Neonatal Eating Outcome Assessment
Eating is an important part of daily life; it ensures nutrition for growth and is an important activity of daily living with strong social implications. The construct of feeding/eating is especially important in preterm infants, who are born without the maturity that enables successful oral feeding. Further, preterm infants have high rates of long-term feeding problems. While much emphasis has been placed on maintaining the quality of nutrition, through breast milk or formula and supplemental feeding strategies, less attention has focused on the feeding ability of preterm infants.
There are few tools available to assess feeding in neonates, and the ones that are available do not account for the significant developmental changes that occur from preterm birth until term equivalent age. To address this issue, we have developed the Neonatal Eating Outcome Assessment tool, which assesses the most important clinically and research-derived factors associated with feeding skills in preterm infants. This tool can potentially improve the understanding of age appropriate feeding skills, improve early identification of feeding difficulties, and enable targeted interventions to preterm infants with problems eating.
The Neonatal Eating Outcome Assessment is a comprehensive, standardized assessment of feeding for preterm infants in the neonatal intensive care unit. It can be used from the time that feeding is initiated throughout the neonatal period. It is used to delineate alterations in the feeding trajectory.
- Feeding/eating component skills are scored based on expected performance across postmenstrual age.
- Quantitative scoring provides valid outcome measures for research as well as an objective way to track progress clinically. The Neonatal Eating Outcome Assessment defines if feeding skills are age-appropriate.
- Markers in the assessment enable the clinician to understand if feeding is appropriate to initiate and if feeding should be stopped due to lack of safety with oral feeding.
- The Neonatal Eating Outcome Assessment can be used for both breastfeeding and bottle feeding infants.
Content validity has been conducted with neonatal feeding experts. Additional revisions were informed by initial trials and reliability testing. Reliability testing with neonatal therapists using the final version (Version 5) demonstrated good to excellent inter-rater reliability. Concurrent validity has been established, with its relationship to the Neonatal Oral Motor Assessment. Predictive validity has been established, with its relationship to the PediEAT at 4 years of age. The tool has been finalized, but additional psychometric testing, including a Rasch analysis, is underway.
Ibrahim, C., Chavez, P., Smith, D., Craig, J., & Pineda, R. (2024). Oral motor interventions used to support the development of oral feeding skills in preterm infants: An integrative review. Early Human Development, 198, 106125. https://doi.org/10.1016/j.earlhumdev.2024.106125 Show abstract
Background. One criterion for infant NICU discharge is the ability to meet all nutritional needs by mouth, therefore, it is important to understand interventions that can improve the trajectory to full oral feeding. While many oral motor and feeding interventions are used in clinical practice, it remains unclear which are supported by the literature.
Aim. The aim of this integrative review was to identify and understand what oral motor interventions are defined in the literature to support positive outcomes for preterm infants and their parents.
Methods. An integrative review of studies published from 2002 to 2022 focusing on applied oral motor interventions and their impact on feeding-related outcomes was completed. The systematic search used databases including PubMed, Cochrane, CINAHL, Scopus, and Google Scholar. Studies were included if they used a study population of preterm infants born
Results. Forty articles met inclusion criteria with four different interventions (or a combination of them) identified: nonnutritive sucking, oral motor stimulation [Fucile's protocol, Premature Infant Oral Motor Intervention (PIOMI)], NTrainer, and swallowing exercises.
Discussion. All interventions were associated with positive outcomes and began between 29- and 30-weeks PMA. Detailed information on adverse events (both physiologic and behavioral) in future research could allow for better risk-benefit analysis. The methodology and quality of the studies differed too much to allow for quantitative analysis; however, there does not appear to be compelling evidence that more stimulatory interventions are superior to less stimulatory interventions – a key consideration when working with preterm infants.
Mulrenin, B., Pineda, R., Dodds, C., & Velozo, C. A. (2024). Item-level psychometrics of the Neonatal Eating Outcome Assessment in orally feeding infants. OTJR: Occupational Therapy Journal of Research, 44(4), 554–567. https://doi.org/10.1177/15394492231212399 Show abstract
Background. The Neonatal Eating Outcome Assessment determines feeding performance based on the infant’s postmenstrual age (PMA).
Objective. To examine item-level measurement properties of this assessment’s rating scale.
