Journal of Pediatric Nursing 53 (2020) e179–e185

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Journal of Pediatric Nursing

journal homepage: www.pediatricnursing.org

Turkish Neonatal Nurses' Knowledge and Practices Regarding the

Transition to Oral Feeding in Preterm Infants: A Descriptive,
Cross-sectional Study
Burcu Aykanat Girgin a, Duygu Gözen b,⁎
a
University of Health Sciences, Turkey Hamidiye Faculty of Nursing, Department of Pediatric Nursing, Turkey
b
İstanbul University-Cerrahpaşa Florence Nightingale, Faculty of Nursing, Pediatric Nursing Department, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Neonatal nurses play an important role in preterm infants' safe and successful transition to oral feeding.
Received 21 January 2020 Little is known about neonatal nurses' knowledge and practices regarding the transition to oral feeding in pre-
Revised 24 March 2020 term infants. The aim of this study was to determine neonatal nurses' knowledge levels and clinical practices re-
Accepted 30 March 2020 lated to the process of transitioning preterm infants to oral feeding.
Design and method: This descriptive cross-sectional study was conducted with 275 neonatal nurses working in
Keywords:
the neonatal intensive care units of 9 different hospitals in Istanbul, Turkey. Data were collected using a partici-
Infant
Knowledge
pant demographic form and a questionnaire about the neonatal nurses' knowledge and practices regarding oral
Neonatal nurse feeding.
Oral feeding Results: The mean knowledge score of the nurses in this study was 64.7 out of 100 (SD = ±8.7; range =
Preterm 40–87.5). Rates of correct responses were particularly low for items related to cue-based feeding, interventions
to promote oral–motor development, non-nutritive sucking, and infant positioning for oral feeding. All of the
NICU nurses participating in the study did not use the protocols developed for transitioning preterm infants to
oral feeding.
Conclusions: Nurses need knowledge and practical training on evidence-based therapeutic interventions that
promote oral feeding skills in preterm infants during the transition to oral feeding. The use of protocols developed
for transitioning preterm infants to oral feeding is limited in NICUs.
Practice Implications: In order to facilitate safe and successful feeding, nurses should improve their knowledge
and practical skills regarding the transition to oral feeding and evidence-based therapeutic interventions for pre-
term infants.
© 2020 Elsevier Inc. All rights reserved.

Introduction prolonged hospital stay (Bakewell-Sachs, Medoff-Cooper, Escobar,

Oral feeding in preterm infants is a complex and dynamic process in-
volving an interaction between the oral–motor, neurological, cardiore-
spiratory, and gastrointestinal systems (Amaizu, Shulman, Schanler, &
Lau, 2008; Goldfield, 2007). Preterm infants experience feeding prob-
lems due to their physiological and neurological immaturity
(Jadcherla, Wang, Vijayapal, & Leuthner, 2010; Park, Knafl, Thoyre, &
Brandon, 2015; White-Traut et al., 2013). For this reason, they are
given long-term enteral feeding via an orogastric/nasogastric tube
until they develop adequate oral feeding skills (Viswanathan &
Jadcherla, 2019). This causes delayed development of oral feeding skills
(Griffith, Bell, White-Traut, Medoff-Cooper, & Rankin, 2018) and
⁎ Corresponding author.
E-mail address: duygugozen@gmail.com (D. Gözen).
Silber, & Lorch, 2009; Jadcherla et al., 2010).
Neonatal nurses play an important role in the safe and successful
transition to oral feeding in preterm infants (Embleton, 2013). Neonatal
nurses must be able to assess oral feeding readiness and apply evidence-
based protocols and therapeutic interventions (Embleton, 2013;
Thoyre, Pados, Shaker, Fuller, & Park, 2018). Such interventions de-
scribed in the literature include cue-based feeding (Fry, Marfurt, &
Wengier, 2018; Lubbe, 2018; White & Parnell, 2013), interventions to
support oral–motor development (Fucile, McFarland, Gisel, & Lau,
2012; Ghomi et al., 2019; Younesian, Yadegari, & Soleimani, 2015),
non-nutritive sucking (Foster, Psaila, & Patterson, 2016; Harding,
2009), and feeding in semielevated side-lying position (Aykanat
Girgin, Gözen, & Karatekin, 2018; Clark, Kennedy, Pring, & Hird, 2007;
Park, Thoyre, Knafl, Hodges, & Nix, 2014; Ross & Philbin, 2011).
A review of the literature yields numerous studies on the factors
influencing preterm infants' oral feeding readiness (Hwang, Ma,

