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42]

226 Original article

Effect of an early oral stimulation program on oral feeding in

preterm neonates
Ghada M. El Mashada, Hanan M. El Saieda, Nadia A. Mekawyb
a
Department of Pediatrics, Faculty of Medicine,
Menoufia University, Menoufia, bDepartment of
Pediatrics, Housh Eissa Hospital, Ministry of
Health, El Behera, Egypt
Correspondence to Nadia A. Mekawy, MBBCh,
Housh Eissa Hospital, Ministry of Health,
El Behera, Egypt
Postal code: 22511;
Tel: +20 106 559 7798;
e‑mail: Nadia.mekawy@yahoo.com
Received 04 August 2019
revised 11 September 2019
Accepted 14 September 2019
Published 27 March 2021
Menoufia Medical Journal 2021, 34:226–230
Objective
To evaluate the effect of prefeeding oral stimulation program on feeding performance, weight
gain, and length of hospital stay of preterm infants in neonatal ICUs.
Background
Previous research has declared that poor oral‑motor developments in premature infants are
common. So, most of the preterm infants require individualized therapy. Early intervention of
oral‑motor management on feeding pattern improves the outcome.
Patients and methods
To reach the goal of this research, a case–control study was conducted. A total of 50 preterm
infants were divided into two groups: (a) interventional group (25 preterm infants), which
received prefeeding oral stimulation program by stimulation of the oral and perioral structures
for 5 min for 10 days and was started immediately after delivery, and (b) control group
(25 preterm infants), which did not receive stimulation. Postmenstrual age, total intake volume,
body weight, the transition time from initiation of oral feeding to full oral feeding, and feeding
efficiency were calculated.
Results
We found that the mean oral feeding duration was significantly lower among intervention group
compared with control group (P = 0.04). The percentage of weight change was significantly
higher among intervention group compared with control group (P = 0.03).
Conclusion
Our study reveals that early sensory oral‑motor stimulation with nonnutritive sucking in preterm
infants may be effective to expedite oral feeding and hospital discharge. A touch therapy
program may confer a statistically significant weight gain for premature babies at much shorter
intervals, which leads to a shorter hospital stay.

Keywords:
early stimulation program, neonates, oral feeding, outcome, preterm

Menoufia Med J 34:226–230

© 2021 Faculty of Medicine, Menoufia University
1110‑2098

long‑term health problems. Adverse effects, however,

Introduction
are increased owing to the lack of stimuli from the
Oral feeding is a complex task for preterm infants.
gastrointestinal tract. Safe and successful suckle
Unlike full‑term neonates, most infants born
feeding, via breast or by bottle, is one requirement for
prematurely are not able to begin feeding from
hospital discharge and an ultimate goal for preterm
bottle or breast immediately after birth owing to low
infant feeding. Thus, facilitating oral feeding skills and
muscle tone, immature oral‑motor control, and poor
helping preterm infants’ transit to full oral feeding are a
coordination of suck, swallow, and breathing [1].
key focus for the medical staff of neonatal intensive care
Preterm infants generally need a period of full gavage
units (NICUs) [4]. Recent studies suggest that an oral
feeding and then initiate oral feeding between 32 and
stimulation program [perioral and intraoral stimulation,
35 weeks of age. However, at this age, preterm infants
with or without nonnutritive sucking (NNS)] applied to
may be unable to take in all prescribed formula orally
preterm infants for at least 10 days in the period of full
for each feeding. They usually take days or weeks in
gavage feeding can facilitate their oral feeding progress.
the transition period of combined gavage/oral feeding,
NNS is one of the first coordinated muscular activities
before reaching full oral feeding [2]. Preterm infants
in the fetus. Prefeeding oral stimulation is among the
rely on administered feedings and parenteral nutrition
most common stimulation techniques in use. These
to ensure proper nutritional requirements are met.
interventions have been proved to be beneficial for oral
In addition, providing adequate and safe nutrition
with underdeveloped cardiovascular, respiratory,
gastrointestinal, and central nervous systems is a This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
great challenge for neonatologists [3]. Breastfeeding License, which allows others to remix, tweak, and build upon the work
failure and oral feeding problems in preterm infants non‑commercially, as long as appropriate credit is given and the new
often cause long hospital stays, maternal stress, and creations are licensed under the identical terms.

