Effect of oral stimulation on premature newborns’ feeding performance: a systematic review

Figueiredo, Inês Ferreira; Grilo, Margarida; Campos, Susana Garcia; Rodrigues, Inês Tello

doi:10.1590/1806-9304202500000131-en

person Inês Ferreira Figueiredo

conceptualization · data collection · analysis · research · visualization · writing of the manuscript · approved the final version of the article · declare no conflict of interest

schoolEscola Superior de Saúde do Alcoitão. Rua Conde Barão, 2649-506. Alcabideche, Portugal

0009-0007-7334-7362

person Margarida Grilo

supervision · validation · revision of the manuscript · approved the final version of the article · declare no conflict of interest

schoolEscola Superior de Saúde do Alcoitão. Rua Conde Barão, 2649-506. Alcabideche, Portugal

0000-0003-2187-8253

person Susana Garcia Campos

data collection · analysis · revision of the manuscript · approved the final version of the article · declare no conflict of interest

schoolEscola Superior de Saúde do Alcoitão. Rua Conde Barão, 2649-506. Alcabideche, Portugal

0009-0007-0867-3292

person Inês Tello Rodrigues

project management · methodology · supervision · validation · revision of the manuscript · approved the final version of the article · declare no conflict of interest

schoolEscola Superior de Saúde do Alcoitão. Rua Conde Barão, 2649-506. Alcabideche, PortugalschoolCenter for Innovative Care and Health Technology (ciTechcare), IPL Leiria, Portugal

0000-0001-9953-8529

All the authors approve the final version of the article and declare no conflict of interest.

Associated Editor:

Raphael Perrier-Melo

	Research key (PUBMED Central)	Results
#1	(speech therapy[MeSH Terms]) OR (stimulation)	1,472,764
#2	(((((Breastfeeding) OR (Breast Fed)) OR (Wet nursing)) OR (Sucking Behavior[MeSH Terms])) OR (breast feeding[MeSH Terms])) OR (feeding behavior[MeSH Terms])	222,730
#3	((infant, premature[MeSH Terms]) OR (preterm Infant)) OR (Infant, Preterm)	127,265
#4	#1 AND #2 AND #3	230
	Research key (SciELO)	Results
#1	(speech therapy) OR stimulation	4785
#2	(Sucking Behavior) OR (Breast Feeding) OR (feeding behavior) OR (Breastfeeding) OR (Breast Fed) OR (Wet Nursing)	5336
#3	(infant, premature) OR (Preterm Infants) OR (Infant, Preterm)	1431
#4	((speech therapy) OR stimulation) AND ((Sucking Behavior) OR (Breast Feeding) OR (feeding behavior) OR (Breastfeeding) OR (Breast Fed) OR (Wet Nursing)) AND ((infant, premature) OR (Preterm Infants) OR (Infant, Preterm))	16
	Research key (SciELO)	Results
#1	(Speech therapy) OR stimulation	1 844
#2	(Sucking Behavior) OR (Breast Feeding) OR (feeding behavior) OR (partial breastfeeding)	3212
#3	(extremely premature infant) OR (Premature newborn)	711
#4	((Speech therapy) OR stimulation) AND ((Sucking behavior) OR (breastfeeding) OR (feeding behavior) OR (partial breastfeeding)) AND ((extremely premature infant) OR (Premature newborn))	16
	Research key (LILACS)	Results
#1	(speech therapy) OR stimulation	11897
#2	(Sucking Behavior) OR (Breast Feeding) OR (feeding behavior) OR (Breastfeeding) OR (Breast Fed) OR (Wet Nursing)	12599
#3	(infant, premature) OR (Preterm Infants) OR (Infant, Preterm)	5104
#4	((speech therapy) OR stimulation) AND ((Sucking Behavior) OR (Breast Feeding) OR (feeding behavior) OR (Breastfeeding) OR (Breast Fed) OR (Wet Nursing)) AND ((infant, premature) OR (Preterm Infants) OR (Infant, Preterm))	44
	Research key (CINA-HL Complete, Cochrane Collection Plus, Nursing & Allied Health Collection and Medic Latina via EBSCOHost)	Results
#1	(speech therapy) OR stimulation	275,395
#2	(Sucking Behavior) OR (Breast Feeding) OR (feeding behavior) OR (Breastfeeding) OR (Breast Fed) OR (Wet Nursing)	90572
#3	(infant, premature) OR (Preterm Infants) OR (Infant, Preterm)	35828
#4	((speech therapy) OR stimulation) AND ((Sucking Behavior) OR (Breast Feeding) OR (feeding behavior) OR (Breastfeeding) OR (Breast Fed) OR (Wet Nursing)) AND ((infant, premature) OR (Preterm Infants) OR (Infant, Preterm))	53

