Feeding and swallowing in infants are controlled by the neural centres in the brain. The neural control of swallowing includes the motor and sensory innervations. In infants, optimum nutrition and good feed are the most important determinants of their health, development and growth (Michaelsen, Weaver, Branca, & Robertson, 2000). When the infant meets all the nutritional demands on feeding, focussing on the individual's developmental readiness, then it is considered as the positive feeding experiences (Samour & Helm, 2005).
Prerequisites for successful feeding
In infants, the feeding is controlled by the brainstem without any suprabulbar input. This control is observed at 6 weeks before and after 40 weeks of gestational age. Feeding at this stage is reflexive in nature. In an ascending way the functionality of the central nervous system improves. At around 6-8 weeks of gestational age the synaptogenesis begins, postnatally there is the maximum development of dendrites and synaptic connections. The neural circuits that are precise could be stimulated by the sensory input or the endogenous activity. Thus in the organization of any specific neural pathways foetal swallowing movements will play an important role (Ekberg, 2012)
Thus feeding and swallowing is complex process controlled neurophysiologically. For the development of normal feeding skills the coordination of the motor and sensory functions is essential. Other prerequisites for successful feeding are given below;
Oro motor skills
Gross motor skills
Fine motor skills
Oral sensitivity
Reflexes related to swallowing
Coordination of sucking, swallowing and breathing.
a) Oro motor skills
Ekvall and Ekvall (2005) considered feeding as process which is multidimensional in nature that follows development of the infant that in turn influence feeding. This development of feeding includes oromotor skills, gross motor skills, fine motor skills and behavioural skills. Oro motor skills can be described as the actions or movements of the muscles in face of the infant and these oral motor skills are described below.
Suckling: Paul (2007) considered suckling as a primitive form of sucking that involves retraction and extension of the tongue along with the up and down jaw movements. Suckling behaviour develops early during the gestation period, i.e. at 24 weeks of gestation
Sucking: Sucking is considered as more mature pattern of suckling. During the process intraoral negative pressure is generated, the tip of the tongue is elevated rather than extension or retraction. Jaw movement is observed rhythmic and lip approximation is definite (Paul, 2007).
Swallowing: Miller (1986) reported that swallowing as a motor action which is semiautomatic through the respiratory muscles and gastrointestinal tracts. During swallowing, food is propelled from the oral cavity into stomach.
Chewing - According to Morris and Klien (2000) chewing develops in a sequential manner and it initiate an automatic or reflexive up and down movement touching the biting surface and gums, this is referred to as phasic bite release. The munching pattern provides voluntary bite or chewing motions with experience (Gisel, 1991).
Biting - Curtis and Newman (2005) reported that biting is observed in infants around 5 months old. Ekvall and Ekvall (2005) considered biting is one among in the feeding process, including suckling, sucking, chewing and biting.
Gagging - Gagging or the gagreflex is initiated by the vagal receptors in the posterior oropharynx provided with sufficient stimulation, gag reflex may persuade vomiting, further making the air way evident (White, 2012). A gag reflex helps in protecting the lower airway by aspiration (Margolis, 2003).
Tongue elevation - Caruso and Strand (1999) reported that it is the child's ability to move the tongue when the jaw is not in movement. While keeping the jaw immobile the tongue elevation can be assessed in children.
Tongue Lateralization - Tongue move voluntarily from midline towards sides. This initiate the movement of food inside the mouth, tongue lateralization signals the development of feeding in the infants (Lucas, Feucht & Grieger, 2004).
Gross motor skills
The gross motor skills are referred to those skills that use the large muscles (e.g., head control, sitting, rolling, and walking) (Kyle, 2008). Goss motor skills that are related to feeding include head control, grasping object, sitting without support, holding a small cup or a spoon. It is important for the child to have adequate support for the head, trunk, and legs for feeding (Ekvall & Ekvall, 2005).
Fine motor skills
Hooper and Umansky (2004) stated that fine motor skills are the movements of the hand and finger that are more precise and refined that allow the child to do purposeful manipulation. Fine motor skills that are related to feeding are the self feeding skills (Kyle, 2008).
Samour and Helm (2005) reported that at 4 to 6 months of age, infants become skilled at oral and gross motor skill that are required for intake of solid foods. The reflexive suck enables the infant to swallow non liquid foods and transferring the food by tongue from front to back of the oral cavity. Oral motor skills have emerged or evolved from this reflexive suck behaviour.
b) Oral sensitivity
Oral sensitivity or oral sensation involves the sensation like proprioception, touch, temperature, pressure and taste. Feeding development in infants are learned behaviours which are progressive. This learning is deeply influenced by oral sensation, associated gross and fine movements (Ong, Woo, Seong, Tan & Tang, 2004).
According to Zaoutis and Chiang (2007) the oral phase of swallowing depends on variety of factors such as normal sensation and sensory feedback, normal oral anatomy, sucking in infants (strong), and normal muscular functions.
Issues regarding the oral sensitivity can lead to impairment in the child's ability to feed, chew or swallow. Reduced oral sensitivity can cause reduced control and awareness of food in the oral cavity. In contrary hypersensitivity makes the child refuse to eat (Shipley & Mcfaee, 2009). Loughlin and Lefton-Greif (1994) reported that potential indicators of feeding problems are the hyposensitive and hypersensitive reactions. Hyposensitive reaction is expected to weaker sensation to a specific sensation.
Brodsky and Ouellette (2008) describes that feeding problems are usually multifactorial in nature along with medical problems like gasteroesophageal reflux causing feeding related pain that generate oral sensitivity and oral defensive behaviour. Sullivan (2009) reported that infants with poor oral motor skills may exhibit abnormal oral sensory reactions and it can affect the feeding process, especially if it is a strong gag or hypersensitivity towards temperature, taste and texture of the food.
c) Reflexes related to swallowing
Feeding in infants, depend primarily on reflexes. Reflexes are important life- sustaining movement templates which are pre-wired in the infant and gradually become incorporated to become voluntary movement patterns (Genna, 2012).
Rooting reflex- Rooting reflex is characterized by the infant head turning towards the breast, the infant opens the mouth, extend the tongue and grasp the breast. Rooting reflex happens when the face and mouth is stimulated by touch (Genna, 2012). It is eminent by 32 weeks of gestation and the reflex strengthens gradually until infant becomes term, this reflex disappears at around 3 months to 6 months of age followed by higher cortical pathway inhibition (Averdson & Broadsky, 2002).