Methodology. In this retrospective study, Rasch analysis was completed on clinical data from the Neonatal Eating Outcome Assessment for 100 infants (52 preterm and 48 full-term) using Winsteps version 3.93.1. Instead of PMA-based scores, ordered letters converted to numerical scores were analyzed.
Results. Analysis demonstrated that Section I (Pre-Feeding Skills) represents a separate construct from Sections II and III (Oral Feeding and End of Feeding, respectively). Sections II and III were adequately unidimensional to complete Rasch analysis. These sections fit the Rasch model overall, but rating scale category underuse was common, which may be attributed to sample characteristics.
Ibrahim, C., Grabill, M., Smith, J., & Pineda, R. (2024). Relationships between preterm medical factors and feeding behaviors at term-equivalent age. Early Human Development, 191, 105975. https://doi.org/10.1016/j.earlhumdev.2024.105975 Show abstract
Aim. To identify relationships between early medical factors and preterm infant feeding behaviors at term-equivalent age.
Methods. Forty-three very preterm infants born ≤32 weeks gestation had standardized feeding assessments using the Neonatal Eating Outcome Assessment at term-equivalent age (36–42 weeks postmenstrual age). Medical factors were collected and analyses were run to determine if associations between different medical factors and feeding performance exist.
Results. Lower Neonatal Eating Outcome Assessment scores at term-equivalent age were associated with lower estimated gestational age (p < .01), lower birthweight (p < .01), older postmenstrual age at discharge (p < .01), longer length of stay in the neonatal intensive care unit (p < .01), chronic lung disease (p = .03), as well as more days on total parenteral nutrition (p = .03), endotracheal intubation (p < .01), and noninvasive mechanical ventilation (p < .01).
Conclusion. More feeding problems are observed in infants born earlier, with longer hospital stays, and with complex medical courses. Knowledge of the association between these medical factors and feeding difficulties allows for identification of infants who may benefit from early, targeted interventions to optimize the feeding process.
Grabill, M., Smith, J., Ibrahim, C., & Pineda, R. (2023). Prevalence of early feeding alterations among preterm infants and their relationship to early neurobehavior. American Journal of Occupational Therapy, 77(3), 7703205170. https://doi.org/10.5014/ajot.2023.050123 Show abstract
Importance. Feeding difficulties are common among preterm infants during neonatal intensive care unit (NICU) hospitalization. Although most preterm infants achieve full oral feeding by term-equivalent age, whether feeding difficulties persist despite the infant taking full volume and whether these difficulties may relate to other neurobehavioral challenges remain unclear.
Objective. To identify the prevalence of feeding problems among preterm infants and the relationships between infant feeding behaviors and neurobehavior at term-equivalent age.
Design. Cohort study.
Setting. Level 4 NICU with 85 beds.
Participants. Thirty-nine very preterm infants born ≤32 wk gestation (range = 22–32 wk). Exclusion criteria were congenital anomalies, >32 wk gestation at birth, and lack of feeding or neurobehavioral assessment at term-equivalent age.
Outcomes and Measures. Standardized feeding assessments using the Neonatal Eating Outcome Assessment and standardized neurobehavioral evaluation using the NICU Network Neurobehavioral Scale.
Results. Thirty-nine infants (21 female) were included in the final analysis. The mean Neonatal Eating Outcome Assessment score was 66.6 (SD = 13.3). At term-equivalent age, 10 infants (26%) demonstrated feeding challenges, 21 (54%) demonstrated questionable feeding issues, and 8 (21%) demonstrated normal feeding performance. Lower Neonatal Eating Outcome Assessment scores (poorer feeding performance) at term-equivalent age were associated with more suboptimal reflexes (p = .04) and hypotonia (p < .01).
Conclusions and Relevance. Feeding challenges and questionable feeding performance were prevalent among preterm infants at term-equivalent age and appeared in conjunction with suboptimal reflexes and hypotonia. Understanding this finding enables therapists to take a holistic approach to addressing feeding difficulties.
Kwon, J., Kellner, P., Wallendorf, M., Smith, J., & Pineda, R. (2020). Neonatal feeding performance is related to feeding outcomes in childhood. Early Human Development, 151, 105202. https://doi.org/10.1016/j.earlhumdev.2020.105202 Show abstract
Aim. Define relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment.
