Psychometric characteristics of the Neonatal OralMotor Assessment Scale in healthy preterm infants

Tsu-Hsin Howe PhD, Department of Occupational Therapy, Steinhardt School of Culture, Education, and Human Development, New York University, NY, USA. Ching-Fan Sheu PhD, Institute of Cognitive Science, National Cheng-Kung University; Yu-Wei Hsieh MS; Ching-Lin Hsieh* PhD, School of Occupational Therapy, College of Medicine, National Taiwan University, Taiwan. *Correspondence to last author at School of Occupational Therapy, College of Medicine, National Taiwan University, 17, Floor 4, Xuzhou Road, Zhongzheng District, Taipei 100, Taiwan. E-mail: clhsieh@ntu.edu.tw

We examined the reliability, validity, and responsiveness of the Neonatal OralMotor Assessment Scale (NOMAS) in healthy preterm infants. Feeding records of 147 infants (71 males, 76 females; gestational age [GA] 36wks), taken from the day bottle-feeding was initiated to the day the infants were discharged, were used to examine the psychometric properties of the normal and disorganized categories of the NOMAS. The infants, with or without experience of breastfeeding, were all fed by bottle, with either formula and/or breast milk. GA ranged from 24 to 35.9 weeks (mean 29.7wks, SD 2.7) and birthweight ranged from 470g to 2570g (mean 1251.1g, SD 425.9). Postmenstrual age (PMA) at the starting point of bottle-feeding ranged from 29.4 to 40.1 weeks (mean 33.8wks, SD 1.7). We found that the NOMAS had satisfactory internal consistency (Cronbachs >0.70) in the normal category for 32 to 35 weeks PMA. Moderate correlations were found between scores on the NOMAS and feeding performance for all age groups except for PMA of 36 weeks (absolute Spearmans rs=0.51 0.69), indicating acceptable convergent validity. The NOMAS demonstrated moderate responsiveness to changes in oralmotor skills in every 2-week period, ranging from 32 to 36 weeks PMA (standard response mean greater than 0.5). This study demonstrated that the normal and disorganized categories of the NOMAS are useful, with acceptable psychometric properties, in assessing oralmotor function in preterm infants aged 32 to 35 weeks PMA. Future research on infants with abnormal oralmotor skills is needed to further validate psychometric properties of the dysfunction category of the NOMAS.

Nutritive sucking is considered the most complex activity of infancy.1 Compromised sucking skills can result in suboptimal nutrition and growth. Research findings suggest that sucking can be a sensitive indicator of central nervous system integrity, differentiating stressed from non-stressed infants, whereas standard neurological examinations may fail to do so.24 Recognition of normal and deficient sucking patterns is especially important in preterm infants, because feeding problems are one of the prominent developmental issues in that population.5 A scientifically sound feeding assessment is thus needed both for clinicians and researchers to detect feeding problems and to monitor the success of intervention. An assessment tool should be scientifically sound in three basic psychometric properties: reliability, validity, and responsiveness.6 Reliability addresses the degree to which an assessment tool is free from random error.7 Approaches for examining reliability include internal consistency reliability, typically examined using Cronbachs coefficient , and testretest or interobserver reliability. Validity indicates whether the tool measures what it purports to.8 It can be established by demonstrating a high correlation between the tool and a criterion standard (i.e. concurrent validity). In the absence of a criterion standard, validity is established by assessing the degree to which the assessment tool correlates with others measuring related entities (convergent validity).6 Responsiveness assesses the ability of a tool to detect change over time.9 A responsive measure is essential for documenting clinical changes and for outcome studies. The Neonatal OralMotor Assessment Scale (NOMAS) is a clinical tool commonly used to evaluate the oralmotor skills of neonates who demonstrate reflexive sucking. Several studies have reported the results of reliability and validity of the NOMAS.1014 However, limitations were found in these studies. First, examinations of internal consistency and responsiveness of the NOMAS were not performed in any of these studies. Second, the sample sizes in these studies, ranging from 11 to 40, were small, which limited the scope of generalization from these results. Third, the age of the samples studied, ranging from 34 to 49 weeks postmenstrual age (PMA), may not adequately represent the characteristics of younger preterm infants. Thus, the evidence supporting the psychometric properties of the NOMAS remains inconclusive. The purpose of this study was to examine the psychometric characteristics of the NOMAS. These included the reliability (internal consistency), validity (convergent validity), and responsiveness of the NOMAS in healthy preterm infants. Method
DATA

