Iran Red Crescent Med J. 2015 July; 17(7): e13515. DOI: 10.5812/ircmj.17(5)2015.

13515
Published online 2015 July 31. Research Article

Impact of Oral Sensory Motor Stimulation on Feeding Performance, Length

of Hospital Stay, and Weight Gain of Preterm Infants in NICU
1 1,* 2
Sharife Younesian ; Fariba Yadegari ; Farin Soleimani
1Department of Speech Therapy, School of Rehabilitation, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran
2Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran

*Corresponding Author: Fariba Yadegari, Department of Speech Therapy, School of Rehabilitation, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran.
Tel/Fax: +98-2122180043, E-mail: [email protected]

Received: July 16, 2013; Revised: September 7, 2014; Accepted: March 20, 2015

Background: One of the limiting factors for early hospital discharge in preterm infants is their inability to feed sufficiently to obtain
consistent weight gain. Therefore, feeding difficulty is one of the most significant issues with which a preterm infant is faced.
Objectives: The purpose of this study was to examine the effect of oral sensory motor stimulation on feeding performance, length of
hospital stay, and weight gain in preterm infants at 30 - 32 weeks of gestational age.
Patients and Methods: Premature infants (n = 20) were randomly assigned to experimental and control groups. The experimental group
received oral sensory motor stimulation of the oral structures (15 minutes / day) for 10 successive days, while these stimulations were not
offered to the control group. Days elapsed to achieve oral feeding, length of hospital stay, and weight gain in the two groups were assessed.
Results: Transition to oral feeding was acquired significantly earlier in the infants in the experimental group than in the controls: 13 and
26 days, respectively (P < 0.001). Likewise, the length of hospitalization was significantly shorter in the experimental group than in the
control group: 32 days and 38 days, correspondingly (P < 0.05). The two groups showed no significant difference in terms of weight gain
in the first, second, third, and fourth weeks of birth: first week: 100 vs. 110; second week: 99 vs. 111; third week: 120 vs. 135; and fourth week:
129 vs. 140.
Conclusions: The present research revealed that the number of days to reach oral feeding in our preterm babies was decreased by oral
motor stimulation, which in turn conferred earlier hospital discharge.

Keywords: Preterm Infant; Hospital; Weight Gain

1. Background
The last century has witnessed a considerable rise in the ties on breast /bottle feeding and the length of hospital
survival of young preterm infants with feeding difficulties stay underline the significance of the need to improve
thanks to the advances in their care. Sucking is regarded the normal development of the oral motor structures (3).
as the best way to feed newborns; however, the sucking Various intervention techniques are used by nutrition-
skills of preterm infants become mature between weeks ists to bolster the oral feeding performance of premature
32 and 34 (1). Oral feeding difficulties are almost common infants. One of the widely used strategies is the sensory
in preterm infants due to problems in their cardiorespira- oral motor input, which comprises cheek/chin support
tory and central nervous systems as well as the incomplete and touch and visual, vestibular, and auditory stimula-
development of their oral structures (2). tions (8-10). The effectiveness of some interventions has
Coordinated suck-swallow-breath pattern is a signifi- been previously proved. For example, cheek/chin support
cant aspect of a successful feeding. Under 32 weeks of ges- during the feeding time raises the intake volume (8) and
tational age, most preterm infants are not able to have an an auditory-tactile-visual-vestibular program speeds up
independent oral feeding and they are fed by tubes (1). the transition to independent oral feeding, reducing hos-
Tube feeding throughout hospital stay affects the ability pital stay (11).
of infants to obtain full oral feeding, which may cause Gaebler and Hanzlik (8) reported that infants receiving
considerable feeding disorders and aversive or hypersen- an oral pre-feeding stimulation exhibited better perfor-
sitive responses to being stroked around or in the mouth mance on the Neonatal Oral Motor Assessment Scale, bet-
(3, 4). Indeed, the ability of new-born babies to have a ter weight gain, and shorter hospital stay in all relevant
full oral feeding is necessary for their discharge from the studies. There is an evidence-based systematic review of
hospital (5, 6), where a variety of multidisciplinary team oral motor interventions in preterm infants carried out
members support preterm infants to feed orally and dis- by Arvedson et al. (12), who reported that 7 of 12 studies
charge earlier (7). The effects of early oral motor difficul- evaluating the effects of non-nutritive sucking (NNS) on
Copyright © 2015, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCom-
mercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial us-
ages, provided the original work is properly cited.
 Younesian S et al.

