate of daily weight gain (rwtgain)
contributed to the infant’s feeding skill performance
(fdgskill) in the context of maternal regulation of affect
302
Table 4 Parameter estimates for fixed occasions repeated measures regression analyses of feeding performance skills at 1, 4, 8,
and 12 months, infant post-term age
1 month 4 months
Intercept 0.792 (0.747) 3.378
NMIa 0.192 (0.086)* 0.157
rwtgain b 0.018 (0.005)** 0.006
mrab c 0.189 (0.156) 0.025
Covariance matrix
1 month 0.453 (0.137)
4 months 0.670 (0.086) 0.304 (0.159)
8 months 0.016 (0.173) 0.146 (0.187)
Note: N = 45. Standard errors are shown in parentheses. The data are adjusted for overdispersion in the 8- and 12-month models.
*p b .05; **p b .01.
a
Neonatal Medical Index.
b
Rate of gain in weight.
c
Mother’s regulation of affect and behavior during feeding.
and behavior during feeding (mrab). At four months, the NMI
score made a significant contribution to fdgskill in the
expected negative direction, but neither rwtgain nor mrab
did. At eight months, rwtgain made a significant contribu-
tion to fdgskill, but in an unexpected negative direction.
Feeding skill performance was lower with greater rate of
weight gain per day. Neither of the infant biologic condition
variables nor mrab made a significant contribution to
fdgskill at 12 months. The analysis showed significant
correlation of fdgskill at one month with fdgskill at both
four and eight months. The 12-month fdgskill was not
correlated with 1-, 4-, or 8-month measures of fdgskill.
To estimate the contribution of the predictor variables to
fdgskill, we assessed the difference in the 2 log-likelihood
value when the predictor variables were added to the initial
model (i.e., the constant or estimated logged count of
feeding skills). The 2 log-likelihood at the initial model
(i.e., constant only) was 823.06. With the predictors added,
the 2 log-likelihood was 677.24. With the 12 new para-
meters, or 12 degrees of freedom, chi square was 145.42,
p b .05, indicating a statistically significant improvement in
the predictability of the model.
3.5. Interaction of infant neonatal medical status and
maternal feeding behavior
We examined the interaction of maternal regulation of
affect and behavior during feeding with the infant’s medical
status in the neonatal period in all four models. However,
the interaction was not significant in any of the models.
4. Discussion
We described the feeding skills a small sample of premature
infants weighing b 1250 g at birth performed at four specific
times during the first year (1, 4, 8, and 12 months), thereby
extending knowledge gained from the observations Mathisen
and colleagues [1] and Holditch-Davis, Miles, and Belyea [2]
made at six months. The study is limited by its small sample
and by its snapshot, rather than continuous, approach to
description of feeding skill performance across the first year.
K. Pridham et al.
8 months 12 months
(0.532) 3.219 (0.350) 2.423 (0.431)
(0.057)** 0.004 (0.049) 0.021 (0.064)
(0.007) 0.025 (0.010)* 0.011 (0.014)
(0.093) 0.055 (0.066) 0.002 (0.113)
0.186 (0.174)
Furthermore, the variation of infants in post-term age
within each of the four assessments could have contributed
to variation in skill performance. The comprehensiveness of
the description and the longitudinal study, however, con-
tribute an enlarged perspective of premature infant feeding
skills across the first year and specify questions for further,
in-depth study.
The limitations of the method of assessing feeding skill
performance, the Child Feeding Skills Checklist (CFS), must
be considered in reviewing findings for both study questions.
The age range identified from the Gesell and Ilg [7] norms
for each item may not have been appropriate for the
premature infants, many of whom were extremely low birth
weight. Furthermore, the age range given for several skills
we included in our assessments was very broad, and the
likelihood of observing these skills at the ages selected for
this study may have been low as a consequence. For
example, the item, mouths or sucks fist when in vicinity,
which we included in the one-month assessment, was
designated in the Gesell and Ilg reference as being
observable when an infant is term age through 16 weeks.
Moreover, it is likely that not all of the items included in the
CFS are of equivalent importance for characterizing feeding
skill development at a specific age or for differentiating
infants on feeding skill performance. The CFS only permits
recording of performance or non-performance. It does not
capture the extent to which an infant performs a skill when
given the opportunity (once or repeatedly), nor does it
permit description of the quality of performance.