The data were originally collected for a longitudinal study to examine the factors related to bottle-feeding in preterm infants.15 It was conducted at the Mount Sinai Medical Center in New York City with the approval of the institutional review board of the hospital. All medical charts in the Neonatal Intensive Care Unit from July 2001 to July 2003 were reviewed using a standardized form. Infants who met all of the following criteria were included: (1) born at a gestational age (GA) of no more than 36 weeks; (2) free from any major neurological, cardiac, gastrointestinal, or congenital impairment; with neurological impairment, including but not limited to, documented abnormal neurological findings, i.e. grade III or IV intraventricular hemorrhage or periventricular leukomalacia, cardiac

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impairment, including but not limited to, atrial and ventricular septal defects, gastrointestinal impairment, including but not limited, to necrotizing enterocolitis, and congenital impairment including but not limited to orofacial anomalies and Down syndrome; (3) having had at least one feeding assessment during hospital stay with record of the NOMAS; (4) fed by bottle with or without breastfeeding experience; and (5) fed either formula milk or breast milk. Records for a total of 147 preterm infants were included in this study.
PROCEDURES

Records of the NOMAS and feeding performance were collected from chart review. As per hospital protocol, bottle-feeding was initiated when an infant was medically stable and when feeding delivery method had progressed from continuous feeding (the default method for infants weighing less than 1250g in this unit) to bolus feeding. The infant was then referred to the occupational therapy service for a routine feeding assessment and intervention. Observed bottle-feeding was recorded by the occupational therapist after each feeding session as part of a routine progress report. A general protocol was followed for each feeding session. The infant was gently aroused to an awakened state, in which the eyes were open and motor activity was present. Sucking was evaluated with the infant in a semi-reclined position with the neck and head held in neutral alignment. Non-nutritive sucking was rated by observing the infant sucking on the pacifier for 30 seconds. Nutritive sucking was then rated by having the infant suck on an artificial nipple while ingesting the formula specified in the infants medical orders. The

infants oralmotor responses were observed for a 5-minute period during feeding with removal and re-entry of the nipple two or three times. The infants behaviors were recorded on the NOMAS. Bottle-feeding then continued until the infant finished the required amount or the infant stopped sucking for over 2 minutes. The amounts of milk and time taken were recorded. The infants feeding performances were routinely assessed and documented by an occupational therapist twice or thrice per week. The administrations of the NOMAS for all infants were performed by an occupational therapist (the first author of this paper), who has been certified by Ms M Palmer, the developer of the NOMAS, to perform the assessment. The records of the NOMAS and feeding performance were extracted from occupational therapy progress reports from the day of initiation of bottle-feeding to the day of discharge from the hospital. Records obtained were divided into five groups according to the infants PMA. These were 32, 33, 34, 35, and at least 36 weeks.
MEASURES

Table I: Characteristics of preterm infants (n=147)

Characteristic Sex (Male/Female) Gestational age (wks) Mean (SD) Range Birthweight (g) Mean (SD) Range PMA first oral feed (wks) Mean (SD) Range PMA, postmenstrual age. 71/76 29.7 (2.7) 2435.9 1251.2 (425.9) 4702570 33.8 (1.7) 29.440.1

The version of the NOMAS used in the study, revised by Palmer et al. in 1993,12 is a 27-item checklist of feeding characteristics observed during nutritive sucking. On the NOMAS, infants are scored for their overall classification of normal, disorganized, or dysfunctional patterns. Disorganized feeding is characterized by arrhythmic jaw movements, difficulty coordinating sucking, swallowing, and breathing, and an inability to slow down the sucking rate for nutritive intake. Dysfunctional feeding is an atypical pattern characterized by abnormal jaw excursions or flaccid tongue. However, the dysfunction category of the NOMAS could not be examined because most of the infants included in this study did not show atypical feeding patterns. Because there was no scoring system proposed by the original author of the NOMAS,12 items listed in the NOMAS were coded as 0 or 1 point to represent absence or presence of the observed behavior respectively. The total possible score for the normal category is between 0 and 9, and that for the disorganized category is between 0 and 13. Infants feeding performance was measured by transitional rate. The transitional rate was calculated by the ratio of feeding intake (in milliliters) to the feeding duration (in minutes). The volume of milk was the amount of milk that infant consumed by bottle at one observed feeding. The time was measured as soon as the bottle was introduced and sucking had begun. Any interruptions such as burping and allowance

