neonatal e outcome assessment - usc chan division · neonatal eating outcome assessment is based on...

NeonatalEatingOutcomeAssessment

Copyright 2014 by Washington University in St. Louis, Missouri. All rights reserved.

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AbouttheAuthor

Bobbi Pineda, PhD, OTR/L is a Certified

Neonatal Therapist who has been practicing

since 1992. Her first child was born at 29

weeks gestation in 1998. She became intrigued

with conducting research and developing

products aimed at supporting the parents of infants in the NICU as well as supporting the

developmental progress of the premature

infant. She is a former Assistant Professor at Washington University and

current Assistant Professor at the University of Southern California. Her current work focuses on better understanding how early factors in the

NICU environment support the development of the growing, premature

infant and his/her family in addition to how to identify early patterns of

development, including oral feeding. Dr. Pineda is also an author of the

Supporting and Enhancing NICU Experiences (SENSE) program.

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By

RobertaPineda,PhD,OTR/L,CNTUniversityofSouthernCalifornia

ChanDivisionofOccupationalScienceandOccupationalTherapy

KeckSchoolofMedicineDepartmentofPediatrics

[email protected]

NeonatalEatingOutcomeAssessmentManual


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ContentsIntroduction to the Neonatal Eating Outcome Assessment ................................................................... Part I

Purpose ........................................................................................................................................... 1 Ages ................................................................................................................................................. 1 Assessment Procedure .................................................................................................................... 1 Color Coding Reference to Determine Oral Feeding Readiness, Safety and Success ...................... 5 Prescribed Feeding Volume ............................................................................................................ 6 General Scoring ............................................................................................................................... 7 Training ........................................................................................................................................... 8 Psychometrics……………………………………………………………………………………………………………………………. 9 States of Consciousness for Scoring Purposes .............................................................................. 11

Detailed Scoring Criteria for the Neonatal Eating Outcome Assessment ................................................ Part II Pre-Feeding Behaviors .................................................................................................................. 12

I-1. Arousal ....................................................................................................................... 13 I-2. Physiological Stability ................................................................................................. 14 I-3. Respiratory Support ................................................................................................... 15 I-4. Rooting and Grasp ...................................................................................................... 16 I-5. Initiation of Sucking .................................................................................................... 18 I-6. Tongue ....................................................................................................................... 19 I-7. Non-Nutritive Sucking ................................................................................................ 20

Oral Feeding .................................................................................................................................. 21 II-1. Suck-Swallow-Breathe Coordination ......................................................................... 22 II-2. Sucking Burst Length ................................................................................................. 24 II-3. Suction ...................................................................................................................... 25 II-4. Oral Tone ................................................................................................................... 26 II-5. Quality of Sucking Movements ................................................................................. 27 II-6. Behavioral Response to Feeding ............................................................................... 28 II-7. Fluid Loss ................................................................................................................... 29 II-8. Swallow ..................................................................................................................... 30 II-9. Respiratory Control During Feeding .......................................................................... 31

Observations at The End of Feeding .............................................................................................. 32 III-1. Feeding Completion ................................................................................................. 33 III-2. State Maintenance ................................................................................................... 34 III-3. Volume Consumed ................................................................................................... 36

Items Not Scored ........................................................................................................................... 37 Items Not Scored – Breastfeeding only ......................................................................................... 44

Scoring the Neonatal Eating Outcome Assessment and Score Sheet.................................................. Part III Criteria ........................................................................................................................................... 47 Score Sheet .............................................................................................................................. 48-52


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PartI.

IntroductiontotheNeonatalEatingOutcomeAssessment


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Purpose: To assess age-appropriate oral motor and feeding skills in preterm infants prior to and at term equivalent age. This assessment attempts to gauge normal versus abnormal progression of feeding across differing postmenstrual ages (PMA), when lack of feeding success can be either a flag for abnormality or part of the normal process of maturation. While this tool may assist in identifying feeding abnormalities, it does not establish treatment priorities. It can be used with breast or bottle-fed infants. Scoring of the Neonatal Eating Outcome Assessment is based on the infant’s PMA at the time of assessment.

Ages: The full assessment is appropriate for infants who have initiated oral feeding (approximately 30-32 weeks PMA) through approximately 4-6 weeks post-term. An abbreviated form can be used for infants after 30 weeks PMA who are not yet orally feeding.

Assessment Procedure: Feeding performance can change with different modes of feeding, with different positioning and with different interventions. For the first feeding assessment using this tool, use the most common mode of feeding, along with typical interventions used for the specific infant being assessed. Thereafter, the effect of different interventions can be determined through reassessment while incorporating those interventions.

Abbreviated form: For infants not yet orally feeding, provide non-nutritive sucking using a gloved finger or pacifier for 1-3 minutes and score only Section I (Pre-Feeding Behaviors).

Full assessment: For infants who are orally feeding or for whom oral feeding is attempted, make observations prior to and during bottle nipple insertion or latch to the breast (and score Section I). Score Section II after 10 minutes of oral feeding. Section III and IV should be completed after the feeding is completed or after 20 minutes of oral feeding (from the time the nipple enters the mouth). Scoring should cease after 20 minutes, even if feeding continues.

Each item has scoring criteria represented by a letter. The letter score that is bolded in each item represents the optimal response for an infant at or beyond term equivalent age. The letter score that is in italics in each item represents a response that is always abnormal, irrespective of PMA. Not all items have an italicized option. If an infant demonstrates behaviors that are described in two letter responses, choose the one that is most representative of the infant’s abilities at the time of assessment, prior to the occurrence of factors that may have impacted the item being scored. When two letter score responses equally represent the infant’s behavioral response, score the least optimal score (the one farthest away from the bolded letter score).


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The test is composed of 4 different sections:

Section I: Pre-Feeding Behaviors (7 items) For infants not yet orally feeding, provide the infant with 1-3 minutes of non-nutritive sucking using a gloved finger or pacifier, then score Section I. For breastfed infants, non- nutritive sucking can be assessed with a gloved finger, pacifier, or at the breast (as in when the mother has expressed milk prior to a sucking attempt). For infants not being orally fed, score only Section I, using the abbreviated form scoring criteria. For infants who are orally fed, observe the time prior to and immediately after bottle nipple insertion or latch to the breast and score Section I, giving the infant a score of ‘D’ or ‘normal’ for item I-7 (Non-Nutritive Sucking) if a sucking pattern is initiated. If a sucking pattern is not initiated, oral feeding should be stopped and Pre-Feeding Behaviors should be the only items on the assessment scored.

Item I-3 (Respiratory Support) is used to determine readiness for oral feeding, but it is not a scored item.

Items marked with an asterisk (*) are highlighted in green on the score sheet. These items relate to feeding readiness. If an infant receives a score of ‘A’ on any of these items, oral feeding is not appropriate, and the abbreviated scoring of the Neonatal Eating Outcome Assessment should be used. If items in green are scored a ‘B’ or ‘C’, cautious assessment of feeding with a neonatal therapist or nurse trained in cue based feeding may occur. Feeding readiness may be developmentally regulated in the preterm infant prior to term. In infants who continue to demonstrate low arousal and inadequate root and grasp at term and beyond, their responses may be related to alterations in development rather than the need for maturation, and careful assessment by a neonatal therapist is warranted.

Section II: Oral Feeding (9 items) For infants being orally fed, feed the infant according to standard procedure. Ensure that a side view of the lips, jaw, and nipple/breast can be viewed, as shown in the picture below. Score Section II based on observations in the first 10 minutes of the oral feeding.


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Sometimes performance differs a few minutes into the feeding compared to later in the feeding. When this happens, chose the score that best represents the infant’s overall performance after the infant has settled into the feeding experience, but prior to factors that may impact performance, such as coughing/choking. Adaptations made by the feeder (such as providing external pacing) should be considered as necessary, if provided, and should be reflected in the scoring.

Items marked with two asterisks (**) are highlighted in red on the score sheet. These items are related to safety issues during feeding. If a score of ‘A’ is achieved, feeding should be stopped and either 1) time for maturation be allowed to occur, or 2) if an infant is term age, a formal swallowing evaluation should be considered. Other items that are highlighted in red are in Section IV and also relate to safety.

The scoring of infant performance changes as PMA advances. Due to this, the changing skills of the preterm infant across time may not be fully appreciated on the total score for this assessment, due to the changing scoring based on level of immaturity. For clinicians interested in observing the maturation of feeding skills across time with the use of a consistent measure of feeding for static comparison, the scoring criteria for a full term infant can be used across time. By using the full term criteria, the examiner can compare how far the infant is from ‘mature’, by comparing the infant’s score to the ‘term’ score for that item.