https://doi.org/10.1016/j.pedn.2020.03.017
0882-5963/© 2020 Elsevier Inc. All rights reserved.
e180 B. Aykanat Girgin, D. Gözen / Journal of Pediatric Nursing 53 (2020) e179–e185
Tseng, & Tsai, 2013; White-Traut et al., 2013), assessment tools used in
evaluation (Thoyre et al., 2018; Zarem et al., 2013), and the effects of
evidence-based therapeutic interventions (Aykanat Girgin et al., 2018;
Ghomi et al., 2019; Kirk, Alder, & King, 2007) and protocols on oral feed-
ing (Dalgleish, Kostecky, & Blachly, 2016; Drenckpohl, Dudas, Justice,
McConnell, & Macwan, 2009). However, there have been few studies
evaluating neonatal nurses' knowledge and practices with regards to
the process of transitioning to oral feeding (Neto, França, & Cruz,
2016; Pham et al., 2018). Based on this information, the current study
was conducted to address the need for research investigating neonatal
nurses' levels of knowledge and practices related to the transition to
oral feeding in preterm infants.
Research questions
• What is the knowledge level of neonatal nurses related to the transi-
tion to oral feeding in preterm infants?
• What are the clinical practices of neonatal nurses related to the tran-
sition to oral feeding in preterm infants?
• What are the factors that affect the knowledge level of neonatal
nurses on transition to oral feeding in preterm infants?
Methods
Design
This descriptive, cross-sectional study was conducted to determine
knowledge levels and practices related to preterm infants' transition
to oral feeding among neonatal nurses in Istanbul, Turkey. The study
was carried out between April and October 2019 at nine research and
training hospitals under the administration of the Turkish Ministry of
Health and located in Istanbul, Turkey. These hospitals are homogenous
and provide level III neonatal intensive health care services, particularly
in central Istanbul.
Participants and setting
A convenience sampling technique was used in this study. Neonatal
nurses working in the neonatal intensive care units (NICUs) of these
nine hospitals (n = 340) were invited to participate to the study. A
power analysis was performed using the G*Power (v 3.1.7) program
to determine the necessary sample size at the beginning of the study.
Post-hoc analysis revealed that the power of a sample size of 275 nurses
with α = 0.05 and effect size (w) = 0.20 was 1 – β = 0.91. The study
was completed with a sample of 275 nurses who met the inclusion
criteria. The power calculated by the G*Power (v 3.1.7) program and
based on the comparison of the mean knowledge scores of the neonatal
nurses (n = 275) was found 1- β = 0.86 at the end of the study (SD
within each group = 16.04; effect size = 0.21). The power of 0.80 or
higher is an indicator of an adequate sample size (Malone, Nicholl, &
Coyne, 2016).
The inclusion criteria were a) having at least 1 year of clinical expe-
rience and holding a permanent position in the NICU, b) caring directly
for preterm infants, c) working full-time in NICU, d) voluntarily signing
the informed consent form, and e) being able to read and speak Turkish,
as the questionnaire was in Turkish.
Instruments
The data were collected using participant demographic form and
oral feeding knowledge and practices questionnaire for neonatal nurses.
These instruments were developed by the investigators in accordance
with the literature.
Participant demographic form
The form consisted of 5 questions, 2 open-ended and 3 multiple-
choice, about the nurse's age, gender, education level, duration of full-
time service in the NICU, and any education/training they received re-
garding feeding of preterm infants.
Oral feeding knowledge and practices questionnaire for neonatal nurses
The questionnaire was designed to measure the knowledge and
practices of neonatal nurses related to the transition to oral feeding in
preterm infants in accordance with the literature by the investigators
in this study (Aykanat Girgin et al., 2018; Dalgleish et al., 2016;
Drenckpohl et al., 2009; Fucile et al., 2012; Hwang et al., 2013; Pham
et al., 2018; Ross & Philbin, 2011; Thoyre et al., 2018; White-Traut
et al., 2013; White & Parnell, 2013; Zarem et al., 2013). A preliminary
version of the questionnaire was reviewed by a panel of eight experts.
The content validity of the questionnaire was assessed by seeking the
opinion of eight nurse experts. These eight experts completed their doc-
torate education in the neonatal and pediatric nursing. They had pub-
lished research on preterm infants' oral feeding for over ten years and
they were managing doctorate thesis in pediatric nursing as an advisor.
The experts were asked to offer their opinions for each item as highly
relevant (4), quite relevant (3), somewhat relevant (2), and not relevant
(1). The Content Validity Index (CVI) was calculated by dividing the
number of experts assigning 3 or 4 points to the items by the total num-
ber of experts (Polit & Beck, 2006). The CVI of the questionnaire, as cal-
culated in accordance with expert judgment, was 0.94. After the
experts' review, the questionnaire was modified to improve its clarity
and eliminate redundant items. Evaluation of the revised version by
the panel resulted in no further modifications.
The questionnaire has two sections. The first section consists of 40
items containing true and false information to evaluate the neonatal
nurses' level of knowledge about the process of transitioning preterm
infants to oral feeding (Table 1). The nurses responded to the items by
selecting “I agree” or “I disagree”. Using an answer key in which the in-
formation in each item was labeled as true or false, the nurses were
evaluated as “knowing” or “not knowing” each item based on their re-
sponses. Each known item (correct responses) received a score of 2.5
points, while unknown items (incorrect responses) were scored as 0,
resulting in a total score ranging from 0 to 100. Higher scores indicate
higher knowledge level.
The second section includes questions regarding criteria used to as-
sess infants during the transition to oral feeding, assessment tools,
evidence-based therapeutic oral feeding interventions, and alternative
methods used for oral feeding if breastfeeding was not possible. This
practical section consists of 10 items: 4 multiple-choice questions, 3
yes/no statements, and 3 open-ended questions.
Procedure
The researchers met with the nurses included in the sample and ex-
plained the purpose and importance of the study by face to face expla-
nation. Then, the neonatal nurses provided written consent. Nurses
completed the questionnaires independently, taking approximately
20–25 min. Researchers waited in the neonatal intensive care unit
until the nurses completed the questionnaires. The nurses' responses
in the knowledge section of the questionnaire were then evaluated
using the prepared answer key.
Data analysis
Data analysis was performed using licensed SPSS (Statistical Package
for the Social Sciences) for Windows version 21.0 package software. De-
scriptive analysis was performed for all the variables. We compared the
neonatal nurses' mean knowledge scores according to their gender, ed-
ucation level, and receiving education on preterm infants' feeding. In
order to compare the two groups in terms of gender and education on
 B. Aykanat Girgin, D. Gözen / Journal of Pediatric Nursing 53 (2020) e179–e185 e181

Table 1
Neonatal nurses' responses on the knowledge section of the questionnaire (n=275).