Table II: Estimated values (95% confidence intervals [CI]) of Cronbachs coefficient for normal and disorganized categories of Neonatal OralMotor Assessment Scale
Postmenstrual age (wks) 32 33 34 35 36 n Cronbachs 37 74 95 79 56 0.83 0.82 0.82 0.70 0.64 Normal 95% CI (0.74 0.92) (0.76 0.89) (0.76 0.88) (0.60 0.81) (0.49 0.79) Number of itemsa 9 9 9 8 5 Cronbachs 0.72 0.65 0.63 0.68 0.64 Disorganized 95% CI Number of itemsa (0.59 0.86) (0.54 0.77) (0.52 0.74) (0.57 0.78) (0.50 0.79) 11 12 11 11 7

aTotal number of items for normal category is nine; that for disorganized category is 13. Actual numbers of items used for analysis varied by

postmenstrual age because of lack of response variability.

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for breathing during feeding were included as part of the feeding. The time was recorded when infant finished his/her required amount or stopped sucking for over 2 minutes.
STATISTICAL ANALYSIS

0.2 to 0.5 was small.18 In addition, Wilcoxons matched-pairs signed ranks tests were performed to determine the statistical significance of the change scores. Results The sample cohort consisted of 147 infants (71 males, 76 females). GA ranged from 24 to 35.9 weeks (mean 29.7wks, SD 2.7) and birthweight ranged from 470 to 2570g (mean 1251.1g, SD 425.9). PMA at the starting point of bottle-feeding ranged from 29.4 to 40.1 weeks (mean 33.8wks, SD 1.7). The baseline characteristics of these 147 infants are shown in Table I. The number of recorded feedings varied and ranged from 1 to 12, with a median of 5. Two infants were recorded only once. Individual feeding records were excluded if values of major variables were missing, i.e. the NOMAS scores, drinking volume, and time. Five feeding records were removed from the data set before the analysis. In addition, the data recorded under the dysfunction category were less than 2% of total data. Thus, the data recorded under the dysfunction category were excluded in the analysis.
RELIABILITY

Reliability The internal consistency of both the normal and disorganized categories of the NOMAS was examined at 5 PMA groups using Cronbachs . An coefficient greater than 0.70 was considered a minimal reliability criterion.16 Validity The convergent validity of the NOMAS was assessed by examining the relations between total scores of the NOMAS in both categories and infants feeding performance using Spearmans rank correlation. Correlations between 0 and 0.25 indicate low validity of the measures; those between 0.25 and 0.5 indicate fair validity; those between 0.5 and 0.75 indicate moderate to good validity; and those greater than 0.75 indicate good to excellent validity.17 Responsiveness Responsiveness was examined to determine whether the NOMAS can detect changes in oralmotor skills over time (from 3236wks or older) using standardized response means (SRMs). SRMs were calculated by the mean change scores divided by the SD of the change scores. An effect size greater than 0.8 was considered large; 0.5 to 0.8 was moderate; and

Using the criterion of greater than 0.70, internal consistencies of the NOMAS for 32 to 35 weeks PMA of the normal category were deemed acceptable; and the same is true for 32 weeks PMA in the disorganized category (Table II). However, the values of coefficient for PMA of at least 36 weeks in both

Table III: Spearmans rank correlations (95% confidence intervals [CI]) between transitional rate and scores of Neonatal OralMotor Assessment Scale in normal and disorganized categories
Postmenstrual age (wks) 32 33 34 35 36 n Normal Spearmans rs (95% CI) 0.69 (0.47 to 0.83) 0.63 (0.47 to 0.75) 0.51 (0.34 to 0.64) 0.55 (0.37 to 0.68) 0.23 (0.04 to 0.46) pa <0.001 <0.001 <0.001 <0.001 0.087 Disorganized Spearmans rs (95% CI) 0.67 (0.82 to 0.44) 0.60 (0.72 to 0.42) 0.60 (0.72 to 0.46) 0.62 (0.74 to 0.46) 0.26 (0.49 to 0.006) pa <0.001 <0.001 <0.001 <0.001 0.054

37 74 95 80 56

aThe p value is the probability of whether the null hypothesis (r =0) is true. n, number of infants. s

Table IV: Standard response means (SRM) of normal and disorganized categories of the Neonatal OralMotor Assessment Scale
Postmenstrual age (wks) n 32 to 33 32 to 34 32 to 35 33 to 34 33 to 35 33 to 36 34 to 35 34 to 36 35 to 36 29 22 15 57 37 27 56 39 44 SRM 0.60 1.08 0.87 0.41 0.65 0.67 0.44 0.74 0.26 Normal pa <0.001 <0.001 0.050 <0.001 <0.001 0.002 0.002 <0.001 0.100 SRM 0.48 0.98 0.97 0.61 0.81 0.78 0.49 0.85 0.33 Disorganized pa 0.020 <0.001 0.002 <0.001 <0.001 0.001 0.001 <0.001 0.042

aThe p value is the probability of whether the null hypothesis (change score=0) is true using the Wilcoxons matched-pairs signed ranks tests.