1110-2098 © 2021 Faculty of Medicine, Menoufia University DOI: 10.4103/mmj.mmj_241_19

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feeding skills, attainment of full oral feeding, weight
gaining, and reducing the length of hospital stay [5].
Early oral‑motor interventions (OMIs) are beneficial
for oral feeding in preterm infants. OMI is defined as
sensory stimulation of the lips, jaw, tongue, soft palate,
pharynx, larynx, and respiratory muscles, which are
thought to influence the physiological underpinnings
of the oropharyngeal mechanism, to improve its
functions. Previous research has shown that OMI can
shorten the transition time from gavage feeding to full
oral feeding and improve oral feeding efficiency [6].
The aim of this work to evaluate the effect of prefeeding
oral stimulation program on feeding performance and
weight gain of preterm infants in NICU and assess the
effect of early oral stimulation on length of hospital
stays.
Patients and methods
After approval of the Local Institutional Ethical
Committee of Menoufia University Hospital and
after taking a written consent from the guardians of
the neonates, this case–control study was performed
by selecting 50 preterm neonates delivered in the
hospital from NICUs, Menoufia University Hospital,
in the period between February 2018 to January 2019.
The preterm neonates were divided into two groups:
(a) interventional group (25 preterm infants), which
received prefeeding oral stimulation program consisting
of stimulation of the oral and perioral structures for
5 min for 10 days and was started immediately after
delivery, and (b) control group (25 preterm infants)
did not receive stimulation. The inclusion criteria were
healthy preterm infants less than 37 weeks of gestation,
males and females, received all feedings through a
tube, stable vital signs, without congenital anomalies
or severe complications, and birth weight less than
1.5 kg. Exclusion criteria were full‑term infants;
congenital anomalies such as chromosomal, genetic, or
neurological abnormalities; complex congenital heart
disease; congenital gastrointestinal malformations; and
infants with medical complications, such as grade III
or IV intraventricular hemorrhage, periventricular
leukomalacia, or necrotizing enterocolitis, severe
birth asphyxia and severe infections. All infants were
subjected to full history taking, and clinical data
were collected like age, sex, weight (kg), natal history,
Apgar score, gestational age assessment according to
Ballard score, physical maturity of the Ballard, and
maturational assessment of gestational age. Moreover,
oral stimulation program was done by 5‑min
prefeeding oral stimulation program included two
forms of oral stimulation: 3 min of manual perioral and
intraoral stimulation followed by 2 min of sucking on a
pacifier was delivered. The oral feeding progression was
Oral feeding in preterm El Mashad et al. 227
measured. The initiation of oral feeding was defined
as the first oral feeding. Independent oral feeding
was defined as the point at which the nasogastric
tube was removed for 48 h and all milk volume per
day was taken from a bottle at 120 ml/kg day 1. The
transition time was defined as the number of days
between the introduction of oral feeding to obtaining
autonomous oral feeding. Infant postmenstrual age at
the two feeding milestones was recorded. Oral feeding
performance/efficiency was defined as the volume of
milk consumed relative to the duration of the oral
feeding session (ml/min). The volume transfer was
defined as the volume consumed as a percentage of
the prescribed volume (%). The nurse on duty, who was
blind to the group assignments, recorded the duration
and volume in every observed oral feeding session.
The length of hospital stay was calculated from the
recorded date of admission and date of discharge from
the hospital.
Statistical analysis
Data were collected and entered to the computer
using SPSS 18 (statistical package for the social
science) (SPSS Inc., Chicago, Illinois, USA),
program for statistical analysis. Data were entered as
numerical or categorical, as appropriate. Two types of
statistics were done: (a) descriptive statistics, in which
quantitative data were expressed in mean, SD of the
mean, and SE and (b) qualitative data, which were
expressed in number (frequency) and percent (%).
Analytical statistics were done by using  2 test and
Fisher exact test to measure association between
qualitative variables as appropriate. Moreover, Student
t test, which is a test of significance, was used for
comparison between two groups having quantitative
variables. Mann–Whitney test (nonparametric test),
which is a test of significance, was used for comparison
between two groups not normally distributed having
quantitative variables. The level of significance used
was 95%, so P value of more than 0.05 was considered
statistically nonsignificant, P value of less than 0.05
was considered statistically significant, and P value
of less than 0.001 was considered statistically highly
significant.
Results
A total of 50 preterm infants (30 males and
20 females) were enrolled and divided into two groups:
(a) interventional group (25 preterm infants), which had
16 (64%) males and nine (36%) females, and (b) control
group (25 preterm infants), which had 14 (56%) males
and 11 (44%) females. The mean gestational age
of the interventional group was 34.3 ± 0.75 weeks.
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228 Menoufia Medical Journal, Volume 34 | Number 1 | January-March 2021