If a certain skill could not be observed, due to lack of elicitation during the assessment, write in NT (not tested) and give that item a score of 5. If the infant is on an ‘ad lib on demand’ feeding schedule and does not appear to have appropriate arousal or latch/grasp onto the nipple, it is suggested to return for the next time the infant is fed to complete the assessment.

Section III: Observations at the End of Feed (3 items) Twenty minutes is allotted for the assessment, but the feeder can stop the feeding prior to that time, based on clinical judgment. After the feeding is stopped, completed, or 20 minutes of time has elapsed since the nipple was first placed in the infant’s mouth, score Section III.

The item marked with three asterisks (***) is highlighted in yellow on the score sheet. This item relates to success with oral feeding. A score of ‘F’ indicates success with meeting prescribed volume. Any other score may indicate the need for supplemental feeding. There are items in Section IV that are highlighted in yellow and also relate to volume/nutritional needs.


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Section IV: Items Not Scored (13 items) Section IV provides more information about the nature of the feeding environment to better define performance in relation to nipple type, position, feeder experience, etc.

If the goal of using this assessment is to evaluate the effectiveness of adapted feeding methods or interventions, re-assess an entire feeding on a different day using the apparatus, methods, and positioning that have been recommended. Section IV documents what was used/what context during the assessment, while Sections I, II, and III documents the resultant performance. Recommendations for subsequent feedings can be made at the bottom of the score sheet.


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Score Sheet Color Coding Reference to Determine Oral Feeding Readiness, Safety, and Success:

Section Item(s) Construct Score Response

One: Pre-Feeding

I-1. – I-5.

Pages 9–13

Feeding Readiness Score of ‘A’ Oral feeding is not appropriate,

use abbreviated scoring

One: Pre-Feeding

I-1. – I-5.

Pages 9–13

Feeding Readiness Score of ‘B’ or ‘C’

Cautious assessment with a professional trained in cue based

feeding is necessary

Two: Oral Feeding

II-8. & II-9.

Pages 25–26 Safety Score of ‘A’ Oral feeding should be stopped

Four: Breastfeeding Non-Scored

IV-18.

Page 38

Breastfeeding Complications

Any boxes checked in this section

Breastfeeding is medically contraindicated, and the decision to proceed with breastfeeding

should be carefully considered in conjunction with a physician

Three: End of Feed Observations

III-3.

Page 30

Success with Oral Feeding

Score of ‘A’, ‘B, ‘C’, ‘D’, or ‘E’

Need for supplemental feeding should be evaluated

Four: Breastfeeding Non-Scored

IV-15.

Page 37

Mother’s Milk Supply

Check of anything other than ‘89-100% of volume needed each day for infant’

Need for supplemental feeding should be considered


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Prescribed Feeding Volume:

In the NICU, the delivery of fluids, nutrition, and calories are important for growth and development. Several items on the Neonatal Eating Outcome Assessment are in relation to how much volume the infant consumed in relation to the prescribed volume within a 20-minute period. The prescribed volume of intake is most often established by theneonatologist or dietician in the neonatal intensive care unit or the pediatrician if theinfant is home.

Appropriate volume is often determined by calculating the nutritional and fluid needs of the infant, but calculation of appropriate volume is balanced by the increasing maturity of the gastrointestinal system across PMA in the preterm infant and in conjunction with other co-morbid factors. Nutritional needs, coupled with the routine assessment of gastrointestinal tolerance, are used to determine a daily prescribed volume for each infant. Typically, the goal volume of formula or breastmilk is calculated at 100-120 calories per kilogram per day. However, the number of calories in breastmilk varies, but is considered on average to be consistent with regular formulas, which are 19-20 calories per ounce. Breastmilk can be modified to be higher in caloric density or it can be fortified for preterm infants. Preterm formulas typically are 22-24 calories per ounce. For infants with established gastrointestinal tolerance, the total needed volume (based on caloric density of the milk as well as current infant weight) is then divided by the number of feedings per day (typically 8) for a prescribed volume per feeding.

If a full term infant is being fed within a couple of days of birth, very small amounts of intake may be appropriate. Consider small amounts of intake to be adequate (a full feeding), even if the infant only eats for a few minutes, unless otherwise specified by a pediatrician. After the third day of life, at term age or beyond, the amount of a feeding must be considered in the context of what has been consumed over the past 24-hour period. When there is poor feeding of a small amount over a short period of time, re-assessing at the next attempted feeding may be appropriate.


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General Scoring:

• Scoring of the Neonatal Eating Outcome Assessment is based on the infant’sPMA at the time of assessment. PMA is calculated by adding the number ofcompleted weeks of gestation at birth to the number of completed weekselapsed since birth. Use 40+ PMA for infants born full-term or those beingassessed up to 4-6 weeks post-term.

• In this assessment, some items are intended to evaluate pre-feeding behavior,while others assess feeding behaviors and responses to feeding. If the infant isnot orally feeding, score only the Pre-Feeding Behavior items during Non-Nutritive Sucking (Section I) and use the abbreviated form scoring criteria. If oralfeeding is attempted, use the full form (Section I, II, and III) for scoring afterobserving non-nutritive sucking and oral feeding for 20 minutes. CompleteSection IV to document environmental, positioning, and adaptive strategiesused during the assessment process.

• Circle the letter designation for the closest description of how the infantperformed on each item. This is approached based on standard criteria definedin the manual (not determined based on age of infant). Sometimes infantsdemonstrate behaviors across more than one scoring criteria. When thishappens, score the one that more closely represents the infant’s performance,paying closer attention to the first criteria/sentence listed under eachdescription. If scoring clearly falls between two scores, score the least optimalresponse of the two.

• Each letter score for each item is then translated to a point value, based on theinfant’s PMA at the time of testing. Each item is worth 1, 3, or 5 points (unlessspecified that the item is not scored). A score of 1 on each item reflects afeeding challenge for that PMA, a score of 3 reflects a questionableperformance, and a score of 5 reflects a normal performance. A questionableperformance indicates that the skill may be emerging, may be impacted byconcurrent medical complications, or could indicate abnormal performance.

• Find the infant’s current PMA in the upper right-hand section of the score sheetand draw a vertical line to the bottom of the page from that PMA. Use theinfant’s PMA at the time of assessment, using scoring criteria that intersect thevertical line, to determine the assessed value of each item (1, 3, or 5 points).

• All point-valued items are added for a total raw score. Raw scores can becategorized as normal, questionable, or abnormal based on established ranges.The range of scores and appropriate classifications are available on the bottomof the score sheet and on page 42 of this manual under ‘Scoring Criteria’.


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• Some items (in section IV) are designed to provide information about thefeeder, the feeder’s experience with feeding infants, the infant’s experiencewith feeding, the position during feeding, external supports during feeding, andother factors within the feeding. These items are NOT scored. Items numberedIV-15 through IV-22 are non-scored items for breastfeeding only. ***Item IV-15is highlighted in yellow, indicating that checking any box other than “89-100% ofinfant’s volume each day” may signify the need for supplemental feeding.**Item IV-18 is highlighted in red, indicating that checking any box may indicatea safety issue and that breastfeeding may be contraindicated, with continuationof breastfeeding needing to be carefully considered in conjunction with aphysician.

Example Item Scoring: Item: Arousal/State Organization (I-1) Letter score most closely matching performance: B. Short periods of arousal with stimulation

On the scoring sheet under Arousal/State Organization (I-1), ‘B’ for an infant who is 37 weeks PMA is worth 1 point. If the infant were 34-35 weeks PMA, ‘B’ would be worth 3 points, and if the infant were 33 weeks PMA, ‘B’ would be worth 5 points.

Training: Therapists seeking to use the Neonatal Eating Outcome Assessment should undergo training to ensure accuracy in scoring. Training typically involves approximately 2 hours of learning involving a PowerPoint and observations of feeding videos. Trainees then rate 5 feeding sessions and score feeding performance using the Neonatal Eating Outcome Assessment, with more feeding sessions used/scored until reliability is achieved. Trainees are considered reliable if they have 80% accuracy of scores (this means that trainees have agreement in the assigned letter scores in a minimum of 15 of the 19 scored items).


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Psychometrics: Following creation of the Neonatal Eating Outcome Assessment, the tool has undergone extensive revision informed by psychometric analysis.

Tool development consisted of a review of the literature and observations of feeding performance among 178 preterm infants born ≤32 weeks gestation. Eleven neonatal therapy feeding experts then provided structured feedback about the assessment tool to establish content validity and define the scoring matrix. The tool was then used to evaluate feeding in 50 preterm infants born ≤32 weeks gestation and 50 full-term infants. Multiple revisions occurred with simplification of terms, ensuring each score was mutually exclusive, and achieving agreement of wording. Finally, six neonatal occupational therapists participated in reliability testing by independently scoring five videos of oral feeding of preterm infants. 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), which is 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 [1].