Study design. Ninety-one infants (44 preterm infants born ≤32 weeks at term-equivalent age and 47 full-term infants within 4 days of life) had feeding evaluated using the Neonatal Eating Outcome Assessment and the Neonatal Oral Motor Assessment Scale (NOMAS). At 4 years of age, 39 of these infants (22 preterm infants and 17 full-term infants; 43% follow-up rate) had parent-report measures of feeding conducted using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Pediatric Eating Assessment Tool (PediEAT).
Results. Lower Neonatal Eating Outcome Assessment scores were related to higher PediEAT scores (p = 0.01; r = −0.44), but were not related to BPFAS scores (p = 0.17; r = −0.23). Relationships were not detected between the NOMAS and BPFAS (p = 0.35; r = 0.17), and relationships between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34). There was a relationship between the BPFAS and PediEAT scores at 4 years (p < 0.001; r = 0.66). Preterm infants performed poorer than full-term infants on the Neonatal Eating Outcome Assessment (p < 0.001) and NOMAS (p < 0.001), but no differences were detected in preterm compared to full-term performance on the BPFAS (p = 0.87) and PediEAT scores (p = 0.27).
Discussion. Neonatal feeding performance is an important predictor of feeding outcomes at 4 years of age. The Neonatal Eating Outcome Assessment has predictive validity, and the Pediatric Eating Assessment Tool has concurrent validity with relationships to another childhood feeding tool.
Keywords. Oral motor, Neonatal intensive care unit, Development, Assessment, Neonatal Eating Outcome Assessment, Outcome
Pineda, R., Prince, D., Reynolds, J., Grabill, M., & Smith, J. (2020). Preterm infant feeding performance at term equivalent age differs from that of full-term infants. Journal of Perinatology, 40, 646–654. https://doi.org/10.1038/s41372-020-0616-2 Show abstract
Objective. To identify differences in feeding skill performance among preterm infants at term equivalent age compared with full-term infants.
Study design. Ninety-two infants (44 preterm infants born ≤32 weeks gestation at term equivalent age and 48 full-term infants within 4 days of birth) had a standardized oral feeding assessment.
Result. Preterm infants at term equivalent age had lower Neonatal Eating Outcome Assessment scores (67.8 ± 13.6 compared with 82.2 ± 8.1; p < 0.001) and were more likely to have poor arousal (p = 0.04), poor tongue positioning (p = 0.04), suck–swallow–breathe discoordination (p < 0.001), inadequate sucking bursts (p = 0.01), tonal abnormalities (p < 0.001), discoordination of the jaw and tongue during sucking (p < 0.001), lack of positive engagement with the feeder and/or discomfort (p < 0.001), signs of aspiration (p < 0.001), difficulty regulating breathing (p < 0.001), and have an inability to maintain an appropriate state (p < 0.001), and complete the feeding (p < 0.001).
Conclusion. A broad range of feeding-related difficulties appear to remain evident in preterm infants at term equivalent age.
Pineda, R., Liszka, L., Kwon, J., & Wallendorf, M. (2020). Interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment. American Journal of Occupational Therapy, 74(2), 7402205050. https://doi.org/10.5014/ajot.2020.039578 Show abstract
Importance. Few neonatal feeding assessments are currently available, and the Neonatal Eating Outcome Assessment is the only one that identifies feeding impairment while considering the developmental changes that occur from preterm birth to term-equivalent age.
Objective. To determine the interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment.
Design. Prospective, observational study.
Setting. Level 4 neonatal intensive care unit.
Participants. A convenience sample of 7 neonatal therapists participated in reliability testing. For concurrent validity, a prospective cohort of 52 preterm infants born ≤32 wk gestation had feeding assessed at term-equivalent age.
Outcomes and Measures. Intraclass correlations (ICCs) and Fleiss’s κ statistics were used to define reliability across therapists, who independently scored five videos of preterm infants orally feeding using the Neonatal Eating Outcome Assessment. Concurrent validity was determined by evaluating relationships between the Neonatal Oral Motor Assessment Scale (NOMAS) and the Neonatal Eating Outcome Assessment using an independent-samples t test and χ2 analysis.
Results. The ICC for the Neonatal Eating Outcome Assessment total score was 0.90 (confidence interval [CI] [0.70, 0.99]). Fleiss’s κ scores for the 19 scorable items on the Neonatal Eating Outcome Assessment had predominately moderate, fair, and slight agreement, with 3 items having poor agreement. Dysfunctional NOMAS scores were related to lower Neonatal Eating Outcome Assessment scores (t[49.4] = 3.72, mean difference = 12.2, 95% CI [5.60, 18.75], p = .001).