Transverse tongue reflex- When the lateral edge of the tongue is stroked, the transverse tongue reflex occurs. The infant moves the tongue towards the side of stimulation. Tongue protrusion disappears at around 6-9 months of age. (Arverdson & Brodsky, 2002).
Phasic bite reflex- Phasic bite reflex is considered as the rhythmic closing and opening of the jaws in response to the external stimulation (Arverdson & Brodsky, 2002). According to Genna (2012) this reflex diminishes at around 6 months of age during time of transitional feeding.
Cough reflex- Cough reflex has a great importance on feeding as a reflexive measure to avoid any food materials to enter in to the airway cough reflex is essential (Genna, 2012). This protective reflex is controlled by sensory receptors (chemoreceptors) which are present in the larynx, which makes the vocal fold to adduct and expels the foreign material out. The chemoreflex is not mature in preterm when compared of term infants, hence they may experience bradycardia, apnea and but no cough. If these infants failed to swallow safely they are at the risk of stop breathing. According to Becker, Zhang and Pereyra (1993) these issues resolves as the vagus myelination improves with maturity and feeding experience.
Gag reflex - Gag reflex is another protective reflex that avoids the infant from swallowing large bolus of food that the pharynx can't handle (Genna, 2012). Johnson and Jacobson (2007) observed that gag reflex is evidently seen by 26 to 27 weeks of gestation and it become strongly evident at 40 weeks of gestational age. This reflex is characterized by stimulation over the posterior region of the tongue or pharynx eliciting tongue protrusion, pharyngeal contraction, head and jaw protrusion. This reflex is considered to be independent of swallowing.
Tongue protrusion- Arverdson and Brodsky (2002) reported that tongue protrusion occurs when the tongue or lips are touched. This reflex usually disappears by around 4-6 months of age.
d) Coordination of sucking, swallowing, and breathing
In infants and as in adults, on swallowing the breathing ceases. During this process pharynx act as the centrepiece of the activity, providing a channel to move air from the mouth and nose to the lungs and moving food from mouth to stomach. This dual role makes the coordination of sucking, swallowing and breathing. In infant feeding, when the infant sucks, infant stop breathing and elicits swallow. Following this the infants starts to breathe again, forming a cycle. This cycle repeats around once each second during sucking burst. Like other aspects of feeding, coordination of sucking, swallowing, breathing improves or mature as the child's feeding skills develops (Genna, 2012).
Modes and consistency of feeding
In infants as they mature the feeding modes and consistency or the texture of foods varies. Cichero and Murdoch (2006) compiled information on modes and texture or the consistency of feeding at different ages, and it is described below:
Birth to 3 months- Infant is provided with milk, liquid food through breast feeding or bottle feeding.
4 to 6 months- At this period infant is provided with cereals, purees using spoon.
6 to 9 months - Chunky puree, mashed food, soft finger foods can be given in this period, spoon feeding is continued with the introduction of cup feeding.
9 to 12 months - When the infant reaches 9 to 12 months, chopped foods and finger foods can be given. At this stage the food is provided using a spoon and cup.
Role of feeding in Speech & Language development:
Yule and Rutter (1991) reported that, feeding and pre-speech vocalizations have been assumed to be manifestation of neurological maturation of the infant. They postulated, early vocalization that is possibly speech has thought to be influenced by the infant's feeding patterns. Mothering the child during feeding may also include psychosocial considerations. The prelinguistic behaviours that involve reciprocal and mutual eye contact and turn taking can happen during feeding situations.
Averdson and Broadsky (2002) well thought-out that, feeding moment as an appropriate time for communication between the feeder and infant. The feeder imitates vocalizations, and he/ she may talk or sing to the child in a gentle voice, were the infant is held in a comfortable position to give a proper eye contact with the child. The feeder even can use touch to elicit pleasurable interactions. These interactions can be considered as the integral part of early communication.
Selley, Ellis, Flack, and Brooks (1990) provided enough evidence connecting successful feeding as a predictor for normal communication. They stated that, the speech and normal feeding depends on several factors such as.
Liptone
Rhythm
Breath control
Finely coordinated tongue movements
Well developed sensory feedback systems
Speed of the muscle movement.
During swallowing, muscles of the lip, tongue and cheeks must be well coordinated. Any failure in this coordination can lead to the difficulties in speech.
Preterm infants and feeding difficulties
Infants when born can be classified as term, preterm or post term, which help us to find the level or stage of risk in neonatal morbidity and long term developmental problems. Gestational age is calculated as the duration from mother's last menstrual period to the baby's birth (GA) (Zaichikin, 1996).
Term infant: A term infant is an infant who is born at the beginning of 37 weeks through end of 42nd week, after the last menstrual period (260-294 day's gestation) (Fletcher, 1998).
Post term infants: Post term infants are born at the beginning of the first day of the 43rd week (after 294 days)
Preterm infants: Brodsky and Ouellette (2008) stated preterm as, those infants born below 37 weeks of gestation.
According to Gupte (1998) preterm infants are more likely to have cardiac or respiratory disease associated with intracranial haemorrhage, tachypnea and neonatal jaundice. These factors can lead to feeding difficulties in these infants. Likewise preterm infants are prone to have suckling and swallowing difficulties. Singh (2004) reported that preterm infant may fail to suck and face difficulty in suck swallow coordination. According to Gewolb and Vice (2006) neurological, feeding, respiratory abnormalities may be predicted by coordination of suck- swallow patterns and swallow- respiration.
Infant may faces vomiting or spitting that can be classified in feeding problems. These feeding problems can affect the child's food intake (Miller- Loncar, Bigsby, High, Wallach, & Lester, 2004)
Gupta (2011) compared the feeding performance in preterm and term at 40 weeks postmenstrual age (PMA) the study revealed there was a high significance difference between the two groups regarding the feeding duration, presence of vomiting, cough/choking and noisy breathing. High percentage of preterm infants needed nasogastric tube feeding than term infants, when history of the use of nasogastric tube was considered.
Preterm infants face feeding difficulties that are attributable to medical co-morbidities that the infant had at time of birth. This may have short term and long term outcomes on feeding development of these infant.
Need of the study
The presence of an adequate oro-motor skills, oro-sensory skills and oral reflexes provide a major role in successful oral feeding in infants (Pickler, Best & Crosson, 2008). Infants are fed with foods with various consistency using different modes as the infant mature from birth. Department of health (1994) defined complementary feeding (also known as transitional feeding or weaning) as the process of incorporating foods or drinks other than breast milk or infant formula. In India, weaning is introduced at 6 months of age and once the weaning is completed, breast feeding should be withdrawn (Dhaar & Robbani, 2008); (WHO, 2001). Eastwood (2009) stated that in western countries the weaning usually practiced before 6 months of child's age.