Following this revision, interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment was evaluated. Seven neonatal therapists participated in reliability testing by independently scoring 5 videos of neonatal feeding. The intraclass correlation for the Neonatal Eating Outcome Assessment total score was 0.90 (confidence interval [CI] [0.70, 0.99]), which is considered excellent reliability [2].

For concurrent validity, a prospective cohort of 52 preterm infants born ≤ 32 weeks gestation had feeding assessed at term-equivalent age. 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. 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) [2].

Other studies were conducted using the Neonatal Eating Outcome Assessment to better establish validity and provide a better understanding of early feeding performance.

To explore relationships between early feeding performance and neurobehavioral performance at term equivalent age, 50 preterm infants born ≤32 weeks gestation had feeding assessed with the Neonatal Eating Outcome Assessment and neurobehavior assessed using the NICU Network Neurobehavioral Scale at term equivalent age. Poorer feeding performance, with lower Neonatal Eating Outcome Assessment scores, were related to more suboptimal reflexes (p=0.04) and hypotonia (p<0.01) [3].


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To identify differences in feeding skill performance among preterm infants at term equivalent age compared with full-term infants, 92 infants (44 preterm infants born ≤32 weeks gestation at term equivalent age and 48 full-term infants within 4 days of birth) had feeding assessed using the Neonatal Eating Outcome Assessment. 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 (<0.001) [4].

Predictive validity of the Neonatal Eating Outcome Assessment was investigated by enrolling 50 preterm infants and doing a feeding assessment at term equivalent age followed by assessing feeding outcome [Pedi-Eat scores and Behavioral Pediatrics Feeding Assessment Scale (BPFAS)] at 3-5 years of age. Early feeding performance on the Neonatal Eating Outcome Assessment was related to feeding outcome on the Pedi-Eat (p=.042), with relationships with the BPFAS failing to reach significance (p=.056)[5]. 1. Pineda R, Harris R, Foci F, Roussin J, Wallendorf M. (2018). The Neonatal Eating

Outcome Assessment: Tool development and inter-rater reliability. Acta Paediatrica,107 (3): 414-424

2. Pineda R, Liszka L, Kwon J, Wallendorf M. (2020). Inter-rater reliability andconcurrent validity of the Neonatal Eating Outcome assessment. American Journal ofOccupational Therapy, 74 (2).

3. Grabill M, Smith J, Pineda R. The prevalence of early feeding alterations in preterminfants: relationships to early neurobehavior. Submitted for publication, WashingtonUniversity School of Medicine.

4. Pineda R, Prince D, Grabill M, Reynolds J, Smith J. (2020). Preterm infant feedingperformance at term equivalent age differs from that of full-term infants. Journal ofPerinatology, 40: 646-654.

5. Kwon J, Smith J, Kellner P, Roberta P. (2020). Predictive Validity of the NeonatalEating Outcome Assessment, in preparation, Washington University School ofMedicine.


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States of Consciousness for Scoring Purposes: There are 6 states of consciousness through which an infant cycles several times throughout the day. Two are sleep states, and the other four are waking states. As an infant’s nervous system becomes more developed, the infant will begin to settle into a pattern of waking and sleeping with increased periods of arousal to engage in eating.

State 1 Deep Sleep Infant lies quietly without movement or responses to general noise in the environment.

State 2 Light Sleep Infant is asleep with eyes closed but demonstrates some movement; eye movements beneath closed eyes are visible; noise may startle the infant and cause the infant to wake.

State 3 Drowsy

Infant may be waking or falling asleep; heavy eyes are present and fussiness may be observed. Movement is often subdued and eyes most often are closed or glazed. Drowsiness

is differentiated from light sleep by the amount of activity, as active rooting and sucking responses and body movements are typically observed in a drowsy state but not in light

sleep.

State 4 Quiet Alert Infant is awake and alert with open eyes and clear visual focus, however, there is little

movement of the body; infant appears attentive.

State 5 Active Alert Infant is awake with eyes open and is alert, and demonstrates active movements of extremities, body, or neck.

State 6 Crying Infant may be flailing extremities and demonstrating disorganized movements; audible, sustained cry is heard.

Adapted from (Brazelton and Nugent, 1995)


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PartII.

DetailedScoringCriteriafortheNeonatalEatingOutcomeAssessment


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If the infant is not yet orally feeding, score after observing 1-3 minutes of non- nutritive sucking on a pacifier or gloved finger. If the infant is orally feeding, this section is scored as oral feeding is beginning, during the time prior to and at bottle nipple insertion or latch to the breast. If the infant is orally feeding, score item I-7 (Non-Nutritive Sucking) as “normal” if a sucking pattern is achieved. If a sucking pattern is not initiated, oral feeding should be stopped and Pre-Feeding Behaviors the only ones scored, using the abbreviated form.

*Items with an asterisk or that are green on the score sheet indicate those that arerelated to whether the infant is ready for oral feeding. If the infant achieves a score of ‘A’on any of the asterisked or green items, oral feeding is not appropriate. Use theabbreviated form scoring criteria, and only score Section I. Infants achieving a score of‘D’ on all items in section I may be appropriate to continue with the oral feedingassessment. If an infant achieves a score of ‘B’ ‘C’ or ‘E’, it is advised that there be furtherassessment of whether the infant is ready for oral feeding by skilled personnel.

I. PRE-FEEDINGBEHAVIORS

• Bolded letter scores are the most optimal or performance expected of a full terminfant or infant at term age.

• Italicized letter scores are abnormal performance, irrespective of the infant’sPMA.


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I-1. Arousal/State Organization* - This item is intended to assess the level of ease ofarousing the infant for the feeding and should be assessed within 15 minutes of thescheduled feeding/care time. Observe the initial state, and if no spontaneous waking isevident, re-assess following a diaper change, gently changing the infant’s position, and/orassessing vital signs.

A. Unable to rouse to state 3, even with stimulation

Feeder is unable to rouse the infant long enough to initiate feeding. Infant maintains a state 2 or lower, even with

stimulation.

B. Short periods of arousal with stimulation

Infant predominantly remains in state 2 or lower with brief periods being at or above state 3. Infant rouses to state 3 or above, but arousal is limited to less than 1-2 minutes. Brief arousal may occur with stimulation (diaper change, rocking,

bouncing, auditory stimulation), however the infant falls asleep when the stimulus is removed.

C. Prolonged

arousal sustained after stimulation

Infant achieves state 3 or higher following stimulation and maintains it for greater than two minutes. Infant may be

wakened with diaper change or stimulation, but did not arouse on his/her own. If infant has been wakened due to routine

activities, score ‘C’.

D. Wakes Spontaneously

Infant wakes independently in anticipation of feed or to signal hunger. Infant independently achieves ≥ state 3 and sustains it.


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I-4. Rooting and Grasp* - This item is intended to assess how an infant demonstratesthe rooting reflex and grasp in preparation for feeding. It is also an assessment ofperioral/facial sensitivity.Rooting demonstrates the infant’s awareness and response to tactile cues and/or his or her ability to seek food. The rooting and grasp response should be assessed prior to oral feeding by gently stroking each side of the mouth with a finger, pacifier, or breast and observing the infant’s response. If a response cannot be seen on the sides of the mouth, stroke the upper and lower lip surfaces. The rooting response is observed when the infant turns the head toward the stimulated side or orients the head to the stimulus with an open mouth and grasps with mouth. A grasp is when the infant contacts the bottom of the nipple with the top of the tongue and closes the mouth around the bottle nipple. For breastfeeding, this item assesses whether the infant responds to the cue of the nipple and gets the mouth somewhere on the breast. It is ideal that the infant is sufficiently roused (in state 3 or higher) with the head in midline for an optimal response. *Rooting is elicited with stimulation or input to the area around the mouth. Providingstimulation or input 1 to 3 times is considered part of the input or stimulation neededto elicit spontaneous root and grasp, whereas ‘with stimulation’, as defined in ‘C’, isdefined as stimulation that exceeds 3 times.


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Version5.8 17I-4. Rooting and Grasp*

A. No response

The infant does not demonstrate sensory or motor awareness of the pacifier, gloved finger, or nipple. The infant is unable to suck due to inadequate grasp. The infant does not respond to the cue of the pacifier, finger, nipple, or breast, does not turn his/her head toward the stimulus when the examiner attempts to elicit the rooting response, and does not open/close his/her

mouth for the placement. Even with passive placement of a pacifier, gloved finger, or nipple the infant does not appear to respond to the stimulus by closing the mouth around it.