Reference	Type of study	Population	Methodology	Experimental Group Results	Conclusions	Evidence level
Fucile et al.,⁹	Double-blind randomized clinical trial	32 premature newborns	Experimental group (n=16): oral stimulation program and non-nutritive sucking (15 minutes, once a day for 10 days). Control group (n=16): Sham procedure (simulated procedure).	Milk transfer rate: better performance in overall milk transfer over time, reaching 100% of total intake in 1 to 2 oral feedings per day compared to the control group. Independent oral feeding: achieved independent oral feeding faster. Volume of milk ingested: the rate of volume ingested was higher than in the control group. Feeding performance/sucking pattern: Better sucking performance compared to the control group. Early hospital discharge: The difference in time to hospital discharge was not significant.	Pre-feeding oral stimulation program may benefit feeding performance. Faster transition to independent oral feeding was associated with better oral feeding performance.	Strong
Fucile et al.,¹⁵	Double-blind randomized clinical trial	32 premature newborns	Experimental group (n=16): non-nutritive sucking program for oral stimulation (15 minutes). Control group (n=16): Sham procedure (simulated procedure).	Milk transfer rate: higher milk transfer rate. Overall milk intake volume: higher overall intake volume. Feeding performance/sucking pattern: Both groups showed maturation of the sucking pattern and a decrease in sucking frequency over time (The sucking frequency for the experimental group was 2.3 and 1.1 from the 1^st to 2^nd and from the 6th to 8th oral feedings/day, respectively. For the control group, it was 2.6 and 1.3 at these two moments).	A non-nutritive oral stimulation program that facilitates the development of the expression component of sucking can improve oral feeding performance.	Strong
Lyu et al.,²⁶	Double-blind randomized clinical trial	63 premature newborns	Experimental group (n=32): oral stimulation and non-nutritive sucking (15 minutes). Control group (n=31): Standard neonatal care (no stimulation).	Milk transfer rate: No differences in milk volume transfer. Feeding performance/sucking pattern: higher feeding performance (34.70 and the control group 35.66). Independent oral feeding: Experimental group: shorter time to gain independent feeding (9.56 and the control group 13.19). Early hospital discharge: no significant difference - experimental group - 39.97 ± 14.81 days; control group - 41.25 ± 16.15 days.	This program can shorten the time from tube feeding to full oral feeding. Oral stimulation brought benefits in feeding performance and the introduction of oral feeding.
Arora et al.,¹⁹	Double-blind randomized clinical trial	30 premature newborns	Experimental group (n=16): PIOMI before feeding (5 minutes for 7 days). Control group (n=14): Sham procedure (simulated procedure).	Feeding performance/sucking pattern: better score on the Neonatal Oral-Motor Assessment scale (9.25 vs 4.79). Independent oral feeding: earlier transition from tube to independent oral feeding (4 vs 6.6). Early hospital discharge: shorter hospital stay (13.6 vs 16.1).	It was effective in reducing the transition time from tube feeding to independent oral feeding and in improving the oromotor performance of premature babies.
Fucile et al.,¹⁶	Double-blind randomized clinical trial	31 premature newborns	Experimental group (n=16): sensorimotor intervention (15 minutes, once a day for 10 days). Control group (n=15): Sham procedure (simulated procedure).	Independent oral feeding: achieved full oral feeding 8 days earlier.Breastfeeding: higher breastfeeding rate at hospital discharge (11 vs 5). Early hospital discharge: discharged 10 days earlier.	Oral sensorimotor intervention can facilitate the transition from tube feeding to oral feeding and increase direct breastfeeding rates at hospital discharge.
Thakkar et al.,²⁰	Double-blind randomized clinical trial	102 premature newborns + 10 of Hawthorne’s group	Intervention group (n=51): PIOMI (2 times a day, for 5 minutes). Control group (n=51): Standard neonatal care (no stimulation). Hawthorne group (n=10): No intervention of any kind.	Milk transfer rate: No differences. No difference between the control group and Hawthorne.Overall milk intake volume: intake volume (10.37 vs. 9.81). Feeding performance/sucking pattern: No differences. Independent oral feeding: shorter transition period to reach 4 oral feedings/day and 8 oral feedings/day. Early hospital discharge: shorter length of stay (22.12 vs 24.88). No difference between the control group and Hawthorne.	Oral stimulation in preterm infants improves feeding performance, promotes earlier achievement of independent oral feeding and reduces length of hospital stay.