Preterm infants are prone to have feeding difficulties. Literatures on understanding feeding skill or feeding behaviour in preterm infants who are born between 30 and 34 week at 6th month are scanty. Information regarding the oral sensitivity of the infant during the transitional feeding or the weaning period (start feeding puree food) is scant. Hence there lies the necessity to study the feeding ability of these infants at six months of age.
Aim of the study
To compare the feeding behaviour in term infants and preterm infants (30 to 34 week) at six months corrected age.
Feeding is considered as a complex activity in neonatal period with efficient coordination of suck, swallow, and respiration as rhythmic process. Gewolb, Vice, Schweitzer-Kenne, Taciak and Bosma (2001) stated that any compromise or concession in the co-ordination of these skills can lead to suboptimal respiration, nutrition or growth of the infant. According to Averdson and Broadsky (2002), feeding or swallowing difficulties in infants who were not identified as early, may rapidly cause malnutrition and it can cause growth failure in infants and children with little nutritional serve. This suggests that, feeding skills or behaviours has relationship with development of an infant. For a better view of understanding this has been explained in detail.
Feeding development from foetus to infancy
Several feeding milestones emerge at different age of an infant and it begins to occur during the foetal life itself. Morris and Klein (2000) described that in foetus, swallowing was observed as early as a 5th month of pregnancy. This was characterised by suckling movement i.e. the anterior and posterior movement of the tongue touching the lips. Averdson and Broadsky (2002) reported that pharyngeal phase of swallow, one of the first motor responses in the pharynx was observed, can be observed at 10th to 11th weeks of foetal life, which can be observed when stroking the lips provides suckling responses, but the true suckling is seen at around 18- 24 weeks of gestational age. Pharyngeal swallow is found to be observed in foetuses at 12.5 weeks of gestation (Humphrey, 1970).
According to Tuchman and Walter (1994) deglutition described as the act of swallowing appears approximately around 16 to 17 weeks of gestation. He also reported by 34th week of gestation, the healthy foetus can well enough suck and swallow. They can sustain strictly through oral feeding.
In addition, Bosma (1985) described suckling as a unique act that includes all of the motor structures i.e., the tongue, lower lip, mandible and hyoid. All these structures act as a single motor organ during suckling. Suckling inhibition occurs by 6 to 12 months as transitional feeding or weaning begins. Sucking action is described it when the tongue body raises and lowers with the help of the intrinsic muscles and it is characterised by smaller vertical excursion. Sucking is reported to be developed between 6 and 9 months after birth. The term "sucking" is considered the generic term and will be used to refer the organized intake of a liquid or soft solid, where as "suckle" will be used when importance is placed on a specific developmental sequence of mouth movements. Suck or suckling will be used to describe infants who are younger than 6 to 9 months of age who might use a mixture of both suck and suckle.
Cichero & Murdoch (2006) reported that at 6 months, both suckling and sucking behaviours are observed during feeding. However, sucking behaviour is observed predominantly.
At 4 to 6 months, the infant initially does sucking, the tongue to palate movement is observed. Later when the child fed through spoon child may eject food involuntarily from spoon. During this period the child when the infant was initially introduced with transitional feeding, the child may cough, splutter, and spit food out. The reason for this behaviour because of the change on the texture of the food makes the infant difficult to suck and swallow as they used to do previously (Cichero & Murdoch, 2006).
Johnson and Jacobson (2007) illustrated that, coordinated suckling and swallowing are usually observed by 34 to 35 weeks of postmenstrual age, it is sufficient for competent oral feeding and make way for spoon feeding and sucking, which will be evident during transition feeding (6 months). During feeding a burst pause pattern is observed at 30th week to 33rd week of gestational age, indicating readiness of the infant for oral feeding.
The two main prerequisites for a successful oral feeding consist of a strong and rhythmic non-nutritive suck (2 suck per sec), and constant airway system (Johnson & Jacobson, 2007).
Feeding infants at regular intervals is a major factor in establishing and maintaining arousal episodes. The arousal can in turn help to prepare the infants for feeding. The arousal is noted or considered by gross motions of head, face, trunk, and extremities, with respiratory irregularities and increased respiratory rate. It is common that incidental phonation prior to crying that may become prominent with delays in initiation of feeding process.
From foetus to infancy in infants achieves several feeding skills. These skills provide the success in feeding development. Any delay in achieving these skills could lead to delay in feeding development.
Feeding in term infants
Breast feeding
Human milk is considered remarkably required for the infant and it provides the best start in the infant's life. Hence it is encouraged that infant should be breast fed for at least first 6 to 12 months of life (Gupte, 1998). During breast feeding the infant keeps the tongue tip at the back of lower lip and lower gum. The mandible moves up and compressing the breast areola against the infant's alveolar ridge. The infant keeps the anterior portion of the tongue raised, were the posterior part of the tongue is depressed and retracted, causing groove that drains milk in the oral cavity (Arverdson & Brodsky, 2002). They also reported that the depressed portion of the tongue, make the buccal mucosa move inward slightly and then forward at the same time as the mandible and the tongue is raised, the milk is drained in to the oral cavity. Suck/swallow sequence is approximately repeated one time per second that depends on how hungry is the infant and how long the mother can provide milk.
Bosma (1985) reported that during breast feeding infants show gradual consistency decrease of the suck- swallow rhythm, characterized by suckle with reduced force. Infants empty each breast within 4 minute during breast feeding.
Driscoll (1992) considered breast feeding as a relationship and method of communication. Success or failure in breast feeding is depended on the mother's self definition and individual perceptions.
Breast feeding in preterm infants
Considering breast feeding the premature infants, these infants lack the strength or maturity for breast feeding until they reach their due date. Hence primarily, expressed milk can be given through gavage (Brodsky & Ouellette, 2007). Preterm infants born between 30-34 weeks of gestation, nasogastric tube feeding is initiated in stable infants. In infants who are born above with 32 weeks of gestational age, as a part of weaning from nasogastric tube feeding to spoon/ paladai is attempted (Singh, 2004).
Paladai is small cup-like device, in India mothers use paladai for centuries for feeding infants (Lauwers & Swisher, 2010). When the infant achieves 34 weeks of gestation direct breast feeding is tried at once. Irrespective of the gestational age, preparation for breast feeding should begin, by facilitating the development of the rooting reflex (Singh, 2004).
When the infant attain the coordinated sucking, swallowing and breathing necessary for oral feeding, the learning breast feeding becomes lengthy and a challenging process. The mothers/ caregivers should keep away from using bottles when feeding until the infant is familiar in breastfeeding (Brodsky & Ouellette, 2007).