B. Weak or

unilateral root and grasp

Despite attempts to provide extra stimulation (as described in item ‘C’), the infant does not respond and requires the feeder to passively place the nipple, pacifier or finger in the infant’s mouth due to lack of adequate mouth opening. Upon passive placement, the infant’s mouth may close around the finger, pacifier, or nipple, but grasp of the stimulus is weak. The infant may demonstrate diminished rooting response to either or both sides. This may include a

delayed response (turning toward the stimulus after a few seconds or multiple stimuli) or only a partial head turn toward the stimulus. Score ‘B’ if the infant does not demonstrate appropriate arousal and/or responsiveness to the nipple, resulting in the examiner not attempting to place

the nipple in the mouth.

For breastfeeding, the infant may have a diminished rooting response or demonstrate licking in response to the breast, but does not demonstrate an adequate response or mouth opening to get the mouth on the breast. The mother may attempt to passively place the breast into the

infant’s mouth.

C. Root and grasp with stimulation

The infant may appear interested in the stimulus and respond to the stroking stimulus for rooting and may turn or orient the head partially or fully toward the stimulus, but the infant does not open the mouth adequately in response to the stimulus in order to grasp the finger, pacifier or nipple. The infant’s mouth does not immediately open for the feeding with tactile stimulation around the face. Infant may require additional stimulation (>3 attempts), such as

increased tactile stimulation of the perioral surface or jaw, touching the lips or other stimulation provided by the feeder in addition to eliciting the rooting response. The infant

responds to this stimulation and closes around the finger, pacifier, or nipple once in the mouth.

For breastfeeding, score ‘C’ if the infant appropriately responds to and places the mouth on the breast after >3 attempts, demonstrating a need for the extra stimulation. The stimulation may include: increased tactile stimulation of the perioral surface or jaw with a finger or the breast; touching the lips or other stimulation provided by the feeder in addition to eliciting the rooting response, squeezing the breast, or increasing tactile stimulation through use of a breast shield.

D. Spontaneous root and

grasp

Infant responds to a stroking stimulus, turns or orients the head toward the stimulus, opens the mouth in preparation for sucking, and closes the mouth around the finger, pacifier, or

nipple. The infant must meet all of these criteria to receive a score of ‘D’ for this item. Score ‘D’ if the tactile input for rooting and grasp are provided between 0-3 times.

For breastfeeding, score ‘D’ if infant roots and places the mouth around the breast within 3 trials of elicitation.

E. Brisk

response, frantic

response, or avoidance

Infant’s response is excessive or avoidant. The infant may frantically turn toward the stimulus, may demonstrate jerky or uncoordinated movements toward the nipple, and may appear over-stimulated by the rooting stimulus (response may appear frantic or obligatory). The infant may

abruptly open the mouth, find the finger, pacifier or nipple and close around it in a hyper-responsive fashion that appears to indicate significant hunger or haste. The infant also may abruptly open the mouth and search frantically with a disorganized response that does not

result in an appropriate grasp OR the infant may demonstrate jaw clenching or lip pursing and demonstrate avoidance (i.e. turning the head away from the stimulus). If infant demonstrates

jaw clenching or lip pursing without avoidant behaviors, score ‘A’ or ‘B’.

For breastfeeding, score ‘E’ if infant demonstrates activity that is too high to enable root and close around the nipple or if infant demonstrates an avoidant response. Score ‘E’ when infant’s

activity level is too high and infant’s hands consistently get in the way of latching onto the breast due to rigorous rooting and hands to mouth responses.


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Score this section based on the first 10 minutes of oral feeding. Score each item based on the criteria that best represents the infant’s performance. If the infant’s performance appears to fall between two criteria, score the item based on the least optimal response. Since performance can vary based on timing throughout the assessment, score this section based on a gestalt perception on each feeding item, based on overall performance.

For infants who are assessed during breastfeeding, in order to assess the infant’s ability to demonstrate adequate oral feeding skills, it is important for the mother to have adequate milk supply (750-1000 ml per day), for the mother’s breasts to be full at the time of feeding, and for 2 or more hours to have elapsed since the last feeding or milk expression. Alterations to milk supply can be made as an intervention, but this assessment should then be used to assess the infant’s performance with those adaptations, rather than as a tool to identify alterations in feeding performance.

** Double asterisk or items that are red on the score sheet indicate items relating to safety with feeding. A score of ‘A’ on items in red or with a ** may indicate the need to stop feeding, seek a feeding consultation, and/or hold feedings until the infant is more mature.



II. ORALFEEDING


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II-1. Suck-Swallow-Breathe Coordination - This item assesses the infant’s ability to coordinate sucking, swallowing, and breathing for successful oral feeding, with particular focus on the first two minutes of oral feeding when the infant adjusts to the flow of milk and then achieves a pattern of suck-swallow-breathe. The rate of suck- swallow-breathe should be different between non-nutritive sucking (NNS) and nutritive sucking (NS). There is minimal to almost no fluid to swallow during NNS (sucking a pacifier, on a gloved finger, or the infant sucking on his/her own fingers) when compared to NS (oral feeding). The rate of NS is generally slower than the rate of NNS (1/2 the rate of NNS).

The rate of suck-swallow-breathe is generally considered a 1:1:1 ratio (1 suck, 1 swallow, 1 breath) in the mature infant. In preterm infants, the ratio can be up to 4:1:1. The infant must be able to intersperse breaths within the suck/swallow sequence for adequate air exchange. These breaths must be both well timed with sucking and swallowing and sufficiently large to provide appropriate ventilation for the baby while eating. If the baby is not able to sequence breathing independently, interventions may be provided by the feeder to maintain physiologic stability.

One intervention is external pacing whereby the flow of milk is stopped or slowed by the feeder to allow the infant to take breaths. External pacing can be done by tipping the fluid out of the nipple or removing the nipple from the infant’s mouth. Another intervention is placing the baby in sidelying during bottle-feeding, which improves respiratory support and changes the liquid flow trajectory which may slow the flow. These interventions may be needed only at some times during the feeding, most often at the beginning of the feeding. Sidelying is considered an intervention for bottle-feeding, but not for breastfeeding, as it is the most common breastfeeding position.

This item assesses the infant’s ability to independently sequence breaths within the sucking burst to enable a rhythmic pattern of suck-swallow-breathe synchrony with adequate ventilation. For bottle-feeding, this item can be observed and scored immediately after sucking commences and beyond. In the breastfeeding baby, there is a period of minimal milk flow prior to the onset of the milk ejection reflex, also known as ‘let-down’. Therefore, this item cannot be observed and scored until active let-down has occurred and beyond.


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Version5.8 23II-1. Suck-Swallow-Breathe Coordination

A. Unable to coordinate sucking swallowing and breathing; immediate

sequelae

Upon initiating feeding, the infant is unable to sequence breaths within the suck/swallow pattern and immediately experiences physiological

sequelae/decompensation, such as oxygen desaturation or heart rate drop. The infant does not respond to interventions, or consequences occur quickly before intervention can occur. Additional feeding attempts result in the

continuous inability to coordinate suck-swallow-breathe, even with external supports. Also score this item ‘A’ if the infant is not able to exhibit sufficient

bursts or movements to establish a pattern and continue feeding.

B.

No independent suck/swallow/breathe coordination; able to coordinate only when

provided with interventions

Infant is unable to independently intersperse breaths within the suck/swallow sequence and experiences sequelae, such as physiologic

(oxygen desaturation or heart rate drop) or motor (arching, facial grimace, increase in tone) consequences. However, infant is able to feed with

intervention techniques such as: external pacing; tactile cues; positioning in sidelying and/or changing to a slow flow nipple. Without these techniques, the infant would breath-hold or underventilate during feeding. Techniques may need to be used throughout the feeding but continue after the initial

adjustment to oral feeding. The infant is dependent on the feeder’s interventions to coordinate the suck-swallow-breathe sequence.

For breastfed infants, the infant may demonstrate stress signs such as physiologic (oxygen desaturation or heart rate drop) or motor (arching, facial

grimace, increase in tone). However, the infant is able to feed with intervention techniques, such as expressing milk prior to feeding or removing

the infant from the breast regularly to enable a pause in sucking and swallowing to breathe. The success of feeding relies on continuous caregiver

intervention, therefore, the length of breastfeeding may be shortened due to inability to have a continuous breastfeeding process.

C.

Able to feed with intermittent interventions; independent

swallow/breathe sequencing

After an initial adjustment to feeding (after the first couple of minutes), the infant is able to independently intersperse appropriate breaths in the

suck/swallow sequence to remain physiologically stable with minimal to no stress cues. However, there is evidence of challenges with suck-swallow- breath, largely at the beginning of feeding. Interventions may be needed

only a few times during the feeding with the infant taking over independent swallow/breathe control at other times.