feeding parameters showed that the preterm infants their newborns’ medical condition. Parental consent was
achieved full oral feeding earlier, although there were no gained before the infants were entered into the study.
significant differences regarding the other criteria such
as weight gain and intake volume. Two of the 12 studies 3.1. Procedure
examined just the effects of touch therapy on feeding per-
In this experimental research with convenience sam-
formance. The results of these studies, however, were not
pling, a random assignment was performed using a sim-
sufficient, and the authors noted that there was limited
ple randomization method. The study began on July 2011
evidence to support the effect of touch therapy without
and lasted for 5 months. An oral sensory motor stimula-
NNS. Three of the 12 studies examined the effects of both
tion program was given to the experimental group, and
touch therapy and NNS on the efficiency of feeding in
the infants in the control group received no stimulation
preterm infants: the experimental groups reached inde-
except routine nursery. The oral stimulation was not ad-
pendent oral feeding earlier than the control groups (12).
ministered as routine in this hospital. Interventions were
Therefore, substantial evidence implies that sensory oral
started before the outset of oral feeding and were applied
motor input to the oral structures or oral motor stimula-
once per day for 10 sequential days, 20 to 40 minutes be-
tion during NNS exerts significant effects on the perfor-
fore the initiation of tube feeding. The commencement
mance of oral feeding if given before or while feeding by
and advancement of oral feeding was assigned to the
mouth in premature infants with medical stability (3).
attending physician. Both nurses and physicians were

2. Objectives
blinded to group assignment.
If the infants were not fully stable 45 minutes before
The purpose of the present study was to examine the ef- the intervention, the program was not implemented. The
fects of an early oral motor stimulation program on the program was also discontinued if the infants had medi-
performance of oral feeding in preterm infants. The oral cal instability and/or had an oxygen instauration and ap-
motor program was commenced prior to the introduc- nea/bradycardia throughout the intervention. All the in-
tion of oral feeding since the aim was to improve oral fants in both groups were monitored from the beginning
motor skills before the probable development of oral of the intervention to hospital discharge. Breast feeding
feeding disorders. was the routine in this hospital. The types and times of
feeding per day were recorded. Independent oral diet,
3. Patients and Methods length of hospital stay, and weight gain were the depen-
dent variables of this research. Independent oral diet for
Participants were chosen from the Neonatal Intensive
an inborn was begun at the discretion of a physician,
Care Unit (NICU) at Valie Asr Hospital in Imam Khomeini
who was blinded to group assignment. After the start of
Hospital Complex, Tehran, Iran. This referral treatment
the independent oral diet of a baby, the number of the
center is a governmental general hospital, including a 20-
independent oral diets for each baby in each day was re-
bed NICU and several wards and clinics.
corded by the nurses. The first time an infant achieved 8
Using mean and SD values from a previous study by
oral feedings per day for 2 consecutive days was defined
Fucile et al. (3) with a power of 80% and confidence level of
as the time to gain full oral feeding.
95%, we reached a sample size of 10 for each group. From
The weight gain of each infant was measured and re-
30 subjects being examined initially, 20 preterm neonates
corded using a digital balance. A digital scale sensitive
(10 boys and 10 girls) who met our inclusion-exclusion cri-
to one g (Seca 334, Mobile digital baby scale, CE 0123) was
teria were randomly assigned to the experimental group
used daily for weight measurement. This equipment is
(10 newborns) and the control group (10 newborns). The
calibrated every 3 months by the company. The babies
enrolled infants were: 1) born between 30 and 32 weeks’
were weighed by the same nurse every day at 7 a.m. with-
gestational age, which was set in accordance with the date
out clothes and diapers and before feeding.
of last menstruation and the first-trimester ultrasound;
The practitioners who measured the newborns’ weight
2) appropriate for gestational age; 3) fed by tube; and 4)
were blinded to their assigned group and hospital dis-
without chronic medical complications such as bron-
charge time. The length of hospital stay was calculated
chopulmonary dysplasia, intraventricular hemorrhage
from the newborns’ day of birth.
grades 3 and 4, periventricular leukomalacia, necrotizing
enterocolitis, and congenital anomalies examined by a
neonatologist as the exclusion criteria. 3.2. Interventions
This research was approved by the Research Ethics Com- This program was in accordance with the Beckman
mittee of the University of Social Welfare and Rehabilita- principles (1, 3, 10, 13, 14). The program was performed
tion Sciences, Tehran, Iran (Code = USWR.REC.1393.103). once a day for 10 successive days, 20 to 40 minutes be-
The parents were free to agree or disagree with the inclu- fore feeding by tube. Oral stimulation can enhance the
sion of their babies into the experimental group and to performance of infants’ oral feeding if the procedure is
withdraw cooperation whenever they deemed fit, and carried out before feeding time (15). The oral sensory mo-
they were given reassurances as to the confidentiality of tor stimulation program comprised a 15-minute stimula-