Transitional feeding
Infants at the period of 4 to 6 months of age, transitional feeding begins. The changes related in the central nervous system and anatomic structure make the infant ready for a different textured food after long period of suckle feeding (Arverdson & Brodsky, 2002). Supporting the statement Foote and Marriot (2003) reported that until 4 to 6 months of infant's age, the benefits from exclusive breast feeding has been observed. Similarly Bentley, Aubrey and Bentley (2004) believe weaning should be done between 4 and 6 months of age, which go with recommendation given by the Committee on Medical Aspects of Food Policy (COMA). But the World Health organisation (WHO, 2001) advices that infant must be breast fed exclusively until first six months of age.
The introduction of solid feeding and gradual replacement of milk (human or formula) by solid food is known as weaning as put forward by Foote and Marriot (2003). They also reported that the important determinant to know the appropriate age for weaning depends on the physiological maturity of gastrointestinal function and renal function.
In economically developing countries diarrhoea and respiratory illness are more common among infants introduced solid feeding early, than among infants who were exclusively breast fed (Brown, Black, de Romaña, & de Kanashiro, 1989).
Rao and Rajpathak (1992) reported that in India, low socio-economic communities must provide exclusive breast feeding well beyond 6 months. This is because of the poor lactational performance of these poorly nourished mothers. Social class or community related issues are prominent when considering weaning or transitional feeding. Inappropriate weaning or transitional feeding practices are observed in poor communities due to lack in nutritional knowledge, awareness about hygienic habits can lead to growth flattering.
Infants are not weaned in their early life because their bowel lining is not mature and are not sophisticated enough that may absorb foodstuffs that may cause allergy. The developmental reasons could be poor head control that the child can't maintain an optimal position for swallowing that is unless aided (Bentley, Aubrey & Bentley, 2004). The authors also states that if weaning is delayed above six months of age, the infant face difficulties due to the new method of feeding and new food. The delayed introduction of lumpy foods lead to significant reduction in the infant's dietary intake and the infant faces feeding difficulties. Hence the authors suggest that weaning process or transitional feeding term infants should initiate between four and six months.
There are several anatomic changes that can be observed at this period. The mandible of the infant grows downward and forward, creating intraoral space more and oral cavity elongate (vertical dimension). During this period breathing and swallow coordination becomes a major factor in feeding, as the hyoid bone and larynx shift downwards. At this occasion swallowing and breathing becomes a reciprocal activites (Arverdson & Brodsky, 2002).
Moore (1988) reported that at 6 to 8 months after birth mandibular incisors usually erupt. Occasionally the mandibular incisors eruption may become delayed as 12 to13 months even at normal infants. The buccal space of the infant increase as the oral cavity increases, re-absorption of the sucking pads and eruption of the molar teeth. Food is manipulated between the tongue and buccal wall as this buccal wall increase (Arverdson & Brodsky, 2002).
According to Integerated Management of Neonatal and Childhood Illness (IMNCI, 2003) recommendations for breast feeding and complimentary feeding at 6 to 12 months are as follows;
If the child wants to be breast fed, the mother can often breast feed the child.
Mashed roti/ bread/ biscuit/ mixed and sweetened in oil or ghee in one katori serving at a time
Or Mashed rice/ roti/bread mixed with ghee and thick dal.
Cooked vegetables can a be given
Or dalia/ sevian/ kheer/ halwa prepared in milk.
Porridge made out of cereal cooked in milk can also be given.
Banana/ biscuit/ cheeko/ papaya/ mango can be offered as snacks in between servings.
Frequency- 5 times per day if the child is not breast fed, or 3 times per day if the infant is breast fed.
The tongue movement changes in this period i.e. tongue moves more antero- posterior making the food push out the mouth. Hence tongue movement becomes an important contributor in oral feeding. Later the tongue moves gradually towards the lateral sides, with rotatory jaw action. This rotatory action is very much important for an efficient oral stage functioning. When infants mature, the tongue moves more towards the lateral sides, at this point the food is mashed by the vertical movement of the jaw and tongue (Arverdson & Brodsky, 2002).
There is a parallel gain happens in the development of speech as well as in trunk, head and neck stability when the child can able to control different food textures. During this transitional period some child may face suckling difficulties, especially when these infants are ill, distressed or sleepy.
Transitional feeding in preterm infants
In preterm infants who are born before 3 weeks than term should be weaned between four and seven months or at six months of age, if they are breast fed. Food to be provided during this period should be energy- dense to provide the needful for the infant growth (Bentley, Aubrey & Bentley, 2004). The authors also report that preterm infants perform better with food than milk hence adequate weaning is important. At eight months, preterm infant can be fed with finger foods and lumpy foods by nine months. Caregivers should encourage the infant in self-feeding.
The mother or the care giver should continue providing breast feeding or formula feeding until one year of age. The care givers should monitor if the child faces any feeding difficulties, if then early intervention must be provided.
Frequency of feeding in preterm infants
Preterm infants are fed best approximately on a four hour (approximate) schedule until these Infants reach their term age. When they reach at their term age, infants are fed in a 2 to 3 hour schedule (Riordan & Wambach, 2010)
Factors affecting the feeding milestones in preterm infants
Illingworth and Lister (1964) proposed the 'sensitive period' in infancy, failure in introduction of oral feeding may lead to feeding difficulties in later life. Infants fed with through artificial method (nasogastric tube feeding) in the first few periods may miss this sensitive period.
Wolff (1968) reported that, in preterm infants poor feeding is often the crisis which delays the discharge from the neonatal units and may be an early sign of subsequent neurological abnormality. Guilleminault and Coons (1984); Mathew (1988) put forwarded that the high incidence of cardiopulmonary problems are observed in preterm infants and it may also result in aspiration. Preterm infants tire quickly during feeding and hence have difficulty in consuming sufficient calories (Einarsson-Backes, Deitz, Price, Glass, & Hays, 1994).
Hanlon et al. (1997) compared the maturation of deglutition apnoea duration in 42 preterm infants (28 to 37 weeks gestation), who were bottle fed and asymptomatic with 29 normal term infants. The results suggested that the single- swallow average deglutition time in term infants was a (mean ± SD) 672ms ±104ms. In preterm infants (Post conceptual age) who are born between 32 to 35 weeks of gestation had (mean ± SD) 760ms ±120ms on single- swallow average deglutition time, and in preterm infants who are born between 36 to 37 weeks had (mean ± SD) 740ms ± 160ms. There were also significant differences between the preterm infants either at PCA and the same infants when they reached term. The study also putforward that the maturation of ventilator control during feeding is not complete at the term gestation as multiple swallow deglutition apnoea was observed in term infants.