In breastfed infants, the feeder may need to remove the infant during milk ejection but then the infant can successfully pace thereafter. Interventions to slow the flow down or aid the infant in handling the flow of milk is only observed a few times during the feeding, usually near the beginning of the

feeding during let-down.

D.

Independently demonstrates appropriate

suck/swallow/breathe sequence

Infant is able to independently intersperse breaths within the sucking/swallow sequence for the entire feeding. Breaths are adequate for ventilation. Score this item if the infant displays multiple sucks per burst in a rhythmic, predictable suck-swallow-breathe ratio ranging from 1-4:1:1.

Score ‘D’ even if the infant uses a slow flow nipple to achieve coordination of the suck-swallow-breathe sequence.

In the breastfed infant, there is a change in the rate of sucking with an adjustment to swallow during milk ejection or let-down. The suck-swallow-

breathe pattern is rhythmically organized and results in physiological stability.


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II-3. Suction - This item assesses the infant’s ability to form a vacuum and enablemovement of liquid from the bottle or breast. This is achieved through coordination of aproper anterior seal, oral stability and appropriate tongue and jaw movement to createsuction pressure. For breastfeeding, assess suction after let-down.

A. No suction

Infant appears to be unable to generate suction pressure to create liquid flow, despite being in the appropriate state. Infant may use

solely a compressive force on the nipple. The nipple easily slides out of the infant’s mouth due to inability to form a vacuum. The infant is

unable to maintain a grasp on the nipple.

B. Minimal suction

Infant demonstrates minimal suction pressure, which may cause minimal liquid to be expressed into the mouth. Some suction is

achieved that may or may not result in the feeding being completed. A decrease in suction is observed, and the nipple can be pulled out of the mouth with little effort. It may appear that the infant is doing non-nutritive sucking during oral feeding. Minimal milk volume is

pulled into mouth.

During breastfeeding, the infant may initially grasp and shape the breast but cannot maintain the nipple in the mouth. This may be

observed as a release of the nipple during a sucking pause. Very little movement of the breast inward toward the mouth may be observed.

C. Normal suction

Infant achieves a good suction pressure and grasp on the nipple without excess effort and with appropriate energy expenditure to

express liquid into the mouth. Suction provides a steady flow of milk from the bottle. Pulling the nipple out of the mouth results in a

break in suction and then the nipple can be removed with minimal effort.

For breastfeeding, the infant is able to pull the nipple into the mouth, shape it into a teat and maintain suction while sucking.

During sucking pauses, the infant maintains adequate suction to retain the breast in the appropriate position in the mouth. Small

movements of the breast in toward the mouth followed by relaxing can be observed.

D. Excessive suction

Infant demonstrates strong suction that may cause the nipple to collapse due to the suction (note that some bottles are vented so the nipple will not collapse with excess suction). Excessively fast flow of fluid through the nipple may also occur. Increases in oral tone may accompany strong suction. Strong movements and visible motion of the cheeks being sucked in may be observed. Removing the nipple

from the infant’s mouth requires some effort.

For breastfeeding, the infant maintains strong suction at the breast and a seal that is difficult to break. Maternal discomfort may be

noted. The breast is round, but not flattened, when removed from the mouth.


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II-4. Oral Tone - This item is designed to capture the infant’s oral tone, including thetongue, cheeks and lips. Appropriate maintenance of the oral-musculature tone enablesefficient milk expression and movement of the milk into the pharynx for swallowing.

A. Flaccid

Infant’s mouth is largely flaccid throughout the feed, and the infant cannot maintain sufficient tone to efficiently express and control the milk within the mouth. This may be observed through flaccid cheeks, flattened tongue, or inability to control the flow of

milk to the back of the mouth for adequate swallow.

B. Decreased tone

Infant’s oral tone allows for limited success with feeding. Tone is decreased in the tongue, cheeks, and lips, but the infant is able to

demonstrate some success with milk expression and management. There may be some poor liquid expression or

intermittent breaking of seal. Tone is decreased to the point that it requires increased energy expenditure to engage in feeding and fatigue is rapid, which may or may not lead to poor completion of the feeding. This item is differentiated from ‘A’ in that the infant

may be able to express some milk, yet inefficiently.

C. Adequate tone for feeding

Infant maintains sufficient oral tone throughout the feed to facilitate efficient feeding. The infant is able to express milk from

the breast or bottle without excessive effort and is able to control the passage of milk to the back of the mouth for efficient

swallowing.

D. Increased oral tone,

clenched jaw, and/or pursed lips

Infant demonstrates increases in tone in the jaw, tongue, and/or lips during feeding. The infant may be observed as making tight,

restricted movements that may impact the efficiency of the feeding and require increased or decreased effort to efficiently

express liquid. Clenching of the jaw may be observed. For infants with increased tone in the lips, it may appear that they fail to form a good seal around the nipple. The lips may appear pursed around

the nipple. Increased tone interferes with the efficiency or mechanics of feeding. Increased tone could result in significant increases in intraoral suction resulting in rapid milk expression,

which may or may not be handled effectively. Alternatively, tone may be increased to the extent that the infant clamps down on the

bottle nipple and collapses it, which could prevent milk from passing through the bottle nipple. Initial pre-feeding observations

of a clenched jaw or pursed lips could give clues to increases in tone (and may interfere with initial nipple placement), but the

observation of tone for scoring of this item should be made during the first 10 minutes of oral feeding.

In the breastfed infant, increased compression of the breast nipple is observed and may result in pain and discomfort for the mother,

resulting in limited stimulation of milk ejection. The infant may express minimal liquid due to excess tone,

preventing milk from passing through the ducts into the mouth.


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! Score these items after 20 minutes of oral feeding (elapsed since the nipple firstentered the infant’s mouth) or once feeding has been stopped by the caregiveror the infant.

***Triple asterisk or items in yellow on the score sheet indicate items that relate to success with full volume of intake. If the infant scores anything other than “F”, supplementation may be indicated and should be discussed with the medical team.

III. OBSERVATIONSATTHEENDOFFEEDING




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III-1. Feeding Completion - This item is intended to evaluate why the feeding isdiscontinued and/or to define behaviors that are present after a 20-minute attempt atoral feeding. Feeding discontinuation may be due to physiologic sequelae (airwaycompromise, excessive apneas, and bradycardias), inability to maintain arousal, inabilityto organize behavior, discomfort, or because the infant completed the feeding.

Refer to section on prescribed volume in this manual on page 4.

A. Stops due to physiologic instability

Infant experiences physiologic instability or problems sufficient to require stopping the feeding prior to full intake. This may include excessive apneas and bradycardias, increased work of breathing, or desaturation events. If A is selected on II-8 or II-9, select ‘A’ here.

B.

Stops due to fatigue (unable to

continue) or feeder stopped the

feeding

The feeding is stopped prior to full intake due to the infant’s fatigue or inability to maintain an alert state. The infant may fall asleep

during feeding and does not rouse with external cues (stimulation of rooting with the nipple) provided by the feeder. Score ‘B’ if the infant

falls asleep, even if the feeder wakes infant to continue. OR

The feeder may make the decision to stop/end the feeding. *If infant re-arouses independently, without stimulation, andcompletes the feeding, score ‘D’, as long as it is within 20

minutes of feeding initiation.

C. Discomfort

Infant displays excessive discomfort that the feeder is unable to alleviate, so the feeding is stopped. The infant is too uncomfortable

(exhibits too many stress signs, such as back arching, squeezing eyes closed, strong withdrawal from nipple, abrupt color changes) to

continue with the feeding. This can also include gastrointestinal signs such as straining, grunting, color changes, or squirming. If infant is unable to continue after a pause to burp, due to discomfort, score

this item ‘C’.

D. Completed

feeding

Infant may need to pause to burp, but continues the feeding to completion within a 20 minute period. Infant appears

comfortable after feeding.

Score ‘D’ if the infant is a full term infant in the first couple of days of life and has a small intake over only a couple of minutes, and the

pediatrician has not specified a minimum volume of intake.

E.

Completed feeding, but demonstrates discomfort after

feeding

Completed full volume of feeding, but following the feeding, the infant displays significant, non-state related signs of stress (such

as color change, arching, grunting).


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PartIII.