Ghomi et al.,²²	Double-blind randomized clinical trial	30 premature newborns	Experimental group (n=15): PIOMI (5 minutes, once a day for 10 days). Control group (n=15): Standard neonatal care (no stimulation).	Feeding performance/sucking pattern: 1st oral feeding (7.2 days) and 8 oral feedings (13.47 days) earlier. Time to start oral feeding: feeding progression was 6.27 days shorter. Independent oral feeding: 14.73 days earlier transition from tube to independent oral feeding.Early hospital discharge: discharged 9.47 days earlier.	PIOMI is suitable for premature infants and has a positive impact on the development of oral motor skills, feeding progression and reduction in hospital stay.	Strong
Lessen et al.,²⁷	Double-blind randomized clinical trial	30 premature newborns	Experimental group (n=15): PIOMI (5 minutes, once a day, for 7 days). Control group (n=15): Standard neonatal care (no stimulation).	Overall milk intake volume: higher oral milk intake volume over the 5 days (61.66 on day 5 vs 34.83). Feeding performance/sucking pattern and time to start oral feeding: rate of improvement over the 5 days exceeded that of the control group, showing a more efficient first feeding (39.64 vs 26.62).	PIOMI increased the average volume of oral intake of the newborns who benefited from the intervention.	Moderated
Mahmoodi et al.,²³	Double-blind randomized clinical trial	40 premature newborns	Experimental group (n=20): PIOMI (5 minutes, for 7 days). Control group (n=20): Standard neonatal care (no stimulation).	Time to start oral feeding: average time to start oral feeding was earlier (9.55±1.70 days; in the control group it was 11.5±2.77 days). Independent oral feeding: achieved independent feeding earlier. Early hospital discharge: shorter average hospital stay (16.5±3.9; control group 19.4±4.08 days).	PIOMI had positive effects on the readiness for oral feeding as well as on the progression to full oral feeding and subsequently, the improvements in oral feeding led to a reduction in the length/days of hospital stay, making it suitable for premature newborns.	Strong
Aguilar-Rodríguez et al.,²⁸	Double-blind randomized clinical trial	46 premature newborns	Experimental group (n=24): oral sensorimotor stimulation (10 minutes for 2 weeks). Control group (n=22): Standard neonatal care (no stimulation).	Time to start oral feeding: The control group’s first oral intake took 5.88 days longer. Control group took 8.3 days longer to achieve full oral feeding Control group took 6.03 days longer. Early hospital discharge: The control group took 6.9 days longer to be discharged from hospital.	Oral sensorimotor stimulation speeds up the achievement of full oral feeding, as well as the achievement of first oral intake and first full oral intake, resulting in a significant reduction in hospitalization days.	Strong
Ostadi et al.,²⁴	Double-blind randomized clinical trial	40 premature newborns	Experimental group I (n=13): Non-nutritive sucking (for 10 days). Experimental group II (n=14): swallowing exercises + non-nutritive sucking (for 10 days). Control group III (n=13): Standard neonatal care (no stimulation)	Feeding performance/sucking pattern: Compared to the control group, both intervention groups showed an increase in the Preterm Oral Feeding Readiness Scale (POFRAS) in improving readiness for oral feeding, but no statistically significant differences between the two. Time to initiation of oral feeding and independent oral feeding: Compared to group III, more babies in group II were discharged without tube feeding (78.6% vs 30.8%). Between group I and II, there were no differences in the number of babies discharged without tube feeding.	Although the interventions studied had no effect on the functional outcomes examined, both were superior to routine care in improving the readiness for oral feeding of premature infants based on the POFRAS score. The combined program of non-nutritive sucking together with swallowing exercises may be more effective in transferring tube feeding to oral feeding than non-nutritive sucking exercises alone.	Strong
Kore and Mathew²¹	Estudo quase experimental com grupo de controle não aleatorizado	40 premature newborns	Experimental group (n=20): Oral sensorimotor stimulation (5 minutes for 5 days). Control group (n=20): Standard neonatal care (no stimulation).	Feeding performance/sucking pattern: In the pre-assessment, in the control group, 70% were in the reasonable category and 30% in the good category with regard to feeding performance. In the experimental group, 75% were in the reasonable category and 25% were in the good category. After the intervention, 95% of the participants in the experimental group were in the good category and in the control group only 75% were in the good category in terms of eating performance.	Oral stimulation was effective in reducing feeding problems, improving feeding performance and having a positive impact on the development of oral motor skills.	Weak