Gewolb, Bosnia, Reynolds and Vice (2003 ) reported that the complications of prematurity such as Broncho-Pulmonray Dysplasia (BPD) or the chronic lung disease of prematurity can affect the neurological development, feeding and breathing control. According to Poore, Barlow, Wang, Estep and Lee (2008) Respiratory Distress Syndrome (RDS) or BPD, can affect the precious sensory- motor experiences of the infant at the critical period of brain development. At this critical period the preterm infant were at this point suck and pre-feeding skills are getting developed. Even the trusses and tubes on the NICU infants can cause restriction on oral movement and can alter the sensory experiences.
In preterm infants due to immature suck-swallow pattern they often require nasogastric tube feeding (Morris & Klien, 2000). Cataldi-Betcher, Seltzer, Slocum, and Jones (1983)(as cited in Bazyk, 1990) stated that, although nasogastric tube feeding is considered as essential in preventing malnutrition in these infants, complications related to long-term use, which include physical discomfort has been frequently reported. Complications that are reported due to the long term use are pharyngeal or nasal irritation (Dobie, 1978). Benda (1979) reported that there can be changed breathing pattern due to the obstruction of one of the nasal passage caused by the nasogastric tube feeding. Esophageal reflux with subsequent esophagitis can be observed with long- term usage of nasogastric tube feeding (Shellito & Malt, 1985). As a result of these complications nasogastric tube feeding is recommended only for short- term use (Moore & Greene, 1985).
Bazyk (1990) considered that feeding through nasogastric tube can cause aversive stimulation to the nasal and pharyngeal region and it may be considered traumatic, especially if esophagitis occur. This unconditioned aversive stimulus that when combined with swallowing, resulted in avoidance to swallowing on subsequent less stressful stimulation of esophagus or mouth. Thus avoidance behaviour can be caused when food is introduced to mouth, resulting in expelling the food, vomiting, gagging, pushing the food away (DiScipio, Kaslon, & Ruben, 1978).
Medical co-morbidities are common in preterm infants. These factors can somehow affect the development of the infant including the feeding milestones. As these milestones get delayed or affected could lead to a negative impact on the infant's feeding development.
Feeding behaviours in preterm
Herbst (1983) reported that many premature infants have poorly developed suck and swallow mechanism. These infants are found to have neurological immaturity, abnormal muscle tone and depressed oral reflexes, and have difficulty in regulating stage and can decrease the oral motor skills and quality of life.
Einarsson-Backes, Deitz, Price, Glass and Hays (1994) stated that preterm infants have decreased tongue mobility, decreased lip seal, diminished buccal sucking pads and irregular respiratory pattern can contribute to poorly initiated, unsustained, weak and inefficient sucking pattern.
Feeding can be considered as a complex motor activity and it serves as a marker of neurological maturation. Feeding in infants requires the sensorial and motor integration of suckling, breathing, swallowing, numerous muscle groups participate in a visible rhythmic process (Hanlon et al. 1997).
In preterm infants, feeding disorders are extremely common due to disorganized or weak oral movements, hypotonia, lack of arousal and irritability, behavioural disorganization, presence of assistive ventilation devices or poor endurance (Hall, 2001). Many feeding aspects are manifestations of normal motor development and cognitive development, hence when the feeding skills are abnormal or delayed the index of suspicion for abnormal motor and cognitive development should be raised (Arverdson & Brodsky, 2002). In preterm infants feeding difficulties are common, particularly in those born at the earliest gestation or with complex health (Burklow, McGrath, & Kaul, 2002).
Gryboski (1969) observed that there was improvement in the coordination of sucking and swallowing at 34 weeks of gestational age. Case-Smith, Cooper and Scala (1989) described that infants who are 34 to 35 weeks of gestational age was found to have had in-coordination, inconsistent jaw depression, lack of rhythm, or wide jaw excursion during was common.
Hawdon, Beauregard, Slattery, and Kennedy (2000) reported that during beginning of bottle feeding many preterm infants were found to have disorganized suck pattern which shows the general immaturity of organization of behaviour and responses of the preterm infants. It was also reported that at 6 months these infants were found to have dysfunctional and disorganised feeding, as the neonates were six times more likely to vomit and three times more likely to cough with solid food compared to normal feeders. All these differences were statistically significant. At 6 months over a half of parents described feeding problems in their infants discharged from neonatal unit. Suggesting that preterm infants, born at the median gestational age of 34 weeks have feeding issues at 6 months of corrected age.
In addition feeding problems in preterm infants can be long-term, which can contribute to nutritional problems with failure to succeed and presents major emotional and practical problems to the family. In preterm infants, distinct feeding patterns (normal, dysfunctional, disorganized) can be observed when sucking feeds were given (Palmer, Crawley, & Blanco, 1993)
According to Hall (2001) infants born before 34 weeks of gestational age are found to have immature or absent coordination of suck, swallowand breath pattern, which can potentially lead to oxygen desaturation, prandial bradycardia, aspiration and periods of apnea (during oral feeding).
But according to Mizuno and Ueda (2005) reported that feeding behaviour in preterm infants shown to be matured significantly between 33 to 36 weeks PMA without any practice. In addition preterm infants demonstrated sucking difficulties earlier, learn to suck as they become matured.
Thoyre (2003) reported that feeding problems are common in preterm infants at first year of life. Dodrill et al. (2004) evaluated the feeding skill and oral sensitivity in preterm infants of low- risk infants at 11- 17 months corrected age. The infants groups of 20 preterm infants (PT), born between 32and 34 weeks and age matched group of healthy 10 full term (FT) infant were assessed. The oral sensitivity assessment revealed that preterm infants sub groups, including preterm infants who had nasogastric feeding for less than 2-weeks (PT< 2weeks) and above 3-weeks (PT>3weeks) showed significantly more behaviours which were suggestive of altered oral sensitivity than the FT group. Hypersensitivity was seen more common than hyposensitivity in these PT group than FT group. The risk of developing conditioned avoidance of the facial contact during feeding was perceived to be greater in preterm infant who received NG feeding more than 3weeks.
According to the previous study, preterm group had significantly less meal than the term group, and demonstrated longer meal duration for preterm infants. In lip cleaning the spoon during the pureed food feeding, preterm infants were less active when compared to the full term infants. When coordination of sucking, swallowing and breathing, is considered preterm infants took fewer sucks of liquid and pulled away to swallow and breathe. Preterm group also showed weaker and less mature jaw movements when biting than the full term group, and there was no difference perceived in feeding development between these two groups.