2 Iran Red Crescent Med J. 2015;17(7):e13515

 Younesian S et al.

tion program, whose first 12 minutes included stroking 4. Results

the newborns’ cheeks, lips, gums, and tongue, and whose
The baseline characteristics were compared between
last 3 minutes included the newborns’ sucking on an in-
the two groups (Table 1). Both groups received all the
dex finger of the speech therapist, who was trained by the
covariates equally (P > 0.05). There were no significant
researchers. Latex gloves were used for touch therapies.
differences in terms of gestational age and birth weight
The intervention group was controlled by cardiorespira-
between the two groups.
tory monitoring and pulse oximetry before, during, and
Table 2 demonstrates the ages at which the oral feeding
after the intervention.
of the experimental and control groups occurred. The in-
fants in the experimental group achieved one (P < 0. 001),
3.3. Outcome Measure 4 (P < 0.001), and 8 (P < 0.001) successful oral feedings
The number of days necessary for preterm infants to significantly in fewer days of life than the controls. There-
transit from tube feeding to oral feeding was consid- fore, the experimental group attained oral feeding mile-
ered as the time to reach oral feeding. The fulfillment stones faster than the controls. In fact, the experimental
of the entire feeding without any occurrence of oxygen group reached an oral feeding (8 oral feedings per day)
unsaturation and/ or apnea/bradycardia implied a suc- approximately 2 weeks earlier than the controls.
cessful feeding. The commencement and advancement From the whole 100 oral motor stimulation sessions
of oral feeding was in accordance with the unit’s written that were managed, there were 8 delayed or halted ses-
routine and was similar for both groups. The number sions. Four sessions were offered with delay because the
of days which the infants spent from birth to hospital infants were distracted 20 minutes before the onset of
discharge was considered the length of hospital stay. the intervention, 2 sessions were implemented with de-
Weight gain from the first to fourth weeks of birth was lay due to medical instability, and 2 sessions were can-
determined. celled because the infants had an episode of bradycardia.
The following covariates were taken into account: The experimental and control groups were discharged
the infants’ behavioral state at the beginning and end after 32 ± 6 and 38 ± 2 days, correspondingly. The infants
of the feeding time via the preterm infant’s behavioral in the experimental group acquired an early hospital dis-
scale (16); bradycardia; apnea; and oxygen desaturation charge compared with the controls insofar as they were
throughout oral feeding. discharged approximately one week earlier.
A repeated measures ANOVA with a Greenhouse-Geisser
3.4. Statistical Analysis correction determined that the mean weight of the case
As the data were normally distributed (Kolmogorov- group differed significantly between the time points
Smirnov), parametric tests were recruited for the analy- (F[1.937,17.434] = 44.892; P < 0.0001). Post-hoc tests using
ses. Yet, given our small sample size, the results were re- the Bonferroni correction revealed that touch therapy
checked using non-parametric tests, and as the results did not evoke a change in weight from pre-intervention
confirmed the parametric probes, they are not reported to one oral feeding (1590 ± 314.2 g vs. 1523 ± 323.9 g, respec-
here. A t-Student test was employed to specify the influ- tively), which was not statistically significant (P = 0.183).
ence of the oral sensory motor stimulation on the time of However, the weight change from one to 4 oral feedings
the achievement of the specified number of oral feedings a day was significant (1523 ± 323.9 g vs. 1573 ± 319.2 g, re-
during a day (i.e. one, 4, and 8 successful oral feedings spectively; P = 0.001). The weight change from 4 to 8 oral
per day) and length of hospitalization. In order to assess feedings per day was also significant (1573 ± 319.2 g vs.
the within-subject effect, at time points of one to 4 and 8 1624 ± 327.7 g, correspondingly; P = 0.002). Finally, the
independent oral feedings per day, a repeated measures weight change from 8 oral feedings a day to the time of
ANOVA was applied. The level of significance was 0.05. discharge from the NICU was also significant (1624 ± 327.7
SPSS (version 16) was used for the analyses. g vs. 1877 ± 234.7 g, respectively; P = 0.001) (Figure 1).