Items of the questionnaire Correct

responses

n %

1. Disease severity and complications adversely affect a preterm infant's oral feeding readiness. (True) 273 99.3
2. The light level in the neonatal intensive care unit has no effect on oral feeding skills. (False) 202 73.5
3. In cue-based feeding, feeds are attempted at 2–3-hour intervals. (False) 21 7.6
4. Immature suck-swallow-breathe coordination emerges at 32 weeks of gestation. (False) 62 22.5
5. Keeping the infant in a flexed posture during feeding has a favorable effect on feeding skills. (True) 248 90.2
6. The attention–interaction system is not important for oral feeding success in preterm infants. (False) 118 42.9
7. In a coordinated feed, there is a 1:1:1 suck-swallow-breathe ratio. (True) 246 89.5
8. The noise level in the neonatal intensive care unit has no effect on oral feeding skills. (False) 231 84.0
9. In cue-based feeding, finishing the recommended feed volume is considered feeding success. (False) 59 21.5
10. Oral–motor interventions should be implemented when the preterm infant has transitioned to full oral feeding. (False) 44 16.0
11. Hand or fist sucking is one of the cues that indicate a preterm infant is ready for oral feeding. (True) 250 90.9
12. In bottle-fed infants, twisting or moving the nipple back and forth in the mouth during feeds stimulates feeding and increases feeding success. (False) 28 10.2
13. Hiccups during oral feeding indicates a preterm baby is full. (False) 200 72.7
14. Licking the lips is one of the cues that indicate a preterm infant is ready for oral feeding. (True) 236 85.8
15. In non-nutritive sucking, no milk enters the infant's mouth. (True) 189 68.7
16. Oral–motor interventions consist of 10 min of only lip and gum stimulation. (False) 69 25.1
17. Breast milk should be the first choice of food during the transition to oral feeding in preterm infants. (True) 259 94.2
18. The recommended position for bottle feeding a preterm infant is the semielevated supine position, in which the nurse holds the baby in her lap with the head 25 9.1
and neck elevated to 45–60 degrees. (False)
19. In non-nutritive sucking, sucking durations are long and rhythmic. (False) 105 38.2
20. There is no difference between using the semielevated supine or semielevated side-lying positions while feeding in terms of preterm infants' vital signs. 178 64.7
(False)
21. Nurses must be certified to practice oral–motor interventions. (True) 123 44.7
22. As the postmenstrual age of a preterm infant increases, neurological maturity decreases. (False) 202 73.5
23. Preterm infants should not be fed orally before 34 weeks of gestation; this prevents infant fatigue and increases feeding success. (False) 111 40.4
24. Non-nutritive sucking has no effect on reducing duration of gavage feeding. (False) 168 61.1
25. The ideal method for transitioning preterm infants to oral feeding is breastfeeding. (True) 206 74.9
26. Coordination between the autonomic, motor, and self-regulation systems of the preterm infant develops with sufficient neurological maturity. (True) 256 93.1
27. Due to the effect of hydrostatic pressure in the semielevated supine position, a large volume of milk from the bottle increases the infant's wakefulness and 112 40.7
shortens feed duration. (False)
28. Allowing a preterm infant time to rest during feeds helps re-establish suck-swallow-breathe coordination and avoid risk of aspiration. (True) 263 95.6
29. Cup feeding absolutely increases the frequency of breastfeeding after discharge. (False) 124 45.1
30. In the synactive theory, all subsystems are interconnected and develop in a hierarchical pattern. (True) 233 84.7
31. Fatigue during oral feeding adversely affects the infant's autonomic–physiological subsystem. (True) 247 89.8
32. During the process of transitioning preterm infants to oral feeding, greater number of bottle feeds shortens the time required for transition to full oral 201 73.1
feeding. (True)
33. Infants whose first oral feeding experience is breastfeeding and are frequently breastfed have longer duration of breastfeeding/feeding with breast milk. 235 85.5
(True)
34. Breast milk can be stored for three hours at room temperature. (True) 258 93.8
35. Non-nutritive sucking is only done with a pacifier. (False) 153 55.6
36. After a feed, the remaining breast milk in the bottle can be put in the refrigerator and reused within 3 days. (False) 182 66.2
37. Non-nutritive sucking is done with the mother's breast, preferably after pumping. (True) 208 75.6
38. Feeding with cup/bottle/spoon/syringe are alternative feeding methods used to deliver expressed breast milk when the mother is not able to come to the 268 97.5
neonatal intensive care unit. (True)
39. Prolonged gavage feeding delays the development of oral–motor skills. (True) 257 93.5
40. Breast milk can be stored on the middle shelves of the refrigerator for 3 days. (True) 271 98.5