Both groups were age and sex matched. The mean Table 1 The sex, age distribution, and anthropometric
measurements of the studied groups
head circumference of the interventional group was
Variables Intervention Control t test P
33.1 ± 1.4 cm and the mean length was 43.6 ± 1.3 cm, group (n=25) group (n=25)
with no statistically significant differences between Sex [n (%)]
intervention and control groups (P > 0.05) (Table 1). Male 16 (64.0) 14 (56.0) 0.33 0.56
We observed that all preterm infants in both groups Female 9 (36.0) 11 (44.0)
had Apgar score ranging from 8 to 10. There were Age (weeks)
no statistically significant differences between both Mean±SD 34.3±0.75 34.5±0.9 1.05 0.29
groups (Table 2). Days of hospital stay were significantly Range 33‑35 33‑36
Head circumference (cm)
shorter among intervention group when compared
Mean±SD 33.1±1.4 33.0±1.3 0.2 0.83
with control group (P < 0.001); the period of parenteral
Range 30‑35 31‑35
feeding was significantly shorter in intervention Length (cm)
group compared with the control group (P = 0.004), Mean±SD 43.6±1.3 43.6±1.3 0.36 0.71
and there were significant differences in the mean Range 42‑46 42‑46
oral feeding duration between two groups, as it was P>0.05 statistically nonsignificant.
reduced in intervention when compared with the
control group (P = 0.04) (Table 3). The weight of the Table 2 Apgar scores of the studied groups
studied groups was comparable at admission and had Variables Intervention Control t test P
no statistically significant differences (P = 0.07) as well group (n=25) group (n=25)
as on discharge (P = 0.13). However, the percentage of Apgar score 1st min
Mean±SD 8.8±0.7 8.850±0.8 0.8 0.95
weight change was higher among the intervention group
Range 8‑10 8‑10
compared with the control group (P = 0.03) (Table 4).
Apgar score 5th min
After receiving prefeeding oral stimulation, the Mean±SD 9.5±0.5 9.5±0.5 0.26 0.79
transition time was reduced significantly in the Range 9‑10 9‑10
intervention group (P < 0.001) (Table 5).
P>0.05 statistically nonsignificant.

