Original Research Published on October 14, 2021


Effectiveness of Pre Feed Oral Stimulation Programme on Feeding Behaviour and Growth Velocity of Preterm Infants

Saritha Naduvile Veedua, Mercy Jacoba


a. Government College of Nursing, Kottayam



Background: Difficulty in feeding is an important problem that preterm infants need to overcome. Facilitating oral feeding skills and helping preterm infants transit to full oral feeding is an important focus of preterm care in Neonatal Intensive Care Unit (NICU).

Objectives: To determine the effectiveness of pre feed oral stimulation programme on feeding behaviour and growth velocity of preterm infants admitted in Neonatal Intensive Care Unit.

Methods: A quantitative research approach with quasi experimental pre-test post-test control group design was used for the study. The framework, Betty Neuman’s System model theoretically supported the study. The study was conducted among sixty preterm infants admitted in the NICU and infants were selected by nonprobability purposive sampling. Clinical data sheet of preterm infants, breastfeeding behaviour assessment scale and growth velocity monitoring sheet were used for data collection. Weighing scale, infantometer and inch tape were used to measure anthropometric measures of preterm infants.

Results: Analysis of data revealed significant difference in feeding behavior of preterm babies after pre feed oral stimulation programme.  Regarding the growth velocity, study shows a significant difference in the weight of preterm infants between control and experimental group, but there was no significant difference in the length, head circumference and chest circumference of the preterm infants.

Conclusion: The current study revealed that, pre feed oral stimulation programme has significant influence on promoting feeding behaviour and subsequent positive weight gain in preterm infants.


The birth of a baby is a wonderful and exciting process in a woman’s life. Preterm birth is a significant public health problem across the world because of associated neonatal mortality as well as short and long term morbidity and disability in later life.1 As per 2013 data, almost 1 million children die each year due to complications of preterm birth. India is the biggest contributor to the world’s prematurity burden, with almost 3.6 million premature births accounting for 23.6% of the around 15 million global preterm births reported each year and this number is rising.2 The survival rates of preterm infants have increased over the last years as a result of significant technological advances, but oral feeding difficulties are the most common problems encountered by them.3

Healthy preterm infants typically achieve independent oral feeding skills by 36 to 38 weeks of postmenstrual age; however, preterm infants who are younger at birth and have medical complications often require longer time to achieve oral feeding competency.4 Most preterm infants will require some degree of tube feeding or feeding with expressed breast milk or parenteral nutrition until they are mature and stable enough to feed exclusively by mouth. The infant’s inability to wean from the tube feeding and feed sufficiently to obtain consistent weight gain likely will delay hospital discharge and mother-infant reunion and will increase the hospital cost and maternal stress.

For preterm infants, oral feeding takes more energy and excessive oral feeding may lead to fatigue, ultimately impacting weight gain.5 Mechanisms for feeding difficulty identified in the literature include immature or dysfunctional sucking skills and poor suck–swallow–breath coordination. The establishment of a safe and efficient feeding in preterm newborn is related to a rhythmic and coordinated sucking.6 Suck begins in utero between 15 and 18 weeks gestational age, and is stable and well patterned by 34 weeks post-menstrual age.7 Approximately 32-34 weeks gestational age(GA), suck-swallow coordination and gag mechanisms mature; however; suck-swallow-breathe coordination does not fully develop until 37 weeks GA.8 Nutritive suck, suck-swallow and coordination of suck-swallow-respiration are the key components underlying the improvement of oral feeding outcomes.9

Factors like intraoral stimulation, extraoral stimulation, conditioning, arousal, hunger, prenatal and perinatal factors modify sucking rhythm. The transition from tube feeding, to oral feeding requires ability to coordinate the muscles of the jaw, lips, tongue, palate and pharynx, upper trunk and respiratory systems in order to support a safe swallow. Several studies have shown that oral stimulation during tube feeding promotes earlier readiness for oral feeding, accelerates the transition from tube to independent oral feeding, and enhance the maturation of sucking reflex.10 In a study conducted to determine beneficial effects of oral sensorimotor input (stroking to the peri- and intra-oral structures, such as the cheeks, lips, jaw, tongue, palate and gums) among 5 neonates (GA : 27-40 weeks), found an increase in sucking rate, defined as number of sucks/minute, when the oral sensorimotor input (stroking the cheeks for 4 minutes during the oral feeding session) was provided.11 Another study using a similar oral stimulation protocol demonstrated that preterm infants 26-32 weeks GA started oral feeding earlier, reached independent oral feeding earlier, and were discharged from the hospital earlier than controls.

A randomized clinical trial conducted to assess the effects of pre feeding oral stimulation on oral feeding among preterm infants (gestational age: 26 and 33 weeks; n=86), shows breastfeeding rates upon discharge were significantly higher than in the control group (70% versus 45.6%).12 In preterm infants, oral stimulation enhances muscle tone and movement which facilitates normal oral motor developmental patterns and improvement of oral feeding performance.

Investigator during her clinical experience noticed that discharge of preterm babies were   delayed due to lack of achievement of proper feeding behaviour and adequate weight gain. Hence the researcher decided to assess the effectiveness of pre feed oral stimulation programme on feeding behaviour and growth velocity of preterm infants.


1. To find out the effectiveness of pre feed oral stimulation programme on the feeding behaviour of preterm infants

2. To determine the effectiveness of pre feed oral stimulation programme on the growth velocity of preterm infants


The investigator adopted a quantitative approach for the study.  The research design used in this study is quasi experimental, pre-test posttest control group design. The study was conducted at Neonatal Intensive Care Unit of tertiary care hospital, Kottayam. The sample consists of 60 preterm infants (30 each in the control and experimental group) selected by nonprobability purposive sampling technique.  Babies born at gestational age between 30-37 weeks admitted to the NICU and ready for initiation of direct breast feeding and whose mothers are willing to participate are enrolled for the study. Babies with congenital malformations of head and face and congenital heart diseases were excluded. 