feeding, Mann Whitney U test for non-normally distributed variables
was used. Kruskal-Wallis test was used for comparisons among three
or more groups in terms of education level of nurses, and Pearson corre-
lation analysis was used to evaluate correlations between variables. The
results were evaluated within a 95% confidence interval and p values
b0.05 were considered statistically significant (Erol, 2010).
Ethical considerations
The study was approved by the ethics committee of a state university
in Istanbul, Turkey. Written permission was obtained from the Istanbul
Provincial Health Directorate to collect data from the nine hospitals sam-
pled in the study. The neonatal nurses were informed about the study and
provided verbal and written consent before participating.
Results
Sample characteristics
In total, 340 neonatal nurses were invited to participate to the study.
Fifty nurses did not participate in the study due to time constraints and
lack of access, and another 15 nurses did not want to participate in the
study. Therefore, the study was completed with a sample of 275 nurses
who met the inclusion criteria (80.8% of the sample population of 340).
The mean age of the nurses who participated in the study was 27.7
(SD = ±5.2; range = 19–49) years. They had worked in the NICU for
between 1 and 20 years, with a mean of 4.00 years of experience
(SD = ±3.9 years). Of the participating nurses, 94.2% (n = 259) were
female; 8% were high school graduates, 5.1% had associate degrees,
76% (n = 209) had bachelor's degrees, and 10.9% had postgraduate de-
grees. In addition, 69.8% (n = 192) stated that they had received educa-
tion/training regarding the feeding of preterm infants.
Knowledge levels of the neonatal nurses regarding transition to oral feeding
The proportions of nurses who responded correctly and incorrectly
to the items in the knowledge part of the questionnaire are shown in
Table 1. The five most known items were items 1 (99.3%), 40 (98.5%),
38 (97.5%), 28 (95.6%) and 17 (94.2%). More than half of the nurses
(55.6–99.3%) responded correctly to the items about preterm infants'
readiness for oral feeding (items 1, 2, 5, 7, 8, 11, 13, 14, 22, 26, 28,
30–32, 39), methods and foods used during the transition to oral
e182 B. Aykanat Girgin, D. Gözen / Journal of Pediatric Nursing 53 (2020) e179–e185

Table 2
Comparison of neonatal nurses' knowledge scores according to their descriptive characteristics (n = 275).

Characteristic n X ± SD Median Min Max Test/p value

Gender Female 259 64.9 ± 8.7 65.0 40.0 87.5 pa=0.10

Male 16 61.4 ± 8.0 60.0 42.5 75.0
Education level High school1 22 61.0 ± 8.4 61.3 45.0 77.5 H = 35.1
Associate degree2 14 53.8 ± 8.9 51.3 40.0 72.5 pb=0.00
Bachelor's degree3 209 64.8 ± 7.9 65.0 42.5 80.0 1,2 b 3,4
Postgraduate degree4 30 71.3 ± 8.2 71.3 55.0 87.5
Education on feeding Yes 192 65 ± 8 68 45 80 pa=0.44
No 83 64 ± 9 65 40 88

The bold p demonstrates that p value is b 0.05.

a
Mann–Whitney U test.
b
Kruskal–Wallis test.