ScoringtheNeonatalEatingOutcomeAssessmentandScoreSheet


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Scoring:

SCORINGCRITERIA

After all of the characteristics have been matched to their appropriate point value based on the infant’s PMA at assessment, place each point value in the far right column of the score sheet for the corresponding item. The sum of all scores will derive a total. Points will fall into one of three categories as listed below:

Normal (expected performance for PMA) Questionable (emerging or could signal challenge) Feeding Challenge (immature for PMA or abnormal feeding)

Abbreviated Form: If only Section I was scored, there is a range of scores from 6-30. Use the following criteria to score:

6-20: Feeding Challenge21-26: Questionable27-30: Normal

Full Form: If Sections I, II, and III were scored, there is a range of scores from 18-90. Use the following criteria to score:

18-57: Feeding Challenge58-76: Questionable77-90: Normal


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Neo

nata

l Eat

ing

Out

com

e As

sesm

ent S

core

She

et: I. P

re-Fee

ding

Beh

avio

rs

Versio

n 5.7

Stud

y ID/Infan

t’s Nam

e:

DOB:

Da

y of

Life:

EGA at

Birth:

Cu

rren

t PMA:

Evalua

tion Da

te:

Breast

or B

ottle

Fee

d:

Rate

r Nam

e:

Post

men

stru

al A

ge (w

eeks

) Sc

ore

Item

Ch

oice

s 30

31

32

33

34

35

36

37

38

39

40

+

Section I-Pre-Feeding Behaviors

I-1.

Arou

sal/

Stat

e O

rgan

izatio

n*

A.Una

ble to

rouse to

state 3,

even with

stim

ulation

B.Short p

eriods

of arousal

with

stim

ulation

C.Prolon

ged arou

sal sustained

after

stim

ulation

D. W

akes

spon

tane

ously

A=3

B, C, D

=5

A=1

B,C,D=

5

A=1

B=3

C, D=5

A, B=1

C,

D=5

A, B,

C=1

D=5

I-2.

Phys

iolo

gica

l Sta

bilit

y*

A.Po

or physio

logical stability

B.Interm

itten

t periods

of ph

ysiological stability with

ene

rgy de

pletion

C.Interm

itten

t periods

of p

hysio

logical stabilit

y with

out e

nergy d

epletio

nD.

Phys

iolo

gica

l sta

bilit

y

A=3

B, C, D

=5

A=1

B=3

C, D=5

A, B=1

C,

D=5

A, B=1

C=

3 D=

5

A, B,

C=1

D=5

I-3.

Resp

irato

ry S

uppo

rt*

A. Ven

tilated

B.

Non

-invasiv

e respira

tory

supp

ort

C. M

inim

al re

spira

tory

supp

ort

D. R

oom

air

Not

Scored

--

I-4.

Root

ing

and

Gras

p*

A. No respon

se

B. W

eak or

unilateral roo

t and

grasp

C.Ro

ot a

nd

grasp

with

stim

ulation

D.Sp

onta

neou

s roo

t and

gras

p E.

Brisk

resp

onse

, fra

ntic

resp

onse

, or a

void

ance

E=1

A=3

B, C, D

=5

E=1

A, B=3

C,

D=5

A, E=1

B=

3 C,

D=5

A ,B, E=1

C,

D=5

I-5.

Initi

atio

n of

Suc

king

* A.

No initiation

of sucking

B. Req

uires m

oderate stim

ulation

C. Req

uires m

inim

al stim

ulation

D. S

pont

aneo

usly

initi

ates

suck

ing

E. A

ctiv

e av

oida

nce

E=1

A=3

B, C, D

=5

A, E=1

B=

3 C,

D=5

A,E=

1 B=

3

C, D

=5

A,B,E=

1

C,D=

5

A,B,E=

1 C=

3 D=

5

I-6.

Tong

ue

A. Flaccid

or n

on-respo

nsive

B. Flat w

ith so

me

tong

ue cu

pping

C.Elevated

and

retracted

D.To

ngue

cupp

ing

with

cent

ral g

roov

e E.

Devi

ated

to si

de, t

ongu

e th

rust

ing,

or t

ongu

e bun

chin

g

E=1

A, B, C=3

D=

5

A, E

=1

B, C

=3

D=5

A, B,

E=1

C=3

D=5

A, B, E

=1

C=3,

D=

5

A, B, C

, E=1

D=

5

I-7.

Non-

Nutr

itive

Suc

king

A.

Absen

t B.

Arrhythmic

C.

Inte

rmit

ten

t b

urs

t-pa

use pa

ttern

D. N

orm

al b

urst

-pau

se p

atte

rn E.

Prolong

ed burst-pau

se pattern

E=1

A, B, C

, D=5

E=1

A=3

B,C,

D=

5

E=1

A,B=

3 C,D=

5

A,E=

1 B=

3 C,D=

5

A,E=

1 B,C=

3 D=

5

A,B,E=

1 C=

3 D=

5

A, B, C

, E=1

D=

5

TOTA

L:

(Sec

tion

1)

Abbr

evia

ted

Form

: If

only

Sectio

n I w

as sc

ored

, the

re is

a ra

nge of

scor

es from

6-30.

Use

the followin

g crite

ria to

scor

e:

6-20

Fee

ding

Cha

lleng

e21

-26 Que

stiona

ble

27-30 Normal

.

Cop

yrig

ht 2

014

by W

ashi

ngto

n U

nive

rsity

in S

t. Lo

uis,

Mis

sour

i. A

ll rig

hts

rese

rved

.

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Neo

nata

l Eat

ing

Out

com

e As

sesm

ent S

core

She

et: II. Oral F

eeding

& III. Observatio

ns at the

End

of F

eed

Post

men

stru

al A

ge (w

eeks

) Sc

ore

Item

Ch

oice

s 30

31

32

33

34

35

36

37

38

39

40

+

Section II and III-Oral Feeding and Observations at the End of Feed

II-1.

Suck

-Sw

allo

w-B

reat

he

Coor

dina

tion

A.Una

ble to

coo

rdinate sucking sw

allowing an

d breathing;

Immed

iate

sequ

elae

B.No inde

pend

ent suck/sw

allow/breath

sequ

encing

; able

to coo

rdinate

only

whe

n provided

interven

tions

C.Ab

le to

feed

with

interm

itten

t interven

tions; i

nde

pend

ent swallow/breath sequ

ence

D.In

depe

nden

tly d

emon

stra

tes a

ppro

pria

te su

ck/s

wal

low

/bre

athe

sequ

ence

A, B, C

, D=5

A=

3 B,C,D=

5 A,

B=3

C,

D=5

A=1

B=3

C, D=5

A=1 B,C=

3 D=

5 A,

B=1

C=3

D=

5

II-2.

Suck

ing

Burs

t Len

gth

A. No sucking bu

rst

B. M

inim

al su

cks p

er burst

C. A

ppro

pria

te su

cks p

er b

urst

D.

Lon

g pa

ttern of

suck

s pe

r burst

D=

1 A,

B, C=5

A,

B=3

C, D

=5

A, B

= 1

C, D=5

II-3.

Suct

ion

A. No suction

B. M

inim

al su

ction

C. N

orm

al su

ctio

n.

D. Excessiv

e suction

D=1

A, B, C=5

D=1

A, B=3

C=

5

A, D=1

B=

3 C=

5 A,

B=1

D=

3 C=

5

II-4.

Ora

l Ton

e A.

Flaccid

B. Decreased

tone

C.

Ade

quat

e to

ne fo

r fee

ding

D. In

crea

sed

oral

tone

, cle

nche

d ja

w, a

nd/o

r pur

sed

lips

D=1

A=3

B, C=5

A, D=1

B,

C=5

A, D=1

B=

3 C=

5

A, B, D

=1

C=5

II-5.

Qua

lity

of S

ucki

ng

Mov

emen

ts

A. Abn

ormal

sucking pa

ttern B.

Mod

erate discoo

rdination

C. M

ild or intermitten

t disc

oordination

D. M

atur

e, o

rgan

ized

suck

ing

patt

ern

A=1

B, C, D

=5

A=1

B=3

C, D=5

A,B=

1 C=

3 D=

5

II-6.

Beha

vior

al R

espo

nse

to

Feed

ing

A. A

ctiv

e av

oida

nce

or si

gnifi

cant

feed

ing

stre

ss re

spon

ses t

hat i

nter

fere

with

feed

ing

B. Lim

ited po

sitive

en

gagemen

t/comfort

during fee

ding

with

mod

erate dise

nga

gem

en

t

C. M

ostly

positive

eng

agem

ent/

comfort

during feed

ing with

minim

al dise

ngagem

ent

D. N

o di

scom

fort

and

pos

itive

eng

agem

ent

A=1

B, C, D

=5

A=1

B=3

C,

D=5

A,

B=1

C=3

D=

5

II-7.

Flui

d Lo

ss

A. Significan

t fluid

loss

B

. Mod

erate flu

id loss

C. M

inim

al fluid loss

D.

No

fluid

loss

A, B, C

, D=5

A=

1 B=

3 C,

D=5

A,

B=1

C,

D=5

II-8.