The tools used were clinical data sheet of preterm infants, Breast feeding behaviour assessment scale and Growth velocity monitoring sheet. Clinical data sheet comprised of 8 items namely age of the baby, gender, clinical diagnosis, gestational age, mode of delivery, birth weight and birth order. Breast feeding behaviour assessment scale is a 3 point scale which assesses the feeding behavior of preterm infants having 7 categories such as Positioning, Attachment, Latch-on, Sucking, Swallowing, Jaw movement and Responses. Feeding behavior is categorized as poor (1-7), average (8-14) and good (15-21) based on the score obtained. Growth velocity monitoring sheet consist of 4 parameters namely weight (gram), length (cm), head circumference (cm) and chest circumference (cm), which are measured using the weighing scale, infantometer and inch tape.

Data collection procedure began after getting formal permission from the Institutional Ethics Committee and concerned authorities. The purpose of the study was explained and informed consent was obtained from the mothers of preterm infants. Clinical data of preterm infants were collected by the investigator from clinical records using clinical data sheet. Pretest was conducted using breast feeding behaviour assessment scale and growth velocity monitoring sheet on the first day of study.  Routine care was carried out to the control group and routine plus intervention (pre feed oral stimulation programme) was carried out in experimental group.

Pre feed oral stimulation programme is a stimulation procedure with the aim of promoting the sucking in preterm infants. It consists of compressing both right and left cheek from ear to corner of mouth and stroking the upper lip and lower lip. The direction of stimulation is as follows: gently tap the cheeks with index finger, then stroke the cheek with index finger from the base of the nose towards the ear, return back to the corner of the lips and repeat on the other side, after that, place the index finger at the corner of the upper lip, then move the finger away in a circular motion from the corner towards the centre and to the other corner, repeat in reverse direction and repeat the procedure in lower lip. It was carried out for each preterm baby as 5 minutes manual perioral stimulation 6 times per day for 5 consecutive days before breast feeding.

Post test was conducted to measure feeding behaviour and growth velocity on the 5th and 25th day using the same scales. The investigator self has done measurements (pre-test and post-test) for all babies and carried out the intervention in experimental group. The data collected were analyzed using descriptive and inferential statistics. Clinical data of preterm infants were analyzed using frequency distribution and percentage.  The effectiveness of the pre feed oral stimulation programme on feeding behaviour and growth velocity was assessed using Mann Whitney U Test.


 The clinical data of preterm infants namely age, gender, clinical diagnosis, gestational age, mode of delivery, birth weight and birth order are shown in Table 1. The value of chi square shows homogeneity of control and experimental group in terms of clinical data at pretest.

Feeding behavior of preterm infants classified as poor, moderate and good based on score received in feeding behavior assessment at pretest revealed that majority of the preterm infants in the control group (80%) and in the experimental group (90%) had poor feeding behaviour. Moderate feeding behavior was seen in 20%babies in control group and 10% in experimental group. None of the babies exhibited good feeding behavior. Median of feeding behavior of preterm infants on pretest was 7 in both control and experimental group.  Feeding behavior scores of pre term infants given  in Table 2  shows that   median value of feeding behavior is 13 in control group and 17 in experimental group in post test 2.  A significant difference in feeding behaviour of preterm infants between control and experimental group is noted in post test 2(p value 0.012) and no significant difference (p value=0.253) in post test 1.

For assessing the growth velocity in preterm babies, parameters such as weight, length, head circumference and chest circumference were measured.

Growth parameters of preterm infants in Table 3 shows that the pretest median weight (gram) of preterm infants in the control and experimental group is 1515 and 1491 respectively. The pretest median length (cm) is 39.95 and 39.70, head circumference (cm) 28.7 and 29, and chest circumference (cm) is 24.65 and 24.75 respectively.

Data depicted in Table 4 shows that there was significant difference in weight of preterm infants between control and experimental groups in posttest-2 (p value 0.004). Analysis of other parameters: length, head circumference and chest circumference of preterm infants revealed no significant difference between control and experimental group after the intervention.


The present study evaluated the effectiveness of pre feed oral stimulation programme on feeding behavior and growth velocity of preterm infants. It was seen that there is a significant difference in the feeding behaviour of preterm infants between the control and experimental group. This result is consistent with the findings of  study which reveals that, improved oral feeding and decreased hospital stay in preterm infants who got 5 minute oral motor intervention by stimulating the cheeks (internal and external), lips, gums, tongue, and palate with finger stroking for 7 consecutive days.13 The obtained finding was also congruent with the results of another study, where the experimental group, who received a daily 15 minute oral stimulation program (stroking the peri- and intra-oral structures), achieved full oral feedings 7 days sooner than control group.14,15,16

 Evaluation of effectiveness of pre feed oral stimulation programme on growth velocity of preterm infants in the present study showed a significant influence on the weight gain of the preterm infants. The study also revealed that Prefeed oral stimulation programme had no significant effect on the length, head circumference and chest circumference of the preterm infants. Similar results are obtained in a prospective study conducted to evaluate the effects of oral sensorimotor input where preterm infants (30-34 weeks gestational age) who received this treatment, had greater weight gain, and had fewer days of hospitalization.16,17


The present study highlighted the need for providing pre feed oral stimulation in preterm infants. Based on the findings of the study, there was a significant increase in the feeding behaviour and improvement in the weight of the preterm infants with the intervention programme. The prefeed oral stimulation programme is simple, safe and beneficial for preterm infants.       



Based on the present study, the following recommendations are put forwarded for future research.


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