feeding (items 15, 17, 20, 24, 25, 33, 35, 37, 38), and breast milk storage those with postgraduate degrees and 53.8 (SD = ±8.9) among those
conditions (items 34, 36, 40). with associate degrees. Nurses with high school and associate degrees
The five least known items were items 3 (7.6%), 18 (9.1%), 12 had significantly lower mean knowledge score compared to nurses
(10.2%), 10 (16.0%) and 9 (21.5%). More than half of the nurses with bachelor's and postgraduate degrees (H = 35.1; p = 0.00)
(55.3–92.4%) responded incorrectly to the items about cue-based feed- (Table 2).
ing (items 3, 9, 12), interventions to promote oral–motor development Nurses who reported having received education/training about
(items 10, 16, 21), non-nutritive sucking (item 19), and positioning for feeding in preterm infants had a mean knowledge score of 65
oral feeding (items 18, 27) (Table 1). (SD = ±8), while those who did not had a mean score 64 (SD = ±9)
The mean knowledge score of the nurses participating in the study (p = 0.44; Table 2).
was 64.7 out of 100 (SD = ±8.7; range = 40–87.5). When knowledge No significant correlation was detected between knowledge scores
scores were evaluated according to gender, there was no significant dif- and age (r = 0.096; p = 0.11) or years of NICU experience (r =
ference between the scores of the female 64.9 (SD = ±8.7) and male 0.019; p = 0.75).
61.4 (SD = ± 8.0) nurses (p = 0.10; Table 2).
Evaluation of knowledge scores according to education level re- Practices of the neonatal nurses regarding transition to oral feeding
vealed that mean knowledge score was 71.3 (SD = ±8.2) among
When asked what criteria they used in the decision to initiate oral
feeding, 86.2% of the participants stated that they consider whether
Table 3 the infant can actively use oral–motor reflexes, while 69.1% stated that
Neonatal nurses' practices regarding transition to oral feeding in preterm infants they consider the physician's decision.
(n = 275).
Twenty percent of the nurses reported that they had personally used
Practice Yes No an evidence-based intervention to promote the oral feeding skills of
Criteria useda n % n % preterm infants. When asked which evidence-based intervention they
used, all nurses reported using non-nutritive sucking. All of the NICU
Neurological maturity 234 85.1 41 14.9
Disease severity 207 75.3 68 24.7
nurses (n = 275) participating in the study stated that they did not
Suck-swallow-breathe coordination 204 74.1 71 25.9 use the standard protocols developed for transitioning to oral feeding
Behavioral cues 175 63.6 100 36.4 in preterm infants.
Stable vital signs before and during feeding 235 85.5 40 14.5 For preterm infants unable to breastfeed, 98.2% of the nurses stated
Oral feeding experience 197 71.6 78 28.4
that they used a feeding bottle, 44% stated they used a syringe, and
Postmenstrual/gestational age 234 85.1 41 14.9
Physician's decision 190 69.1 85 30.9 10.5% stated they used a cup as an alternative feeding method during
Active use of oral–motor reflexes 237 86.2 38 13.8 the transition to oral feeding. While 40% of the nurses used nipples
Personally used evidence-based interventions 55 20.0 220 80.0 with standard flow rate for bottle feeding, 16.7% stated that they used
Use of oral feeding transition protocol in the nurse's unit 0 0.0 275 100.0 slow-flow nipples. In terms of feeding position, 51.9% of the nurses
Alternative methods useda n % n %
Bottle 270 98.2 5 1.8
stated that they used a semielevated supine position in the incubator
Syringe 121 44.0 154 56.0 for feeding, while 2.9% stated that they held the infant in their lap in a
Spoon 30 10.9 245 89.1 semielevated side-lying position.
Cup 29 10.5 246 89.5 Only 2.9% of the nurses reported using a proven valid and reliable as-
Finger feeding 4 1.5 271 98.5
sessment tool when evaluating preterm infants' oral feeding skills: the
Using an assessment tool to evaluate oral feeding skills in 8 2.9 267 97.1
the nurse's unit LATCH Breastfeeding Assessment Tool (Table 3).
Nipple used for bottle feeding n %
Standard-flow nipple 108 40.0 Discussion
Slow-flow nipple 45 16.7
Moderate-flow nipple 47 17.4
Fast-flow nipple 0 0.0
For preterm infants to have a safe and successful oral feeding expe-
Mixed 70 25.9 rience, it is important for neonatal nurses to have adequate knowledge
Total 270 100.0 and feeding skills (Embleton, 2013). In this study evaluating knowledge
Position used for bottle feeding n % levels and practices of neonatal nurses in Istanbul, Turkey regarding
Semielevated supine position in lap 86 31.8
preterm infants' transition to oral feeding, we determined the nurses'
Cradle hold in arm 5 1.9
Semielevated side-lying position in lap 8 2.9 mean knowledge score to be partially adequate, at 64.7 ± 8.7. Nurses'
Semielevated side-lying position in incubator 31 11.5 knowledge and skills regarding patient care increase with higher level
Semielevated supine position in incubator 140 51.9 and quality of education (Ketefian, Davidson, Daly, Chang, &
Total 270 100.0 Srisuphan, 2005). In Turkey, nursing education is provided at the high
a
Nurses selected multiple options for this item. school, associate, bachelor's, and postgraduate levels. We found in this
 B. Aykanat Girgin, D. Gözen / Journal of Pediatric Nursing 53 (2020) e179–e185
study that nurses with bachelor's and postgraduate degrees constituted
the majority of the sample group and had significantly higher knowl-
edge scores compared to the nurses who held high school diplomas
and associate degrees (Table 2). Their higher level of knowledge on
feeding preterm infants may be attributable to the specific “neonatal
nursing” course given in bachelor's and postgraduate programs
(Table 2). In Turkey, graduates of the nursing departments of health
high schools were employed as nurses in the past. When these nurses
completed the neonatal intensive care nursing certificate program,
they were able to work in NICUs. Now, graduates of these schools are
employed as nurse assistants. However, high school graduate nurses
(certified in neonatal intensive care nursing) who were hired as NICU
nurses in the past are still employed there. In our sample group, 22 of
the nurses were high school graduates certified in neonatal intensive
care nursing. High school comprised only 8% of our study sample,
while the large majority of the nurses (76%; n = 209) held bachelor's