According to Adams -Chapman (2006); Mizuno and Ueda (2005) reported that for a few preterm infants, poor suck and oromotor incoordination may still persist at their early childhood, leading to considerable delays in the appearance of other oro- motor behaviours, which involves babbling, feeding, and speech language production.
Tenhaff (2008) reported that until the neonates reach 34 weeks of post conception age, initiating oral feeding through bottle feeding or breast feeding is typically not attempted. This it is due to difficulties and potential dangers on initiating oral feeding (poor suck swallow coordination may lead to aspiration). It was observed that preterm infants have oral motor dysfunction (OMD) when sucking and in early stages of weaning to solid foods (Buswell, Leslie, Embelton & Drinnan, 2009).
Ruedell, Haeffner, Silveira, Soares, and Weinmann (2011) assessed the oral skills for preterm infants (born between 29 and 35 weeks of gestational age) at 4 and 6 months of age. The results suggest that at 4 and 6 months of corrected age 71. 4% and 85.7% of infants were found to have appropriate lip seal.
Michaleson (2000) reported that a well nourished mother can sufficiently breast feed majority of the full term infants supplying the nutrients need until 6 months of age. Foote and Marriot (2003) concluded that there are abundant evidence to support that continuation of exclusive breast feeding in early life of the infants to reduce mortality and morbidity among infants in early developing countries.
Early intervention on feeding problems
Trykowski, Kirkpatrick and Leonard (1982) stated that the tactile stimulation given over the orbicularis oris and buccinator muscles has shown an improvement of formula volume intake and sucking rate. The oral support given in the above study was a firm touch around the mouth of the infant, provided an organizing (calming) effect on the infant.
Einarsson-Backes, Deitz, Price, Glass and Hays (1994) determined the effectiveness of oral support on feeding efficiency in infants who are poor feeders as mentioned by a medical team. The subjects were 13 premature infants between 34 and 40 weeks. These infants were fed twice within a 26- hr period once with oral support and once without. The result of the study suggested that oral support provided sucking efficiency as there was a change in the volume intake in preterm infants.
In addition the oral support is considered as the tactile input that the infant received around the oral- facial area. There is deep pressure tactile component which is different from light touch techniques.
According to Hanlon et al. (1997) the strategies and goals should concentrate on the oromotor function on the treatment of prolonged deglutition apnoeas in preterm infants which was remained more frequent and significant at term post conceptional age when compared to the term infants, and for multiple swallow deglutition apnoea which was occurred in term infants.
Long term feeding problems which are serious and often unrecognized as a consequence of neonatal conditions may occur. Later problems in feeding with solid food must be found and discussed among professionals who include Speech and Language Therapist, Dietician and Psychologist. They must work along with the parents to gradually increasing the tastes and textures offered.
An experienced Speech and language pathologist and dietician has a role which is essential in identification of immature or abnormal feeding patterns and giving therapeutic interventions, and providing education to the medical and nursing colleagues (Hawdon, Beauregard, Slattery, & Kennedy, 2000).
Hence for intervention of dysphagia in children need some support by later sensorimotor treatment (Gisel & Alphonce, 1995).
Effect of oral stimulation on feeding performance
Borion, Nobrega, Roux, Henrot and Saliba (2007) assessed the effect of oral support and oral stimulation on sucking and feeding performance in preterm. Subjects were neonates born between 29 and 34 weeks gestation with NPO status. The study included three groups i.e, stimulation with support, stimulation and support. The result showed, the transition in duration for oral feeding from tube feeding was significantly faster for support only groups, stimulation plus support group. The non- nutritive sucking pressure and the amount or the number of daily bottle feeds were also greater in all the treatment or the experimental group.
Tenhaaf (2008) evaluated the effect of oral stimulation interventions in preterm infants. The study included preterm infants with NPO status. Eighteen medically stable neonates who were born between 30 to 34 weeks of gestational age were selected. Then these infants were randomly selected to control group and treatment group and the parents were trained to provide an oral stroking protocol and the parents were asked to provide treatments combined and single, daily thrice for 5 days a week. The study also revealed that by stroking alone, oral stimulation can significantly increase the oral feeding skills. The study also suggests that there may be a positive effect on feeding behaviour in preterm infants using oral stroking.
Hwang et al. (2010) investigated the effects of a oral stimulation program before feeding on the behavioural, sucking and feeding ability and feeding related physiological changes of preterm infants who were in the time of feeding transition (gavage feeding to initial oral feeding). Subjects were 19 preterm infants (7 males, 12 females) born between 24.6 - 34.1 weeks. Age of the infants at the time of study ranged from 32.3 to 40.3 weeks. Preterm infants selected for the study were inefficient feeders (infants who consumed less than 4 ml of milk per minutes in 5 minutes).
The oral stimulation program included 2 different forms of oral stimulation i.e. a three minutes of manual peri and intraoral stimulation followed by sucking through a pacifier. Each infant were provided with two feeding condition, intervention condition (oral stimulation) and control condition. For example if an infant received intervention condition in the first day then child is assigned for control condition in the next day. The result showed in the initial 5-min feeding period, the rate of intake of milk (ml/min) was significantly higher in the intervention condition than during control condition. The average mean sucking frequency was higher in the intervention condition when compared to control condition (13.8 vs. 10.8 sucks/ min). Results suggest that peri and intraoral stimulation program applied to preterm infants caused enhancement of feeding efficiency in the initial 5min of feeding. The result also suggests that of preterm infants with poor state regulation for an optimal feeding, prefeeding oral stimulation may be an effective intervention program.
Feeding problems in infants require early intervention. When the intervention is provided as early as possible can decrease the developmental problems and growth problems in infants.
The study aimed to compare the feeding behaviour in term infants and preterm infants, born between 30 and 34 weeks of gestational age at six months of age (corrected age).
Subjects
Parents/ care givers of 50 infants participated in the study. These infants were divided into two, preterm infants and term infants (25 infants each).
Inclusion criteria for preterm infants
Preterm infants at 30- 34 weeks of gestational age.
Normal language development assessed using Language Assessment Tool (LAT) ( Rao, 1992)
Infants who are appropriate for gestational age (AGA).
Medical conditions included;
Respiratrory Distress Syndrome (RDS)
Intrauterine Growth Restriction (IUGR)
Hyperbilirubinemia
Hypoglycemia
Clinical Sepsis
Anaemia.