Swal

low

**

A. High risk (clear, clinical

indicatio

ns of a

spira

tion)

B. M

oderate aspiratio

n risk

C. M

ild aspira

tion risk

D. N

orm

al sw

allo

w

A=3

B, C, D

=5

A, B=1

C=

3 D=

5

A, B,

C=1

D=5

II-9.

Resp

irato

ry C

ontr

ol

Durin

g Fe

edin

g**

A.Re

spira

tory

com

prom

ise with

markedly increased work of

breathing

B. Mod

erately increased work o

f breathing

C.

Mildly

increased work of

breathing

D. A

ppro

pria

te re

spira

tory

cont

rol d

urin

g fe

edin

g

A=3

B, C, D

=5

A, B=1

C,

D=5

A, B=1

C=

3 D=

5

A, B, C

=1

D=5

III-1

.Fe

edin

g Co

mpl

etio

n

A.Stop

s due

to physio

logic instability

B.Stop

s due

to fa

tigue

(una

ble to

continue

) or fee

der stopp

ed th

e feed

ing

C.Di

scom

fort

D. C

ompl

eted

feed

ing

E. Com

pleted

feed

ing,

but

dem

onstrates d

iscom

fort

afte

r fee

ding

C=1

A, B, D

, E=5

C,

E=1

A,

B, D

=5

A, B=3

C,

E=1

D=

5

A, B, C

, E=

1 D=

5

III-2

.St

ate

Mai

nten

ance

E.

Mai

ntai

ns h

igh

leve

l of a

rous

al(s

tate

5 o

r 6) t

hat i

nter

fere

s with

fe

edin

g

A.Re

ache

s state

3 or 4

only briefly

B.Maintains

state 3 or

4 fo

r 4-7

minutes

C.Maintains

state 3 or

4 fo

r 8-10 minutes

D.M

aint

ains

stat

e 3

or 4

>10

min

utes

E=1

A, B, C

, D=5

E=1

A=3

B, C, D

=5

A, E=1

B=

3 C,

D=5

A, B, E=1

C=

3 D=

5

A, B, C

, E=1

D=

5

III-3

.Vo

lum

e Co

nsum

ed**

*

A. No milk

con

sumption

B. M

inim

al m

ilk co

nsum

ption

C. 1/4

milk

con

sumption

D. Half o

f fee

ding

consum

edE.

75%

of fee

ding

consum

ed

F. F

ull f

eedi

ngA,B,C,D,E,F=5

A=3

B,C,D,E,

F=5

A,B=

3 C,D,E,

F=5

A=1

B=3

C,D,

E,F=5

A=1

B,C,D=

3 E,F=5

A, B=1

C,

D=3

E,

F=5

A, B, C

, D=1

E=

3 F=5

TOTA

L:

(Fro

m S

ectio

n 1)

TO

TAL:

(S

ectio

ns 2

& 3

)

Full

Form

: If

Sections

I, II

, and

III w

ere

scored

, the

re is

a ra

nge

of sc

ores

from

18-90

. Use

the follo

win

g crite

ria to

score:

18

-57 = Feed

ing Ch

alleng

e58

-76 = Que

stiona

ble

77-9

0 = Normal

TOTA

L SCO

RE:

(Sec

tions

1, 2

, & 3

)

Cop

yrig

ht 2

014

by W

ashi

ngto

n U

nive

rsity

in S

t. Lo

uis,

Mis

sour

i. A

ll rig

hts

rese

rved

.

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Neo

nata

l Eat

ing

Out

com

e As

sesm

ent S

core

She

et: IV.

Non

-Score

d Ite

ms

Section IV-Items Not Scored

IV-1

.Fe

eder

!Nurse

!

Mothe

r!

Father

!Other:

!Th

erap

istIV

-8.

Exte

rnal

Su

ppor

ts

!Non

e !

Tipp

ing milk

out

of n

ipple

!Pu

lling

nippl

e out

of m

outh

interm

itten

tly

!Sw

addling or

other

containm

ent

!Unswad

dling

!De

creased au

ditory

stim

uli

! Aud

itory

supp

ort

!De

creased visual

stim

uli

!Tactile

stim

ulation (state

whe

re):

_ !

Turning

bottle

!

Tap

ping

bottle

!Jaw

supp

ort

! Chin supp

ort

!Ch

eek supp

ort

!Sque

ezing breast

!

Holding

/sup

porting breast

!

Massage

breast

! Form

nipple

!Other:

IV-2

.Fe

eder

Expe

rienc

e:

!First T

ime

!

2-4

Fee

ds

! 5-1

0 Fee

ds !

10+

Feed

s/expe

rt!

Unkno

wn

!Previous

breastfe

eding expe

rience for:

weeks

Previous

cha

lleng

es with

breastfe

eding (if

any):

IV-9

.Po

sitio

n Du

ring

Feed

!Side

-lying

! Se

mi-side-lying

! Upright

! Enface

! Foo

tball hold

!Crad

led

!Cross-Crad

led

!Laid

back n

ursin

g !

Mothe

r nursin

g infant

while

she is sid

e-lying

Indicate

supp

orts

used (nursin

g pillow

, pillow

und

er arm

/und

er bab

y):

Commen

ts:

IV-3

.In

fant

Fee

ding

Ex

perie

nce

!Non

e !

Some du

e to

feed

ing prob

lems o

r immaturity

!Some du

e to

recent

initiation of

oral fee

ding

! M

inim

al re

cent

experience

! M

oderate

!Sign

ificant

!Unkno

wn

!Infant

is fu

ll term

and

has

bee

n feed

ing sin

ce birth:

DOL

IV-1

0.He

art R

ate

!No sig

nifican

t alte

ratio

ns in

HR

Num

ber o

f tim

es with

HR >2

00: #

Long

est tim

e to

recover:

!

Durin

g activ

e sucking an

d sw

allowing

! During a pa

use in

sucking and sw

allowing

!After fee

ding

is com

pleted

Num

ber o

f tim

es with

HR <1

00: #

Long

est tim

e to

recover:

!Du

ring activ

e sucking

and

swallowing

! During a pa

use in

sucking and sw

allowing

!After the

feed

ing is completed

IV-4

.In

fant

’s Cu

rren

t Fe

edin

g Re

gim

en

(che

ck a

ll th

at

appl

y)

!Nuzzle

s at b

reast o

nly

!Only therap

y feed

ing infan

t!

Oral fee

ding

attem

pts <

4 tim

es per

wee

k !

Oral fee

ding

attem

pt!

Oral fee

ding

attem

pts 2

-3 times

per

day

1 tim

e per

day

!Oral fee

ding

attem

pts 4

-6 times

per

day

!

Breastfe

eding attempts

!Attempts a

t full oral fee

ding

with

less

with

subseq

uent

tube

than

50%

of volum

e consum

ed and

feed

ing of:

remaind

er of volum

e tube

fed

!Takes full oral fee

ds on

!Attempts a

t full oral fee

ding

with

a

feed

ing schedu

le

50-90%

of volum

e consum

ed and

!

Ad lib

on

dem

an

d

remaind

er of volum

e tube

fed

!

Cu

e bas

ed

feed

ing

with

___ feed

ings

eng

aged

in with

in th

e previous

24

hou

r period

!Ad

Lib

with

a m

axim

um time elap

sed

betwee

n feed

ings

IV-1

1.Re

spira

tory

Ra

te

!No sig

nifican

t alte

ratio

ns in

RR

RR

at start

of fee

d:

_ R

R at e

nd of fee

d:

Num

ber o

f minutes

with

RR >6

0:

Long

est tim

e to

recover:

!Du

ring activ

e sucking

and

swallowing

!Du

ring a pa

use in

sucking and sw

allowing

!After the

feed

ing is completed

!Breath

holding

for 1

-5 se

cond

s: #

!Breath

holding

for 6

-10

second

s: #

!Breath

holding

10-20

second

s: #_

!Breath

holdi

ng

>2

0 se

cond

s: #

IV-5

.Ni

pple

Typ

e

!Slow

Flow

!

Regu

lar F

low

!

Fast

Flow

!

Breast

!Breast

with

nipple shield

!

Special

Nipple used

:IV

-12.

Oxy

gen

Satu

ratio

n

!No sig

nifican

t alte

ratio

ns in

O2 sats

Num

ber o

f tim

es with

O2 sats

<90

%: #

Long

est tim

e to

recover:

!