degrees.
Preterm infants' oral feeding skills and coordination are adversely af-
fected as complications associated with their medical diagnoses in-
crease (Mizuno et al., 2007; White-Traut et al., 2013). Consistent with
the literature, the most known item among the nurses in our study
(n = 273, 99.3%) was “disease severity and complications adversely af-
fect preterm infants' oral feeding readiness” (item 1; Table 1).
It is well established in the literature that breast milk and
breastfeeding are the ideal food and feeding method for preterm infants,
as for all infants (Lawrence & Lawrence, 2011; LoVerde, Falck, Donohue,
& Hussey-Gardener, 2018). In cases where it is not possible to
breastfeed preterm infants for various reasons, breast milk collected
from the mother can be stored for three days on the middle shelf of
the refrigerator and given using alternative feeding methods such as
cup, spoon, bottle, or syringe until breastfeeding can be achieved
(McGrath, Lussier, & Briere, 2013). The majority of the nurses in our
study (over 90%) knew this information (items 17, 38, 40) (Table 1).
Cue-based feeding is an approach in which the feeding method is de-
termined by evaluating the infant's physiological signs and behavioral
cues during the oral feeding process (Lubbe, 2018; Thoyre, Holditch-
Davis, Schwartz, Melendez Roman, & Nix, 2012; White & Parnell,
2013). In the traditional feeding model, the infant's gestational age is
the main criterion for initiating oral feeding, feeds are attempted at
2–3-hour intervals, and finishing a certain volume is considered feeding
success (Ludwig & Waitzman, 2007). Traditionally, nurses attempt to
encourage the infant to finish the entire recommended feed volume
by using oral stimulation such as twisting the nipple of the feeding bot-
tle or moving it back and forth in the infant's mouth, interventions that
may disrupt suck-swallow-breathe coordination (Shaker, 2013). In re-
cent years, using the cue-based feeding approach is recommended in-
stead of the traditional feeding model (Lubbe, 2018; Shaker, 2013;
Thoyre et al., 2012). This approach adopts an understanding that oral
feeds are initiated when the infant shows signs of hunger and are termi-
nated when the infant shows signs of stress (Morris & Gardner, 2011).
The aim of this approach is to improve the infant's oral feeding skills, re-
gardless of feed volume (White & Parnell, 2013). According to the cue-
based feeding approach, when the preterm infant shows signs of stress
during oral feeding (Kirk et al., 2007; White & Parnell, 2013), they are
allowed to rest until they can re-establish coordination between suck-
swallow and respiratory functions (Thoyre et al., 2012). In our study,
95.6% of the nurses knew that preterm infants require rest, as stated
in the literature (item 28; Table 1). However, most of the nurses failed
to recognize the false statements “in cue-based feeding, feeds are
done at 2-3 hour intervals” (item 3, 92.4%), “in bottle-fed infants, twist-
ing or moving the nipple back and forth in the mouth during feeds stim-
ulates feeding and increases feeding success” (item 12, 89.8%), and “in
cue-based feeding, finishing the recommended feed volume is consid-
ered feeding success” (item 9, 78.5%) (Table 1). In other words, only
7.6%, 10.2%, and 21.5% of the nurses responded correctly to items 3,
12, and 9, respectively.
e183
In recent years, studies have compared the effects of placing preterm
infants in the semielevated supine and semielevated side-lying posi-
tions during feeding on their vital signs (Aykanat Girgin et al., 2018;
Clark et al., 2007; Park et al., 2014) and feeding performance (Aykanat
Girgin et al., 2018; Park et al., 2014). These studies demonstrated that
infants fed in the semielevated side-lying position had higher oxygen
saturation levels (Aykanat Girgin et al., 2018; Clark et al., 2007), less var-
iable heart rate (Aykanat Girgin et al., 2018; Park et al., 2014), and
shorter feeding durations (Aykanat Girgin et al., 2018). Evidence-
based studies have recommended using the semielevated side-lying po-
sition when feeding preterm infants (Aykanat Girgin et al., 2018; Clark
et al., 2007; Park et al., 2014; Ross & Philbin, 2011). However, only
2.9% of the nurses in our study reported using the semielevated side-
lying position during feeding (Table 3), and more than half of the nurses
(%59.3, %90.9) believed the semielevated supine position was preferable
(items 27, 18; Table 1). Although a large proportion of the nurses in our
study (n = 192; 69.8%) stated that they had received training on pre-
term feeding, their low level of knowledge on cue-based feeding and
feeding positions suggests that they need more current information
about feeding, and that the results of evidence-based studies are not
yet reflected in the clinical setting.
In order to facilitate the transition to oral feeding, interventions to
promote oral–motor development are performed for approximately
10 days while the infant is still receiving enteral feeding (Fucile et al.,
2012). In our study, we found that 84% of nurses incorrectly agreed
with the false statement “oral–motor interventions should be imple-
mented when the infant has transitioned to full oral feeding” (item
10; Table 1). This finding indicates that the nurses also require informa-
tion about interventions that promote oral–motor development in addi-
tion to cue-based feeding and oral feeding position.
Assessing preterm infants' oral feeding readiness and deciding to
transition to oral feeding are among the important duties of neonatal
nurses that can be carried out independently (Embleton, 2013). Most
of the nurses participating in our study decided to initiate oral feeding
in preterm infants based on their ability to actively use oral–motor re-
flexes (86.2%), having stable vital signs before, during, and after feeding
(85.5%), and their postmenstrual age and neurological maturity (85.1%)
(Table 3). Compared with the literature data, our results show that the
nurses considered objective criteria during the transition to oral feeding
in preterm infants (Amaizu et al., 2008; Howe, Sheu, Hinojosa, Lin, &
Holzman, 2007; Neto et al., 2016; Pickler, Best, & Crosson, 2009;
White-Traut et al., 2013). However, our findings that 69.1% of the nurses
still defer to the physician's decision regarding transitioning to oral