Exclusion criteria for preterm infants
Infants with any obvious craniofacial abnormality.
Exclusion criteria for term infants
Any obvious craniofacial abnormality
Low birth weight
Co-existing neurological, cardiology or any vital organ issues
This study was carried out in three phases (phase I, II, III).
Phase I: Development of a questionnaire
A questionnaire was devised in English based on the milestones mentioned by Arverdson and Brodsky (2002); Richmond (2006) and Rudzik (2007). The questionnaire was given to Paediatrician, Nutritionist and Speech Language Pathologists for content validity. A developmental paediatrician verified the questions and its applicability to assess the development and growth of the child. A paediatric nutritionist reviewed the questionnaire with respect to the texture and nutritional aspect in Indian context. Two Speech Language Pathologists, currently practising in the field of dysphagia viewed the questionnaire to ensure the appropriateness of feeding behaviour of these infants.
During the content validity these professional also analyzed if any inappropriate, ambiguous words or sentences in the questionnaire were present. About 40% of content was modified in the questionnaire. The questionnaire consisted of two parts. Part I included, demographic details, feeding history, and current feeding status of the infants. Part II included 14 closed ended questions divided into four domains (Appendix A). The four domains are;
Age of the child to start puree feeding
Current feeding behaviour
Difficulties faced by the child during feeding
Duration of feeding
Phase II: Pilot study
The developed questionnaire was administered on parents/ caregivers of 10 term and 10 preterm infants. At the end of the pilot study, appropriate changes in the questionnaire were done based on the suggestions given by paediatrician, nutritionist and speech language pathologists. Pilot study was carried out to determine the appropriateness of the questionnaire and infant's feeding behaviour.
Phase III: Administration of the questionnaire
The Speech Language Pathologist had included the infants who met the criteria of the study. The questionnaire was administered on the parents/ caregivers of these 25 term and 25 preterm infants. An informed consent was obtained from the parents/caregivers prior to the questionnaire administration. An average of 15 minutes was taken to administer the questionnaire.
Statistical Analysis
The study design used was analytical cross-sectional study. Percentage analysis was used to find the frequency of the occurrence of the variables and Pearson chi-square (χ2) analysis was used to obtain significance (p) value to compare between the term and preterm infants.
The purpose of the study was to compare feeding behaviour in term and preterm infants (30 to 34 weeks of GA) at six months of age. The questionnaire was administered by the investigator on parents/ caregivers of 50 infants (25 infants each group). The questionnaire consisted of 2 parts. Part I included demographic details, feeding history and information on current feeding pattern. Part II of the questionnaire included questions on age to start puree, current feeding behaviour, difficulty faced by the child during feeding and duration of feeding. The results of the study are as follows:
Part I
Medical conditions
The age of the pre term infants who were included in the study had corrected age of 6 months. Among term infants, 68% were females and 32% were males. In preterm infants, 36% female and 64% of male infants were included. Information on medical condition was obtained from the discharge summary. In the present study, among preterm infants 56% had hyperbilirubinemia, 36% had history of Respiratory Distress Syndrome (RDS) and 4% had anaemia and Hypoglycemia. 12% of infants had Intrauterine Growth Restriction (IUGR) and sepsis. In term infants, 24% of infants had hyperbilirubinemia at the time of birth. The percentage of term and preterm infants who had history of medical conditions is tabulated in table 1.
Jadcherla, Wang, Vijaypal and Leuthner (2009) studied premature infants who were admitted in NICU. They concluded that some specific aero- digestive co-morbidity such as Gastro-Esophageal Reflux Disease (GERD), longer period of Continuous Positive Airway Pressure (CPAP) and /or ventilation support and enteral nutrition significantly affected oral feeding milestones.
Poore, Barlow, Wang, Estep and Lee (2008) studied effect of respiratory treatment on sucking pattern in 55 preterm infants. They also reported that 38 out of 55 preterm infants with RDS, sensory-motor experiences may get affected during the critical period of brain development. At this critical period prefeeding skills and sucking develops. Associated medical conditions may cause a negative impact in the infant's feeding development.
Feeding history
This section included information on history of mode of feeding and duration of feeding practice at the time of birth.
History of modes of feeding
The modes of feeding included nasogastric (NG) tube feeding, paladai feeding and direct breast feeding. Percentage of infants who were fed with NG tube feeding, paladai feeding and direct breast feeding is tabulated in Table 2.
In the present study, none of the term infants had history of NG tube feeding and 17 preterm infant were fed through NG tube feeding. This study finding revealed that majority of the preterm infants required NG tube feeding. Brodsky and Ouellette (2008) reported that since preterm infants have poor suck swallow coordination, they require nasogastric/ orogastric tube feeding until the suck and swallow sequence mature.
According to Morris and Klien (2000) NG tube feeding can be initiated for infants with poor suck swallow pattern. Literature also revealed that NG feeding can be initiated for stable preterm infants born between 30 and 34 weeks of gestational age (Singh, 2004).
Cataldi-Betcher, Seltzer, Slocum, and Jones (1983) reported that even though NG tube feeding is considered as essential in avoiding malnutrition in preterm infants, long term use of NG tube feeding can lead to physical discomfort.
In the present study, 2 term infants' mothers reported to have difficulty in lactation for breast feeding. Hence these infants were fed through paladai mode. In preterm infants, 17 infants were provided NG tube feeding followed by paladai feeding for 15 of them. Riordon and Wambach (2010) reported that paladai feeding/ cup feeding can be initiated on following reasons:
When the infant is unable to latch on the breast for any reason
When the mother is unavailability in the neonatal period
When breast feeding is not possible for any reason.
Paladai feeding can also be considered as a form of cup feeding. In India paladai feeding is used to feed premature infants.
Direct breast feeding was initiated for 23 term infants and only 8 preterm infants at the time of birth. There was a statistical significant difference (p=0.00001) in the percentage of term and preterm infants who had DBF at the time of birth. Breast feeding can be initiated for healthy infants born at 34 to 36 weeks of gestation at birth (Black, Jarman & Simpson, 1998). In the current study, preterm infants born at 34 weeks of gestation were initiated with DBF. But in majority of preterm infants, DBF cannot be initiated as breast feeding requires suck swallow coordination, which appears at around 34 weeks of gestation. Table 3 shows percentage of term and preterm infants breast fed at the time of birth.