Outcomes
Reference	Milk transfer rate	Volume of overall milk intake	Feeding performance/sucking pattern	Time to initiation of oral feeding	Independent oral feeding	Breastfeeding	Early hospital discharge
Fucile et al.,⁹	+	+	+	-----	+	-----	X
Fucile et al.,¹⁵	+	+	+	-----	+	-----	-----
Rocha et al.,¹⁷	-----	-----	X	+	+	-----	+
Costa et al.,¹⁸	X	X	-----	-----	X	-----	-----
Lessen¹¹	-----	-----	-----	-----	+	-----	+
Bache et al.,²⁵	-----	-----	+	-----	X	+	X
Lyu et al.,²⁶	X	-----	+	-----	+	-----	X
Arora et al.,¹⁹	-----	-----	+	-----	+	-----	+
Fucile et al.,¹⁶	-----	-----	-----	-----	+	+	+
Thakkar et al.,²⁰	X	+	+	-----	+	-----	+
Ghomi et al.,²²	-----	-----	+	+	+	-----	+
Lessen et al.,²⁷	-----	+	+	+	-----	-----	-----
Mahmoodi et al.,²³	-----	-----	-----	+	+	-----	+
Aguilar-Rodríguez et al.,²⁸	-----	-----	-----	+	+	-----	+
Ostadi et al.,²⁴	-----	-----	+	+	+	-----	-----
Kore e Mathew²¹	-----	-----	+	-----	-----	-----	-----