For infants at high risk for neuro-developmental problems
[39—41], as were the ELBW infants who participated in this
study, the Child Feeding Skills Checklist may not be
adequate for assessment of feeding skill performance and
documentation of infant progression in self-regulated feed-
ing. For VLBW and ELBW infants, supplementation of the
Child Feeding Skills Checklist with a more in-depth and
precise assessment of skill in sucking, swallowing, breathing
coordination, and use of the lips and tongue could aid
understanding of feeding outcomes [42—44]. Description of
physiologic regulation and stability, including change in
heart and respiratory rates in relation to feeding, the
pattern and quality of breathing, and signs of respiratory
Feeding skill performance in premature infants during the first year
distress, as well as the quality of positional support an infant
has during feeding may also shed light on a premature
infant’s performance of feeding skills and their development
over time.
4.1. Description of premature infant skills
One of the contributions of this study concerns the
considerable variability among premature infants across
and within time. Exploring the data across time, we learned
that the premature infants were lower in performance on
the expected set of skills at four months relative to one
month and at 12 months relative to eight months, whereas
at eight months, infants were similar in the percent of
expected skills performed to the percent of skills observed
at one month. This change in performance relative to the
set of expected skills may be due to a qualitative difference
in the challenge for the premature infants of the skills
included in a specific, age-related set or in the quality of
maternal competence needed to support infant perfor-
mance on these skills.
In addition to variability across time, feeding skill
performance varied considerably within any one age, a
feature of the sample that began at one month. Our finding
that as many as 75% of the infants performed skills at this
age that, to some degree, indicate active participation in a
feeding weakens the assumption that very young premature
infants are passive in their feeding and not capable of
contributing to the regulation of the feeding. However, at
one month, infant signals may not be clear in all respects,
given that about 49% of the infants did not communicate
distress when the feeding was interrupted.
Examination of feeding skills within the 4, 8, and
12 month assessments and across contiguous assessments
generates new questions about the progress of premature
infants in managing new and more sophisticated types of
food and in using new feeding modalities (e.g., fingers, cup,
spoon), first with caregiver assistance and, by 12 months,
with some degree of independence. At each age, we
observed a subset — on the whole, a minority — of the
premature infants performing the most advanced, for age,
of the expected skills in respect to self feeding. At four
months, for example, some premature infants may demon-
strate postural and trunk skills that are prerequisite for
taking food from a spoon. To learn about patterns of
development within the population of premature infants in
respect to self-regulatory skill performance, the age span
during which premature infants acquire head and trunk skills
that support being spoon fed as well as the hand—mouth—
eye precursors of finger feeding should be explored with
additional, serial skill assessments. These assessments could
provide a foundation for addressing the question of how and
when infants who demonstrate these precursor skills should
be supported in developing finger-feeding and spoon-
feeding skills.
Examination of the four types of feeding skills (i.e., oral—
motor, hand—mouth—eye, head—trunk, communication—
social) in the context of progression towards self feeding
suggests that a comprehensive observation of feeding skills
is needed during the infant’s second half year in order to
better understand the reasons why some premature infants
303
may lag behind expectations for self feeding. This exami-
nation may also help to better specify the reasons why
infants may not be given opportunities for finger-feeding a
cracker, cup drinking, and managing textured or lumpy
foods. At eight months, for example, delay in sitting
unsupported or in balancing the trunk while manipulating
food with the hands may help to explain why a mother does
not give her infant finger food despite the infant’s capacity
to bring a hand to the mouth and to maternal concern about
an infant’s choking. At the 12-month assessment, potential
explanations for the lack of opportunity to eat such table
foods as mashed potatoes, to self feed with a spoon, and to
take continuous swallows from a cup cannot be clearly
conjectured from examination of performance on the total
set of expected skills. This set, at 12 months, did not include
head and trunk skills and more than one communication—
social skill, and should be extended for a more comprehen-
sive assessment.
In sum, non-performance of finger-feeding, cup drinking,
table-food eating, and self-managed spoon feeding may be
multi-determined and extend beyond lack of opportunity.
The condition of the infant or environment at the time of
the observation may not have supported performance of
feeding skills. Infants may not have had sufficient experi-
ence to become accustomed to a type of food or to feeding
utensils by the time of feeding skill assessment. For
example, at about eight months, infants are often expected
to manage food with texture, including lumps. Skill in
managing lumpy food and in eating a mixed diet is likely to
require practice as well as developmental changes in oral—
pharyngeal structure and function that permit management
of the lumps or varying consistency of the food. Practice and
developmental change may be reciprocal [45,46].