Conclusions and Relevance. The Neonatal Eating Outcome Assessment has excellent reliability. Concurrent validity was established.
What This Article Adds. This article reports that the final version of the Neonatal Eating Outcome Assessment (Version 5.7) has excellent interrater and concurrent validity and is an important tool to assess the occupation of infant feeding in clinical practice.
Pineda, R., Dewey, K., Jacobsen, A., & Smith, J. (2019). Non-nutritive sucking in the preterm infant. American Journal of Perinatology, 36(3), 268-276. https://doi.org/10.1055/s-0038-1667289 Show abstract
Objective. To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding.
Study Design. Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA with the NTrainer System. Oral feeding was assessed at 38 weeks PMA.
Results. There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; β = –1.4) was related to feeding success at 38 weeks PMA.
Conclusion. Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.
Keywords. non-nutritive sucking, preterm, medical factors, oral feeding
Pineda, R., Harris, R., Foci, F., Roussin, J., & Wallendorf, M. (2018). Neonatal Eating Outcome Assessment: tool development and inter‐rater reliability. Acta Paediatrica, 107(3), 414-424. https://doi.org/10.1111/apa.14128 Show abstract
Aim. To define the process of tool development and revision for the Neonatal Eating Outcome (NEO) Assessment and to report preliminary inter‐rater reliability.
Methods. Tool development consisted of a review of the literature and observations of feeding performance among 178 preterm infants born ≤32 weeks gestation. 11 neonatal therapy feeding experts provided structured feedback to establish content validity and define the scoring matrix. The tool was then used to evaluate feeding in 50 preterm infants born ≤32 weeks of gestation and 50 full‐term infants. Multiple revisions occurred at each stage of development. Finally, six neonatal occupational therapists participated in reliability testing by independently scoring five videos of oral feeding of preterm infants using version 4 of the tool.
Results. The intraclass correlation for the ‘prefeeding’ score was 0.71 (0.37–0.96), and the intraclass correlation for the ‘total’ score was 0.83 (0.56–0.98).
Conclusion. The ‘total’ score had good to excellent reliability. Fleiss’ Kappa scores for all 18 scorable items ranged from slight agreement to moderate agreement. Items with the lowest Kappa scores were revised, and additional feedback from therapists engaged in reliability testing was incorporated, resulting in final version 5.
Crapnell, T. L., Woodward, L. J., Rogers, C. E., Inder, T. E., & Pineda, R. G. (2015). Neurodevelopmental profile, growth, and psychosocial environment of preterm infants with difficult feeding behavior at age 2 years. The Journal of Pediatrics, 167(6), 1347-1353. https://doi.org/10.1016/j.jpeds.2015.09.022 Show abstract
Objective. To examine the association of difficult feeding behaviors in very preterm infants at age 2 years with growth and neurodevelopmental outcomes and family factors and functioning.
Study design. Eighty children born ≤30 weeks gestation were studied from birth until age 2 years. Feeding difficulties were assessed using the Eating Subscale of the Infant-Toddler Social Emotional Assessment at age 2 years, along with growth measurement and developmental testing. Maternal mental health and family factors were assessed using standardized questionnaires. ANOVA and χ2 analyses were performed to determine associations between feeding difficulties and growth, neurodevelopmental outcomes, and family characteristics.
Results. Twenty-one children (26%) were at risk for feeding difficulties, and an additional 18 (23%) had definite feeding difficulties at age 2 years. Those with feeding difficulties were more likely to be subject to a range of neurodevelopmental problems, including impaired cognition (P = .02), language (P = .04), motor (P = .01), and socioemotional (P < .007) skills. Compared with the parents of children with fewer feeding difficulties, parents of the children with feeding difficulties had higher parenting stress (P = .02) and reported more difficulty managing their child's behavior (P = .002) and more frequent parent–child interaction problems (P = .002). No associations were found between difficult feeding behaviors and growth, maternal mental health, or family factors.
Conclusion. Difficult feeding behaviors in children born very preterm appear to be highly comorbid with other developmental and family challenges, including neurodevelopmental impairment and parent–child interaction difficulties. Focusing on improving feeding skills, in conjunction with supporting positive parent–child interactions, may be beneficial for improving outcomes.