Section and topic	Item	Item check	Page where item is found
TITLE
Title	1	Identifies the publication as a systematic review	1
SUMMARY
Summary	2	Summary of the study.	2-3
INTRODUCTION
Rationale	3	Grounds the review in the context of existing knowledge	4-5
Objectives	4	Explicitly presents the objective(s) or question(s) concerning the review	5
METHODS
Eligibility criteria	5	Specifies the inclusion and exclusion criteria for the review and how the studies were grouped for the syntheses.	6-8
Information sources	6	Specifies all databases, registers, websites, organizations, reference lists and other sources searched or consulted to identify the studies.	6
Research strategy	7	Shows the complete research strategies for all databases, registers and websites, including all filters and limits used.	7
Selection process	8	Specifies the methods used to decide whether a study meets the review’s inclusion criteria, including how many reviewers screened each record and publication selected, whether they worked independently and, if applicable, details of automation tools used in the process automatIzation	7-8
Data collection process	9	Specifies the methods used to collect data from the publications, including how many reviewers collected the information from each publication, whether they worked independently, any processes for obtaining or confirming data by the study researchers and, if applicable, details of automation tools used.	7-8
Data items	10a	List and define all outcomes for which data was searched. Specify whether all outcomes compatible with each outcome were searched for in each study (e.g. for all measures, time points, analyses) and, if not, specify the methods used to decide which outcomes to collect.	6
Data items	10b	List and define all the other variables for which data were researched (e.g. characteristics of participants and interventions, funding sources). Describes the assumptions made about missing or unclear information.	8
Assessment of the risk of bias in the studies	11	Specifies the methods used to assess the risk of bias of the included studies, including details of the instrument(s) used, how many reviewers assessed each study and whether they worked independently and also, if applicable, details of automation tools used in the process.	7-8
Measures of the effect	12	Specify for each outcome the measure(s) of effect (e.g. relative risk and mean difference) used in the synthesis or presentation of the results.	10
Synthesis method	13a	Describes the processes used to decide the studies selected for each synthesis (e.g. present the characteristics of the intervention presented in the study and compare with the groups planned for each synthesis.	6-7-8
	13b	Describes all necessary methods of preparing data for presentation or synthesis, such as dealing with missing data in the summary statistics, or data conversions.	----
	13c	Describes all the methods used to present or display the individual results of studies and syntheses.	8
	13d	Describe all the methods used to summarize the results and provide a justification for the choice(s). If a meta-analysis was carried out, describe the model(s) and method(s) for identifying the presence and extent of statistical heterogeneity, and software used.	7-8
	13e	Describe all methods used to explore possible causes of heterogeneity between study results (e.g. subgroup analysis, meta-regression).	----
	13f	Describe all the sensitivity analyses carried out to assess the robustness of the results.	----
Assessment of reported bias	14	Describes all methods used to assess the risk of bias due to missing results in a synthesis (due to information bias).	----
Assessment of the degree of confidence	15	Describes all the methods used to assess the certainty (or confidence) in the body of evidence of a result.	7-8
RESULTS
Study selection	16a	Describes the results of the research and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flowchart.	8-9
Study selection	16b	Cite studies that appear to meet the inclusion criteria but were excluded, and explain the reasons for the exclusion.	8-9
Characteristics of the studies	17	It cites each included study and presents its characteristics	8-9
Risk of bias in the studies	18	Presents the risk of bias assessment for each included study.	10
Individual results in the study	19	For all the results of each study, it presents: (a) summary statistics for each group (where appropriate) and (b) an estimate of the effect and its precision (e.g. confidence/credibility interval), ideally using structured tables or graphs.t cites each included study and presents its characteristics.	10
Results of syntheses	20a	For each synthesis, a summary of the characteristics and risk of bias among the selected studies.	10
	20b	Present the results of all the statistical syntheses carried out. If a meta-analysis was carried out, for each result, a summary of the estimate and its precision (e.g. confidence/credibility interval) and measures of statistical heterogeneity. If groups were compared, describe the direction of the effect.	10
	20c	Presents the results of all investigations into possible causes of heterogeneity between study results.	8-9
	20d	Presents the results of all sensitivity analyses carried out to assess the robustness of the synthesized results.	---
Biases reported	21	Presents the assessment of the risk of bias due to missing results (resulting from information bias) for each synthesis assessed.	10
Significance level	22	Presents the assessment of certainty (or confidence) in the body of evidence for each result assessed.	---
DISCUSSION
Discussion	23a	Provides a general interpretation of the results in the context of other evidence.	10-14
	23b	Discusses all the limitations of the evidence included in the review.	15-16
	23c	Discusses all the limitations of the review processes used.	15-16
	23d	Discusses the implications of the findings for practice, policy and future research.	15-16
OTHER INFORMATION
Protocol record	24a	Provides information on the record of the review, including the name and record number, or states that the review is not recorded.	---
	24b	Indicates place of access to the review protocol, or states that the protocol has not been prepared.	---
	24c	Describes and explains any changes to the information provided in the records or protocol.	---
Support	25	Describes the sources of funding or non-funding support that underpin the review, and the role of the funders or sponsors of the review.	1
Conflict of interest	26	Declare any conflicts of interest of the authors of the review.	1
Availability of data, codes and other materials	27	Report which of the following materials are publicly accessible and where they can be found model data collection forms extracted from the included studies, data used for analysis; analytical code, any other material used in the review.	---

Effect of oral stimulation on premature newborns’ feeding performance: a systematic review

Abstract