Duration of Practice:
The duration of practice of feeding modes has been discussed under the following
History of nasogastric tube feeding
Table 4 indicates the practice of NG tube feeding for above 1 week and less than 1 week in term and preterm infants. In the present study, 44% of preterm infants were fed with NG tube greater than 1 week of duration. Less than 1 week of NG tube feeding was required for 24% of preterm infants. NG tube feeding for longer duration is generally recommended for infants who have associated medical conditions contributing to feeding disorders. In addition, infants who did not acquire suck swallow sequence were also fed with NG tube. Dodrill et al. (2004) reported that preterm infants who are were fed through NG tube for more than 3 weeks showed increased altered oral sensitivity than preterm infants who were on NG tube feeding for less than 2 weeks. There was a statistical significant difference (p=0.0006) in the percentage of term and preterm infants who required NG tube feeding for greater that 1 week.
Statistical significant difference (p=0.029) in the percentage of term and preterm infants was observed for NG tube feeding above 1 week.
Mode of feeding in preterm is different at the time of birth when compared to the term infants, were majority of them are initiated with direct breast feeding.
Paladai feeding
In this study, 24% of preterm infants required paladai feeding for more than 1 week, 36% of preterm infants required paladai feeding less than 1week and 8% of term infants were fed using paladai. Table 5 indicates the duration of practice of paladai feeding in term and preterm infants.
In term infants, 8% of the infant's mothers had difficulty in lactation, hence these infants were fed through paladai for less than 1 week later they were initiated with direct breast feeding. According to Parthasarathy (2005) paladai feeding is considered as the bridge between the gavage feeding and breast feeding. Paladai feeding is carried out on the assertion that neonates with gestational age of 30 weeks to 32 weeks or more are able to swallow well even though if they may not have achieved sucking coordination. The mothers fed expressed breast milk with paladai. There was a statistical significant difference (p=0.29) in the percentage of term and preterm infants who required paladai feeding for greater that 1 week. Statistical significance difference was observed (p=0.04) in percentage of term and preterm infants who required paladai feeding less than 1week.
Direct breast feeding
In the present study, 92 % of the term infants were initiated breast feeding after birth. Two term infants were initiated with paladai feed less than 1 week followed by breast feeding since the mother reported of having lactation difficulty. In preterm infants only 32 % initiated breast feeding after birth.
Current feeding status
The current feeding status in term and preterm infants include; current feeding mode and consistency food consistency.
Current feeding mode
In table 6, the current feeding mode in term and preterm infants is tabulated. A combination of DBF, bottle feeding (BF) and spoon feeding (SF) were provided for 24% of term and 20% of preterm term infants. DBF and BF was the mode of feeding for 8% of preterm infants and none of the term infants were on only DBF and BF mode as they were only liquid fed. 76% of term infants and 72% of preterm were fed through DBF and SF.
The majority of the term and preterm infants were provided DBF and SF as the current mode at 6 months of age as a part of transitional feeding. Rest of the infants were provided with DBF, BF and SF mode. There was no significance difference observed between the term and preterm infants on current feeding mode. This depicts that current feeding mode is similar between the term and preterm infant at six months as it shows the readiness of preterm infants for transitional feeding.
Current food consistency
Liquid and puree were given for all the term infants and 92% of preterm infants. But 8% of preterm infants were fed only liquids. It was reported by the parent/ caregiver that they did not provide puree food, even though paediatrician advised on transitional feeding. No statistical significance difference was observed between the term and preterm infants. As a part of health education, mothers and caregivers of infants are provided with information about transitional feeding. Hence on advice by paediatrician, majority of the parents/ caregivers term and preterm infants were already initiated transitional feeding at six months of age. Table 7 describes the current feeding consistency in term and preterm infants.
Part II
A. AGE OF CHILD TO START PUREE FEEDING
The information on age at which transitional feeding is initiated in term and preterm infants is retrieved from the parents/ caregivers.
A.1) when did you start feeding purees to the child.
In the present study, 92% of parents/ caregivers reported that all term infants and of preterm infants were initiated puree food at 4 to 6 months of age. In preterm infants 8% of infants were not provided or initiated transitional feeding even at six months. There was no significant difference between the term and preterm on the age to start puree feeding. Table 8 shows the parent's/ caregiver's response on the question.
According to World Health Organisation (2001) infants should be exclusively breast fed until first 6 months of age, followed by weaning. Gupte (2004) reported that weaning should occur between 4 to 6 months of age. In the current study both term and preterm infants began transitional feeding as they reached 6 months of age, whereas 8% preterm infants were not initiated with puree. Parents/ caregivers of a few preterm infants did not initiate weaning even though they were advised to initiate puree by 6 months of age. On probing, the parent/ caregivers attributed the failure to initiate puree to social cultural demands. Kapur (2011) reported that even though the western countries follow a pattern of 4 to 6 months for transitional feeding, the traditional homes in India follows a different pattern. The author also states that, traditional homes in India weaning are initiated at 10 to 12 months of age.
B. CURRENT FEEDING BEHAVIOUR
In current feeding behaviour, speech language pathologist interviewed mothers/ caregivers to acquaint the behaviour or the response of the child during feeding with puree and liquid. This section included 8 questions on various feeding skills.
B.1) Does the child turns the head towards nipple/ bottle/spoon during feeding.
Parents/ caregivers responded that all term infants and preterm infants showed rooting reflex at the time of assessment. Johnson and Jacobson (2007) reported that rooting reflex can be observed even at 6 months of age. Table 9 shows the parent's/ caregiver's response on this question.
B.2) Does the child suck liquid during feeding.
Parents/caregivers reported that all the term and preterm infants were successfully able to suck liquid during feeding. All the term and preterm infants had achieved sucking and are well able to suck liquids. Table 10 shows the parent's/caregiver's response on the question 'does the child suck liquid during feeding'. Zaoutis and Chiang (2007) reported that sucking is one among needful skills for an oral phase of swallowing in infants. Sucking reflex can be observed at around 6 months of age (Arverdson & Brodsky, 2002). In the present study sucking reflex is observed in all term and preterm infants during liquid feeding.
B.3) Does the child can hold breathe and successfully swallow two to three sucks of liquid.
The parents/ caregivers reported that all the term and preterm infants can hold breath and successfully swallow two to three sucks of liquid during feeding. Parent's/ caregiver's response on this question is tabulated in table 11. Weber, Woolridge and Baum (1986) reported that initially an infant who is breastfed or bottle-fed were able to swallow with every suck. Later the infant's feeding ratio of suck and swallow change from 2:1 or more until the sucking is stopped. In the present study, all term and preterm infant were able to suck and successfully swallow two to three sucks of liquid, by holding breath hence stating that Suck swallows coordination is well achieved in liquid feeding in term and preterm infants.
B.4) Does the chil