feeding and only 2.9% use a valid and reliable assessment tool to evalu-
ate oral feeding skills (Altuntaş et al., 2014) suggest that they had diffi-
culty making independent decisions.
Our results showed that evidence-based interventions that promote
oral feeding skills in preterm infants were used in only 20% of the nurses
in our study, all of whom cited non-nutritive sucking as the method
they used. Moreover, we found that none of the nurses followed a pro-
tocol for transitioning preterm infants to oral feeding (Table 3). This
finding suggests that the nurses included in our sample did not use
cue-based feeding, interventions that support the development of
oral–motor functions, or the semielevated side-lying position for oral
feeding, and that they required more information about these practices.
Moreover, the similarity between the knowledge scores of nurses who
did and did not have education/training specific to preterm feeding
demonstrated that all of the nurses need updated education/training
on this topic.
Bottle feeding is the most commonly preferred alternative feeding
method until preterm infants can be breastfed (Flint, New, & Davies,
2016; McGrath et al., 2013). Consistent with the literature, 98.2% of
the nurses in our study used bottles for feeding (Table 3).
The type of nipple used to bottle-feed preterm infants is an impor-
tant factor that impacts oral feeding coordination and skills. Feeding
preterm infants with a slow-flow nipple allows the infant to control
e184 B. Aykanat Girgin, D. Gözen / Journal of Pediatric Nursing 53 (2020) e179–e185
the flow rate during feeding and helps reduce suppression of respiration
through more effective and safer suck-breathe coordination (Amaizu
et al., 2008; Ross & Philbin, 2011). The fact that only 16.7% of the nurses
in our study used slow-flow nipples shows that their knowledge and
practice on this subject should be improved (Table 3).
Conclusions
In light of the results of our study, we concluded that the nurses need
more knowledge and practical training on the evidence-based thera-
peutic interventions used to support oral feeding skills in preterm in-
fants during the transition to oral feeding, including cue-based
feeding, interventions that promote oral–motor development, using
semielevated side-lying position during feeding, and bottle feeding
with slow-flow nipples. We determined that the traditional feeding ap-
proach was more common and the latest evidence-based research find-
ings were not reflected in clinical practice in the NICUs included in the
study. However, the majority of the nurses (over 90%) placed impor-
tance on feeding with breast milk, encouraged breastfeeding, knew
the proper storage conditions for breast milk, and used alternative
methods to continue feeding with breast milk in cases where
breastfeeding is not possible. We also found that the nurses considered
objective criteria during preterm infants' transition to oral feeding, but
only a small proportion evaluated these criteria with a valid and reliable
assessment tool. This study highlights a need for continuous, repeated
education and training for NICU nurses regarding the transition to oral
feeding in preterm infants. Building on the findings of this study, future
research could examine the effectiveness of education and training in
improving neonatal nurses' knowledge levels and practices related to
the transition to oral feeding in preterm infants.
Limitations
A potential limitation of this study is that the sample was comprised
of NICU nurses from the nine hospitals in İstanbul. The results cannot be
generalized to all neonatal nurses in Turkey or in other regions.
Declaration of conflicting interest
The authors declare no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
Ethical statement
The study was approved by the ethics committee of a state univer-
sity in Istanbul, Turkey (IRB number 29.03.2019/46418926).
Contributions
Design: BAG, DG.
Data Collection: BAG, DG.
Data Analysis: BAG, DG.
Manuscript writing: BAG, DG.
CRediT authorship contribution statement
Burcu Aykanat Girgin: Conceptualization, Investigation, Methodol-
ogy, Writing-review & editing. Duygu Gözen: Conceptualization, Inves-
tigation, Methodology, Writing-review & editing.
Acknowledgment
The authors would like to thank all the nurses who participated in
this study.
References
Altuntaş, N., Türkyılmaz, C., Yıldız, H., Kulalı, F., Hirfanoğlu, I., Önal, E., ... Atalay, Y. (2014).
Validity and reliability of the infant breastfeeding assessment tool, the mother baby
assessment tool, and the LATCH scoring system. Breastfeeding Medicine, 9(4),
191–195.
Amaizu, N., Shulman, R. J., Schanler, R. J., & Lau, C. (2008). Maturation of oral feeding skills
in preterm infants. Acta Paediatrica, 97(1), 61–67.
Aykanat Girgin, B., Gözen, D., & Karatekin, G. (2018). Effects of two different feeding po-
sition on physiological characteristics and feeding performance of preterm infants: A
randomized controlled trial. Journal for Specialists in Pediatric Nursing, 23(2), e12214.
Bakewell-Sachs, S., Medoff-Cooper, B., Escobar, G. J., Silber, J. H., & Lorch, S. A. (2009). In-
fant functional status: The timing of physiologic maturation of premature infants.
Pediatrics, 123(5), 878–886.
Clark, L., Kennedy, G., Pring, T., & Hird, M. (2007). Improving bottle feeding in preterm in-
fants: Investigating the elevated side lying position. Infant, 3(4), 154–158.
Dalgleish, S. R., Kostecky, L. L., & Blachly, N. (2016). Eating in “SINC”: Safe individualized
nipple-feeding competence, a quality improvement project to explore infant-driven
oral feeding for very premature infants requiring noninvasive respiratory support.
Neonatal Network, 35(4), 217–227.
Drenckpohl, D., Dudas, R., Justice, S., McConnell, C., & Macwan, K. S. (2009). Outcomes
from an oral feeding protocol implemented in NICU. ICAN: Infant, Child, &
Adolescent Nutrition, 1(1), 6–10.
Embleton, N. D. (2013). Optimal nutrition for preterm infants: Putting the ESPGHAN
guidelines into practice. Journal of Neonatal Nursing, 19(4), 130–133.
Erol, H. (2010). Analyzing data with SPSS program. Adana: Nobel Publishing.
Flint, A., New, K., & Davies, M. W. (2016). Cup feeding versus other forms of supplemental
enteral feeding for newborn infants unable to fully breastfeed. The Cochrane Database
of Systematic Reviews, 31(8), 1–41.