Zarem, C., Kidokoro, H., Neil, J., Wallendorf, M., Inder, T., & Pineda, R. (2013). Psychometrics of the Neonatal Oral Motor Assessment Scale. Developmental Medicine & Child Neurology, 55(12), 1115-1120. https://doi.org/10.1111/dmcn.12202 Show abstract
Aim. To establish the psychometrics of the Neonatal Oral Motor Assessment Scale (NOMAS).
Method. In this prospective cohort study of 75 preterm infants (39 females, 36 males) born at or before 30 weeks gestation (mean gestational age 26.56wks, SD 1.90, range 23–30wks; mean birthweight 967.33g, SD 288.54, range 480–2240), oral feeding was videotaped before discharge from the neonatal intensive care unit (NICU). The NOMAS was used to classify feeding as normal, disorganized, or dysfunctional. Neurobehavior was assessed at term equivalent, and infants underwent magnetic resonance imaging. Children returned for developmental testing at 2 years corrected age. Associations between NOMAS scores and (1) neurobehavior; (2) cerebral injury and metrics; and (3) developmental outcome were investigated using χ2‐analyses, t‐tests, and linear regression. For reliability, six certified NOMAS evaluators rated five randomly selected NOMAS recordings and re‐scored them 2 weeks later in a second randomized order. Reliability was calculated with Cohen's kappa statistics.
Results. Dysfunctional NOMAS scores were associated with lower Dubowitz scores [t=−2.14; mean difference −2.32 (95% confidence interval [CI] −0.157 to −4.49); p=0.036], higher stress on the NICU Network Neurobehavioral Scale (t=2.61; mean difference 0.073 [95% CI 0.017–0.129]; p=0.0110), and decreased transcerebellar diameter (t=−2.22; mean difference −2.04 [CI=−3.89 to −0.203]; p=0.03). No significant associations were found between NOMAS scores and 2‐year outcome.
Interpretation. Some concurrent validity was established with associations between NOMAS scores and measures of infant behavior and cerebral structure. The NOMAS did not show predictive validity in this study of preterm infants at high risk of developmental delay. Reliability was variable and suboptimal.
Crapnell, T. L., Rogers, C. E., Neil, J. J., Inder, T. E., Woodward, L. J., & Pineda, R. G. (2013). Factors associated with feeding difficulties in the very preterm infant. Acta Paediatrica, 102(12), e539-e545. https://doi.org/10.1111/apa.12393 Show abstract
Aim. To investigate early medical and family factors associated with later feeding risk in preterm infants.
Methods. For this longitudinal study, 136 infants born ≤30 weeks gestation were enrolled. Medical and social background factors were assessed at term equivalent age. Infants underwent magnetic resonance imaging, neurobehavioral evaluation and feeding assessment. Parent involvement in the neonatal intensive care unit was tracked, and maternal mental health was assessed at neonatal intensive care unit discharge. At age 2 years, feeding outcome was assessed using the Eating Subscale of the Infant‐Toddler Social Emotional Assessment (n = 80). Associations between feeding problems at age 2 years and (i) early medical factors, (ii) neurobehavioral functioning and feeding at term equivalent age, (iii) cerebral structure and (iv) maternal mental health were investigated using regression.
Results. Eighteen (23%) children had feeding problems at age 2 years. Feeding problems were associated with early hypotonia (p = 0.03; β = 0.29) and lower socio‐economic status (p = 0.046; β = −0.22). No associations were observed between early medical factors, early feeding performance, cerebral structure alterations or maternal well‐being and feeding outcome.
Conclusion. Early hypotonia may disrupt the development of oral‐motor skills. Hypotonia and poor feeding also may share a common aetiology. Associations with lower socio‐economic status highlight the potential influence of family background factors in feeding problems in the preterm infant.
Other references
Connell, A., Knudsen, K., Marginean, H., & Raddish, M. (2023). Associations between feeding and development in preterm infants in the NICU and throughout the first year of life. Early Human Development, 177–178, 105719. https://doi.org/10.1016/j.earlhumdev.2023.105719
The Neonatal Eating Outcome Assessment was created at Washington University and is a copyrighted instrument. Copyright 2014 by Washington University in St. Louis, Missouri. All rights reserved.
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