4.2. Exploration of the contribution of biologic
conditions and mothers’ feeding behavior to
feeding skill performance
We approached this study from a developmental science
perspective and the assumption that assessment of feeding
skill performance requires an understanding of the context
of the infant’s performance to make it clinically and
theoretically useful. To explore feeding skill performance
in relation to a developmentally meaningful context, we
used the parameter estimates for the fixed occasions
repeated measures regression analysis to examine the effect
on feeding skill performance (fdgskill) of infant biologic
conditions (medical status in the neonatal period, estimated
by the NMI score, and concurrent health and well being,
estimated by rate of daily weight gain (rwtgain) and
maternal regulation of feeding affect and behavior (mrab).
In critique of our analytical model, the lack of statistical
significance for predictor coefficients may be due to low
power rather than to true absence of an effect. Although
findings support the contribution of either the infant’s NMI
score or rwtgain or both at the 1-, 4-, and 8-month
assessments, evidence was not found in this study for an
effect of mrab on feeding skill performance at any of the
four assessments.
Several measurement issues may have affected the
results. One issue is that the items of the mrab scale may
304
not be adequately sensitive to facets of maternal regulation
of feeding affect and behavior that are relevant to feeding
skill performance. Other qualities of maternal behavior,
such as expression of positive affect, may help infants to
regulate their behavior and, thus, make a difference in
feeding skill performance. How mothers structure a feeding
and maintain an environment that supports infant partici-
pation has had little study. Moreover, how maternal
compensatory behavior [10,19] enhances or inhibits infant
performance of feeding skills is a question. Observation of
the quality of an infant’s participation in the feeding and
responses to opportunities to perform feeding skills could
lead to identification of infant feeding behaviors that make
a difference in feeding skill performance.
Another issue concerns the unexpected direction of
several of the predictor coefficients. The unexpected
positive contribution of the NMI score to feeding skill
performance at one month may be explained by the greater
attentiveness by mothers to the feeding skills of more high-
risk infants. Mothers may have perceived these infants as
needing more caregiver support. The rwtgain variable made
a significant contribution to fdgskill at one month in the
predicted positive direction, but at eight months, the
significant contribution was in a negative direction. This
variable may inadequately reflect current status if an infant
has had a recent acute illness or severe or protracted acute
illness during the interval between assessments and,
therefore, has had very high or very low catch-up growth.
Physiologic and behavioral variables not included in this
study (e.g., the work of breathing, gastro-esophageal reflux
and associated swallowing difficulties) may influence feed-
ing skill performance [42].
Too little is known about what is involved in premature
infants’ learning skills for new feeding modes and types of
food. How infants can best gain experience in feeding tasks
that challenge their physical capacities to feed safely is an
important question for further study. How parents can be
effectively guided in offering opportunities and supporting
their premature infants in performing and developing
feeding skills is an important research and clinical agenda.
An assessment of feeding skills that can reliably be done by
clinicians in any setting where feeding can be observed
could advance this agenda. Although much work remains to
be done, this study has advanced this agenda through a
description of the variability in infant feeding skills within
and across assessment ages and an exploration of infant
biologic conditions and maternal feeding behavior and
affect that may contribute to variability.
Acknowledgments
This research was supported by the March of Dimes Birth
Defects Foundation (grant number FY-0103), Maternal and
Child Health Bureau (MCJ-550806), the National Center for
Research Resources to the University of Wisconsin Medical
School (NIH M01 RR03186), the University of Wisconsin-
Madison School of Nursing, and National Institute of
Nursing Research Post-Doctoral Fellowship 5 F32 NR07267-
02 to Deborah Steward and NIH Predoctoral Individual
National Research Service Award 5 F31 NR007703-02 to Lisa
Brown.
K. Pridham et al.
Special thanks to the mothers and infants who partici-
pated in this study; Rana Limbo, PhD, RN, and Michele
Schroeder, PhD, RN, for mentoring nurses who made feeding
assessments and for supervision of data collection; the
nurses who assessed feeding skills (Lorna Cisler-Cahill, MS,
RN; Wanda Frazier, BS, RN; Donna Harris, MSN, RN; Mary
Krolikowski, MSN, RN, and Lois Seefeldt, PhD, RN); Wai Fong
Kwok for data entry; and Jeffrey Henriques, PhD, who gave
valuable assistance with data analyses.
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