Table 1. Baseline Characteristics of the Experimental and Control Groups (n = 10)

Group Mean ± SD t df Significance Level

Birth weight 0.279 18 0.783
Case (5 boys and 5 girls) 1590 ± 0.52
Control (5 boys and 5 girls) 1548 ± 0.52
Gestational age 0.878 18 0.391
Case 31.20 ± 0.78
Control 30.90 ± 0.73

Iran Red Crescent Med J. 2015;17(7):e13515 3

 Younesian S et al.

Table 2. Comparison of the Mean Age of the Experimental and Control Newborns for One, 4, and 8 Independent Oral Feedings per
Day (n = 10) a

Group Mean ± SD t df Significance Level

D.O.L.1 O.F. -5.342 18 0.000
Case 6.50 ± 2.59
Control 13.10 ± 2.92
G.A.1 O.F. -1.826 18 0.084
Case 31.84 ± 0.78
Control 32.52 ± 0.87
D.O.L.4 O.F. -6.118 18 0.000
Case 9.80 ± 3.42
Control 19.70 ± 3.80
G.A.4 O.F. -2.953 18 0.009
Case 32.34 ± 0.72
Control 33.51 ± 1.02
D.O.L.8 O.F. -6.716 18 0.000
Case 13.20 ± 4.31
Control 26.90 ± 4.79
G.A.8 O.F. -3.758 17 0.002
Case 32.84 ± 0.81
Control 34.47 ± 1.04
D.O.L. discharge -5.233 18 0.000
Case 27.90 ± 6.15
Control 38.80 ± 2.34
a Abbreviations: D.O.L, days of life (days); G.A., gestational age (weeks); and O.F., oral feeding per day.

points (F[1.577, 14.193] = 41.953; P < 0.001). Post-hoc tests us-

Estimated Marginal Means of weighting ing the Bonferroni correction revealed a change in birth
weight to one oral feeding (1548 ± 112.7 g vs. 1489 ± 102.5 g,
1.900 respectively), which was not statistically significant (P =
0.082). Nonetheless, the weight change from one to 4 oral
Estimated Marginal Means

1.800
feedings per day was significant (1489 ± 102.5 g vs. 1556 ±
103.2 g, correspondingly; P = 0.001). The weight change
from 4 to 8 oral feedings per day was also significant (1556
1.700 ± 103.2 g vs. 1650 ± 103.2 g, respectively; P = 0.001). Finally,
the weight change from 8 to the time of discharge from the
1.600 NICU was also significant (1650 ± 103.2 g vs. 1843 ± 84.85 g,
correspondingly; P = 0.002) (Figure 2). As is evident from
the results, both groups gained weight significantly, but the
1.500
case group reached this milestone earlier. This is shown in a
1 2 3 4 5
weight comparison of the discharge time between the two groups.
Although the t-Student test proved the time of discharge
was not significantly different between the two groups, the
Figure 1. Estimated Weight Gain of Newborns in Case Group Through
Oral Feeding mean discharge time of the experimental group was evi-
dently shorter than that of the controls (Table 3). Because of
A repeated measures ANOVA with a Greenhouse-Geisser the low sample size, a bootstrap was performed, the results
correction determined that the mean weight of the control of which were similar to the t-test (Table 4). Error bar plots
group was also significantly different between the time are illustrated in Figure 3.