Foster, J. P., Psaila, K., & Patterson, T. (2016). Non-nutritive sucking for increasing physio-
logic stability and nutrition in preterm infants. The Cochrane Database of Systematic
Reviews, 4(10), CD001071.
Fry, T. J., Marfurt, S., & Wengier, S. (2018). Systematic review of quality improvement ini-
tiatives related to cue-based feeding in preterm infants. Nursing for Women’s Health,
22(5), 401–410.
Fucile, S., McFarland, D., Gisel, E., & Lau, C. (2012). Oral and nonoral sensorimotor inter-
ventions facilitate suck-swallow-respiration functions and their coordination in pre-
term infants. Early Human Development, 88(6), 345–350.
Ghomi, H., Yadegari, F., Soleimani, F., Knoll, B. L., Noroozi, M., & Mazouri, A. (2019). The
effects of premature infant oral motor interventions (PIOMI) on oral feeding of pre-
term infants: A randomized clinical trial. International Journal of Pediatric
Otorhinolaryngology, 120, 202–209.
Goldfield, E. C. (2007). A dynamical systems approach to infant oral feeding and dyspha-
gia: From model system to therapeutic medical device. Ecological Psychology, 19(1),
21–48.
Griffith, T. T., Bell, A. F., White-Traut, R., Medoff-Cooper, B., & Rankin, K. (2018). Relation-
ship between duration of tube feeding and success of oral feeding in preterm infants.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 47(5), 620–631.
Harding, C. (2009). An evaluation of the benefits of non-nutritive sucking for prema-
ture infants as described in the literature. Achieves of Disease in Childhood, 94(8),
636–640.
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.
Hwang, Y. S., Ma, M. C., Tseng, Y. M., & Tsai, W. H. (2013). Associations among perinatal
factors and age of achievement of full oral feeding in very preterm infants.
Pediatrics & Neonatology, 54(5), 309–314.
Jadcherla, S. R., Wang, M., Vijayapal, A. S., & Leuthner, S. R. (2010). Impact of prematurity
and co-morbidities on feeding milestones in neonates: A retrospective study. Journal
of Perinatology, 30, 201–208.
Ketefian, S., Davidson, P., Daly, J., Chang, E., & Srisuphan, W. (2005). Issues and challenges
in international doctoral education in nursing. Nursing & Health Sciences, 7(3),
150–156.
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.
Lawrence, R. M., & Lawrence, R. A. (2011). Breastfeeding: More than just good nutrition.
Pediatrics in Review, 32(7), 267–280.
LoVerde, B., Falck, A., Donohue, P., & Hussey-Gardener, B. (2018). Supports and barriers to
the provision of human milk by mothers of African American preterm infants.
Advances in Neonatal Care, 18(3), 179–188.
Lubbe, W. (2018). Clinicians quide for cue-based transition to oral feeding in preterm in-
fants: An easy-to-use clinical quide. Journal of Evaluation in Clinical Practice, 24(1),
80–88.
Ludwig, S. M., & Waitzman, K. A. (2007). Changing feeding documentation to reflect
infant-driven feeding practice. Newborn & Infant Nursing Reviews, 7(3), 155–160.
Malone, H. E., Nicholl, H., & Coyne, I. (2016). Fundamentals of estimating size. Nurse
Researcher, 23(5), 21–25.
McGrath, J. M., Lussier, M. M., & Briere, C. R. (2013). Bottle feeding the breastfed infant in
the neonatal intensive care unit. Newborn & Infant Nursing Reviews, 13(1), 5–6.
 B. Aykanat Girgin, D. Gözen / Journal of Pediatric Nursing 53 (2020) e179–e185
Mizuno, K., Nishida, Y., Taki, M., Hibino, S., Murase, M., Sakurai, M., & Itabashi, K. (2007).
Infants with bronchopulmonary dysplasia suckle with weak pressures to maintain
breathing during feeding. Pediatrics, 120(4), 1035–1042.
Morris, A. C., & Gardner, S. L. (2011). Cue-based feeding: Evidence-based practice. Nurse
Currents, 5(2), 1–8.
Neto, F., França, A. P., & Cruz, S. (2016). An algorithm proposal to oral feeding in prema-
ture infants. Nursing Children and Young People, 28(4), 72.
Park, J., Knafl, G., Thoyre, S., & Brandon, D. (2015). Factors associated with feeding pro-
gression in extremely preterm infants. Nurse Researcher, 64(3), 159–167.
Park, J., Thoyre, S., Knafl, G. J., Hodges, E. A., & Nix, W. B. (2014). Efficacy of semi elevated
side-lying positioning during bottle-feeding of very preterm infants. The Journal of
Perinatal & Neonatal Nursing, 28(1), 69–79.
Pham, T., Milanaik, R., Basile, T., Papaioannou, H., Ahmed, T., Rithika, R., ... Spinazzola, R.
(2018). An examination of NICU nurses’ training with regards to feeding infants.
Pediatrics, 141(1), 500.
Pickler, R. H., Best, A., & Crosson, D. (2009). The effect of feeding experience on clinical
outcomes in preterm infants. Journal of Perinatology, 29(2), 124–129.
Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what’s
being reported? Critique and recommendations. Research in Nursing and Health, 29
(1), 489–497.
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. The
Journal of Perinatal & Neonatal Nursing, 25(4), 349–357.
e185
Shaker, C. S. (2013). Cue-based feeding in the NICU: Using the infant’s communication as
a guide. Neonatal Network, 32(6), 404–408.
Thoyre, S., Holditch-Davis, D., Schwartz, T. A., Melendez Roman, C. R., & Nix, W. B. (2012).
Coregulated approach to feeding preterm infants with lung disease: Effects during
feeding. Nursing Research, 61(4), 242–251.
Thoyre, S. M., Pados, B. F., Shaker, C. S., Fuller, K., & Park, J. (2018). Psychometric properties
of the early feeding skills assessment tool. Advances in Neonatal Care, 18(5), 13–23.
Viswanathan, S., & Jadcherla, S. (2019). Transitioning from gavage to full oral feeds in pre-
mature infants: When should we discontinue the nasogastric tube. Journal of
Perinatology, 39(9), 1257–1262.
White, A., & Parnell, K. (2013). The transition from tube to full oral feeding (breast or bot-
tle): A cue-based developmental approach. Journal of Neonatal Nursing, 19(1),
189–197.
White-Traut, R., Pham, T., Ranhin, K., Norr, K., Shapiro, N., & Yoder, J. (2013). Exploring
factors related to oral feeding progression in premature infants. Advances in
Neonatal Care, 13(4), 288–294.
Younesian, S., Yadegari, F., & Soleimani, F. (2015). Impact of oral sensory motor stimula-
tion on feeding performance, length of hospital stay, and weight gain of preterm in-
fants in NICU. The Iranian Red Crescent Medical Journal, 17(7), e13515.
Zarem, C., Kidokoro, H., Neil, J., Wallendorf, M., Inder, T., & Pineda, R. (2013). Psychomet-
rics of the neonatal oral motor assessment scale. Developmental Medicine & Child
Neurology, 55(12), 1115–1120.