Durin

g activ

e sucking

and

swallowing

!Du

ring a pa

use in

sucking and sw

allowing

!After the

feed

ing is completed

!Ch

eck he

re if

add

ition

al oxy

gen

supp

ort w

as given

durin

g or

immed

iately

afte

r the

feed

ing

!Ch

eck he

re if

infant

with

stab

le O

2 sa

ts but

dem

onstrates respiratory

alte

ratio

ns 2-3

minutes

afte

r the

feed

ing e

nds

IV-6

.M

ilk T

ype

!Form

ula

!Breast

Milk

!Mix

of formula an

d breast

milk

! Thicken

ed

Type

of formula,

if app

licab

le:

IV-7

.In

terr

uptio

ns

# Caus

e (cha

nge in

position

, cha

nge nipp

le, suspe

cted

aspira

tion):

IV-1

3.Ti

me

Time infant

eng

aged

in non

-nutritive sucking:

Time it took

for infan

t to gras

p nipple

an

d initiate suckin

g after first p

resentation:

Time infant

eng

aged

in oral fee

ding

:

Num

ber o

f burps: #

Ap

proxim

ate tim

e spen

t burping

: !

Difficulty

burping

IV-1

4.In

fant

Ana

tom

ic an

d Fu

nctio

nal

Varia

tions

!Non

e !

Tong

ue tied

-no

surgical

interven

tion

!Re

cessed

jaw

!Do

wn’s S

yndrom

e De

scrib

e:

!Cleft lip

!To

ngue

tied

with

surgical

interven

tion

!Microgn

athia

!Pierre

Rob

in Seq

uence

!Cleft p

alate

!Cleft lip

and

palate

!Lip tie

with

surgical

interven

tion !

Lip tie

with

out surgical in

terven

tion

!Macroglossia

!

Neo

natal A

bstin

ence

Syndrom

e !

Cardiac a

nomaly

Cop

yrig

ht 2

014

by W

ashi

ngto

n U

nive

rsity

in S

t. Lo

uis,

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sour

i. A

ll rig

hts

rese

rved

.

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Neo

nata

l Eat

ing

Out

com

e As

sesm

ent S

core

She

et: IV.

Non

-Score

d Ite

ms (

FOR

BREA

STFE

EDIN

G ON

LY)

Section IV-Items Not Scored-BREASTFEEDING ONLY

IV-1

5.M

othe

r’s M

ilk

Supp

ly**

*

Volum

e:

Type

: !

Minim

al to

non

e !

Small amou

nts o

f colostrum

or w

ithin

first

!Some

few

days a

fter b

irth an

d milk

has

not

come in

!Diminish

ed!

Mix

!Ad

equa

te

!Mostly

milk

with

some c

olostrum

!Overabu

ndan

ce!

Mature milk

!Unkno

wn

# m

l sup

ply each

day:

# of d

ays s

ince

birt

h of infan

t:_

!Indicate

if th

e Supp

lemen

tal N

ursin

g System

is Used

IV-2

0.Br

east

(s)

!Infant

fed on

only on

e breast:

!Righ

t!

Left

!Infant

fed

on

both breasts:

!Righ

t first

!Left first

If fe

d on

both breasts:

Time on

first:

Time on

second

:

!Sw

itche

d breasts a

second

time

IV-1

6.Pu

mpi

ng S

ched

ule

!N/A

- mothe

r not

expressing milk

! M

othe

r pum

ps interm

itten

tly in

order

to offe

r a bottle

, stim

ulate

milk

produ

ction or

save

milk

! M

othe

r with

a nee

d for m

ilk expression du

e to

infant

not

yet

orally

feed

ing

! M

othe

r not

pum

ping

routinely

! M

othe

r expressing he

r milk

1-3

times

per

day

! M

othe

r expressing he

r milk

4-6

times

per

day

! M

othe

r expressing he

r milk

7+ tim

es per

day

Av

erage leng

th of tim

e pu

mping

: _

Approxim

ate tim

e from

start o

f pum

p un

til let-do

wn:

Amou

nt expressed

at e

ach session:

Type

of p

ump used

:

IV-2

1.M

ater

nal

Anat

omy

!Non

e !

Breast

piercings

!Breast

implan

t!

Only on

e breast

! Breast red

uctio

n!

Other

breast surgery

! La

rge breasts

!Sm

all breasts

!Breast

eng

orgemen

t!

Breast

infection

!Flat

nipples

! In

verted

nipples

!Nipple po

intin

g do

wn

IV-2

2.M

ater

nal

Com

plica

tions

!Non

e !

Iron de

ficiency a

nemia

!Po

stpa

rtum

hem

orrhage

! Overw

eigh

t/Obe

sity

!Hy

pothyroidism

!

Hyperthyroidism

!Po

lycystic

Ovaria

n Synd

rome

!C-section de

livery

!Re

ynau

d’s S

yndrom

e !

Illicit drug

use

!Re

tained

placenta

IV-1

7.M

ater

nal C

omfo

rt Le

vel

Pain/D

iscom

fort:

!No discom

fort

or p

ain in

breasts.

!Pa

in of 7

-10

with

breastfe

eding

!Pa

in of 4

-6 with

breastfe

eding

!Pa

in of 3

or less O

R repo

rt of d

iscom

fort

with

out p

ain

Whe

n:

!Only at

beginning

of fee

ding

!Th

roug

hout

the feed

ing

!Be

twee

n feed

ings

IV-2

3.M

anag

ing

Brea

stfe

edin

g

! M

othe

r manages

tasks o

f breastfe

edin

g well w

ithou

t inciden

ce

Difficulty

motorically

man

aging task

of b

reastfee

ding

: !

Yes

! No

Physical

impa

irmen

t: Lack

of skill:

!Yes

! No

!Yes !

No

!Nee

d for m

ultip

le attem

pts to aid success

Materna

l adaptio

n !

Yes

! No

IV-2

4.M

ater

nal M

otor

Fa

ctor

s

!Infant

not

line

d up

to breast

Materna

l adaptio

n

! Yes

! No

! M

othe

r’s sh

oulders e

levated

Materna

l adaptio

n

! Yes

! No

!Tension throug

hout

bod

yMaterna

l ada

ption

! Yes

! No

IV-1

8.Br

east

feed

ing

Cont

rain

dica

tions

**

!Ch

emothe

rapy

!Ra

diation therap

ies

!Taking

antire

trovira

ls!

Ebol

a vi

rus

!Ha

s her

pes s

impl

ex!

!H

IV

!Infant

galactosemia

!Untreated

brucellosis

!Untreated

active tube

rculosis

!Hu

man

T-cell ly

mph

otropic v

irus

!lllicit drug

use

!Alcoho

l use

with

in th

e last

2 hou

rslesio

ns on breast

IV-2

5.M

ater

nal

Envi

ronm

enta

l Fa

ctor

s

!Nipple po

intin

g do

wn

Materna

l ada

ption

! Yes

! No

!Nipple soft an

d ne

eding shap

ing

Materna

l ada

ption

! Yes

! No

!Nostril occlud

edMaterna

l ada

ption

! Yes

! No

Distractions:

! M

om answers p

hone

or texts

!Other

children de

man

ding

attention

!Televisio

n !

Having

conversatio

n

IV-1

9.M

othe

r’s F

low

Rat

e

!Unkno

wn

!With

in first few

days o

f birth an

d milk

not

yet

in

!Slow

!

Average

!

Excessiv

e

IV-2

6.M

othe

r- Inf

ant

Dyna

mics

!Infant

with

low

activity

Materna

l ada

ption

! Yes

! No

!Infant

with

high activ

ity

Materna

l ada

ption

! Yes

! No

Mothe

r stressed?

Family

mem

bers

(lack of

supp

ort):

!

Yes

!

No

! Yes

! No

Cop

yrig

ht 2

014

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ashi

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hts

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Recommen

datio

ns fo

r Sub

sequ

ent F

eeding

s:

Appa

ratu

s !

Slow

Flow

!

Regular

Flow

!

Fast

Flow

!

Breast

!Breast

with

breast shield

!Breast

with

Sup

plem

ental N

ursin

g System

!

Special

Specifi

c nipp

le ty

pe (spe

cify):

Met

hods

!

Swad

dling

!De

creased au

ditory

stim

uli

! Ja

w su

pport

! Chin/chee

k supp

ort

! Rocking

!

Decreased visual

stim

uli

!Au

ditory

supp

ort

!Other:

Posit

ioni

ng

!Side

-lying

!Upright

! Enface (fa

ce-to-face)

!Footba

ll ho

ld!

Cradled

!

Cross C

radled

!

Mothe

r in sid

elying

Brea

stfe

edin

g in

terv

entio

ns

!Increase

milk

supp

ly!

Breast shield

!Express m

ilk prio

r to feed

ing

an

d have infant

fee

d afterw

ard

Addi

tiona

l Co

mm

ents

Cop

yrig

ht 2

014

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rsity

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t. Lo

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sour

i. A

ll rig

hts

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rved

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