4 Iran Red Crescent Med J. 2015;17(7):e13515

 Younesian S et al.

5. Discussion
Estimated Marginal Means of weighting
The length of the hospital stay of infants born under
the age of 30 weeks’ gestational age is approximately
1.900
between 11 and 12 weeks (4). Because the rate of infants
who survive under the age of 30 weeks’ gestational age is
Estimated Marginal Means

1.800
increasing and there is plenty of evidence indicating that
1.700 most preterm infants are born with feeding disorders (2),
an assessment of whether or not early oral sensory motor
1.600 stimulation can be effective on the feeding performance
of preterm infants is vitally important.
1.500 The results of the current study show that the oral feed-
ing performance of our preterm infants was modified by
1.400
using the sensory oral motor stimulation accompanied
1 2 3 4 5 by NNS and that it led to early hospital discharge. In this
weight
study, the preterm infants who received the program
achieved independent oral feeding earlier than the con-
Figure 2. Estimated Weight Gain of Newborns in Control Group Through
Oral Feeding
trol group. In addition, the infants in the experimental
group were discharged earlier than the controls. Both
groups were similar with respect to such baseline char-
Table 3. Comparison of the Mean Time of Discharge from the acteristics as birth weight and gestational age at birth as
NICU between the Experimental and Control Groups (n = 10) well as oxygen requirement. In addition, the study groups
Mean ± SD t df Significance
were alike in that they had no chronic medical complica-
Level tions. Thus, that the experimental group achieved ear-
lier oral feeding does not mean that its newborns were
Group -0.934 18 0.362
healthier and/or more mature than the controls.
Case 5.78 ± 0.75 The infants in the experimental group achieved oral
Control 6.22 ± 1.27 feeding 2 weeks earlier than the controls. There are some
convincing reasons why the infants who received inter-
vention achieved oral feeding earlier than their counter-
Table 4. Results of Bootstrapping for the Difference of Dis-
parts. The first part of the program, which included some
charge Time between the Experimental and Control Groups
stroking, may have strengthened the oral motor struc-
Standard Error Sig. (2-tailed) 95% CI tures which have a significant role in adequate sucking.
Lower Upper Moreover, NNS, the next part of the oral motor stimula-
0.458 0.368 -1.28490 0.45474 tion program, may have provided the infants with the ex-
perience of sucking. Furthermore, it is likely that the oral
motor stimulations offered in the current study expedit-
ed the maturation of the central and peripheral neural
structures, thereby improving the infants’ sucking skills
7.50
and suck-swallow- breath coordination (13, 16).
In the current study, the infants in the experimental
7.00 group were discharged one week earlier. Owing to the
fact that the experimental infants gained oral feeding sig-
95% CI time discharge

6.50
nificantly earlier than the controls, it was expected that
their hospitalization would be shorter than the controls.
In a study by Fucile et al. (3), there was no substantial dif-
6.00
ference between the experimental and control groups in
relation to the length of hospital stay, which may be due
5.50 to the absence of a universally practiced discharge stan-
dard. Bragelien et al. (14) did not find any connections be-
5.00
tween oral stimulation and early oral feeding. However,
it is worthy of note that they used different stimulation
case control
group techniques. Although another study cited in Rocha et al.
(1) used only the NNS technique, they observed a signifi-
cant difference between the two groups in terms of the
Figure 3. Summary Bar Plot of Mean Time of Discharge (95% Confidence length of hospital stay.
Interval) for Cases and Controls
Lau et al. (17) employed a nonnutritive oral motor thera-

Iran Red Crescent Med J. 2015;17(7):e13515 5

 Younesian S et al.

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6 Iran Red Crescent Med J. 2015;17(7):e13515