Table 3 Days of hospital stay, period of parenteral, and oral

feeding duration of the studied groups
Discussion Variables Intervention Control t P
Oral feeding problems in preterm infants (breast or group (n=25) group (n=25) test
bottle‑feeding failures) often result in delayed hospital Hospital stay (days)
discharge, maternal stress, and long‑term health Mean±SD 9.7±2.4 12.9±3.7 3.5 <0.001**
problems [7]. Most premature infants are not able to Range 6‑13 8‑22
Period of
begin feeding from bottle or breastfeed immediately parenteral (days)
after birth owing to low muscle tone, immature Mean±SD 3.7±1.7 5.1±1.7 3.0 <0.004**
oral‑motor control, and poor coordination of suck, Range 1‑6 2‑9
swallow, and breathing. They generally need a period Oral feeding
of full gavage feeding and then initiate oral feeding duration (days)
between 32 and 35 weeks of age [8]. The transition Mean±SD 20.8±0.7 21.3±0.9 2.05 <0.04*
Range 20‑22 20‑23
to oral feeding from gavage (tube) feeding can be a
challenge for preterm infants, as it requires ability to P>0.05 statistically nonsignificant. *P<0.05 statistically significant.
**P<0.001 statistically highly significant.
coordinate the muscles of the jaw, lips, tongue, palate
and pharynx, upper trunk, and respiratory systems to
mean length was 43.6 ± 1.3 cm, with no statistically
provide a safe swallow [9]. Early OMIs are defined as
significant differences between intervention and
sensory stimulation of the lips, jaw, tongue, soft palate,
pharynx, larynx, and respiratory muscles, which are control groups (P > 0.05). We observed that all preterm
thought to influence the physiological underpinnings infants in both groups had Apgar score ranged from
of the oropharyngeal mechanism to improve its 8 to 10, with no statistically significant differences
functions. OMI can shorten the transition time between both groups. Fucile and Gisel [11], were in
from gavage feeding to full oral feeding and improve agreement with our results and reported that the mean
oral feeding efficiency [10]. Our study showed that Apgar score at 1 min after labor in the intervention
interventional group had 64% male patients, whereas group was 7.78 ± 2.32 and in the control group was
female patients were 36%. Both groups were sex and 7.38 ± 2.42, with no statistically significant differences
age matched. The mean age of the interventional group between both groups (P = 0.496). The mean Apgar
was 34.3 ± 0.75 weeks. The mean head circumference score at 5 min after labor in the intervention group
of the interventional group was 33.1 ± 1.4 cm and the was 8.55 ± 1.93 and in the control group 8.45 ± 1.997,
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Table 4 Weight changes among the studied groups
Variables Intervention Control t P
group (n=25) group (n=25) test
Weight (kg) at admission
Mean±SD 2.0±0.27 1.9±0.29
Range 1.68‑2.4 1.38‑2.26
Weight (kg) on discharge
Mean±SD 2.2±0.28 2.06±0.26
Range 1.78‑2.48 1.56‑2.4
% of change
Mean±SD 10.6±3.3 8±4.2
Range 2‑19 3‑18
*significant values P less than 0.05.
Table 5 Transition Time (period from beginning oral feeding
till full oral feeding) of the studied groups
Variables Intervention Control t test
group (n=25) group (n=25)
Duration (days)
Mean±SD 4.7±1.3 6.1±1.1 4.2
Range 3‑7 4‑8
** Highly significant value P less than 0.001.
with no statistically significant differences between
intervention and control groups (P = 0.847). Days
of hospital stay were significantly shorter among
intervention group when compared with control
group (P < 0.001). The period of parental feeding was
significantly shorter in intervention group compared
with control group (P = 0.004), and there were significant
differences in the mean oral feeding duration between
two groups, as it was reduced in intervention when
compared with control group (P = 0.04). In accordance
with us, Lessen [12], reported that difficulty with
oral feeding leads to longer hospital stays and higher
costs. At their study, the hospital stay was significantly
shorter among intervention group when compared
with control group (P < 0.05). Moreover, Peng [13],
reported that the mean period of parental feeding was
significantly shorter in intervention group (2.7 ± 1.7)
compared with control group (4.1 ± 1.42) (P < 0.05).
In accordance with us, McFarland et al. [14], reported
that the mean oral feeding duration has a statistically
significantly lower difference in intervention
group (34.70 ± 1.03) when compared with control
group (35.66 ± 1.49), with P value of 0.004. In the
contrary, Greene et al. [15], reported that the mean
period of parental feeding in intervention group was
3.7 ± 1.7 and in control group was 25.38 ± 13.675;
there was no statistically significant difference when
comparing both groups (P = 0.973). This contrast
with our results may be related to differences in
number of patients included in each study and patient
selection (comorbidity and socioeconomic factors).
The weight of the studied groups was comparable
at admission and on discharge, with no statistically
significant differences. However, the percentage of
Oral feeding in preterm El Mashad et al. 229
weight change was higher among the intervention group
compared with the control group (P = 0.03). Similar
observation was noticed by Bache et al. [16] who found
1.84 0.07
that mean weight (kg) at admission of the intervention
group was 1597.38 ± 264.263 compared with control
group (1652.50 ± 327.468), with no statistically
1.53 0.13 significantly differences (P = 0.329). On discharge,
the mean weight was 086.56 ± 115.24 in intervention
and 2178.39 ± 210.02 in the control group, with no
2.17 0.03* statistically significant differences (P = 0.728), whereas
the percentage of weight change was significantly
higher among intervention group (11.93 ± 3.86)
compared with control group (9.2 ± 5.2), with P value
of 0.040. On the contrary, Arvedson et al. [17],
reported that the percentage of weight change was
P
significantly lower among intervention group (mean
weight, 1836.09 ± 193.04) when compared with
<0.001** the control group (2002.90 ± 203.41) (P = 0.001).
This could be explained by differences in number
and inclusion criteria of the studied neonates. After
receiving prefeeding oral stimulation, the transition
time was reduced significantly in the intervention
group (P < 0.001). In accordance with us, Karagol
et al. [18], reported that the time from first successful
oral feeding until full oral feeding was statistically
significantly lower for experimental group, with mean
transition time of 3.7 ± 3.5 days, when compared to
control group (9.3 ± 7.7 days) (P < 0.05).
Conclusion
The results obtained in our study support the association
of early sensory oral‑motor stimulation with NNS in
preterm infants and hospital discharge. A touch therapy
program may confer a statistically significant weight
gain for premature babies at much shorter intervals,
which leads to a shorter hospital stay. Further studies
are required to establish this finding.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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