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the normal and disorganized categories and that of 33 to 35 weeks PMA in the disorganized category did not reach the preset criteria, even though estimates of the 95% CI of the coefficient covered this criterion value.
VALIDITY

Moderate convergent validity was observed for the NOMAS of both the normal and disorganized categories (Spearmans rs=0.51 to 0.69 for the normal category, and rs=0.60 to 0.67 for the disorganized category) for 32 to 35 weeks PMA (Table III). For PMA of 36 weeks or older, the association between the total scores of the NOMAS and feeding performance was weak (Spearmans rs=0.23 for normal category, and rs=0.26 for disorganized category).
RESPONSIVENESS

The responsiveness of the normal and disorganized categories of the NOMAS is listed in Table IV . The normal (SRM=0.411.08, p<0.01) and disorganized (SRM=0.48 to 0.98, p<0.01) categories of the NOMAS were moderately responsive in detecting changes in infants oralmotor skills except for comparisons made at later weeks. The responsiveness of the normal and disorganized categories was low to moderate when the changes from 34 to 35 weeks and from 35 to at least 36 weeks (SRM= 0.44 and 0.26 in the normal category; SRM=0.49 and 0.33 in the disorganized category) were examined. Discussion Oralmotor function is one of the important indicators of neurobehavioral maturation in preterm infants.3 A psychometrically sound oralmotor scale enables clinicians to identify, monitor, and manage oralmotor problems commonly occurring in preterm infants. This study attempted to systematically examine the psychometric properties of the NOMAS using a cohort of healthy preterm infants. The findings of this study provide useful information for clinicians in determining whether to select the NOMAS for oralmotor measurement in their settings. In this study, the reliability of the NOMAS was examined in terms of internal consistency. The homogeneity of the NOMAS items listed in the normal and disorganized categories has not been examined previously. Items were homogeneous in measuring infants oralmotor function at four time points (32, 33, 34, and 35wks PMA) in the normal category and at 32 weeks PMA in the disorganized category. However, the point estimates of Cronbachs for PMA of at least 36 weeks in both the normal and disorganized categories and that of 35 weeks PMA in the disorganized category were not greater than the preset criterion of 0.70, even though estimates of the 95% CIs of the coefficient did cover this criterion value. The value of Cronbachs depends on the number of items included for analysis.19 The modest values of Cronbachs observed in the aforementioned contexts may be explained by the fact that items lacking response variability were excluded. For instance, only five out of nine items in the normal category and seven out of 13 items in the disorganized category were included in the reliability analysis for a PMA of at least 36 weeks. The lack of response variability in some items may reveal a developmental hierarchical order embedded in the construct of the NOMAS. Some items may lose their discriminative ability at later gestation ages because of infant maturation. For example, in the normal category, all infants of PMA of at least 36 weeks

demonstrated the behaviors extensionelevationretraction movements occur in anteriorposterior direction and liquid is sucked efficiently into the oro-pharynx for swallow without exception. These two items were no longer discriminative in assessments of infants of PMA of at least 36 weeks. On the other hand, some items may only be appropriate for infants over 40 weeks PMA. For example, in the disorganized category, item persistence of immature suck pattern beyond appropriate age is only suitable for infants of this age. Further investigation into the properties of these items is necessary. In the absence of a criterion standard to measure oralmotor function, we assessed the convergent validity of the NOMAS by examining the strengths of correlations between the NOMAS scores and the infants feeding performances. Our findings showed a moderate degree of correlation between the NOMAS and feeding performance at 32, 33, 34, and 35 weeks PMA. For infants of PMA of at least 36 weeks, the correlation was 0.23 in the normal category and 0.26 in the disorganized category. Similar findings have been reported by other researchers.11,2022 Lau et al.22 reported that preterm infants oral feeding performance improves as oralmotor skills mature, and Case-Smith et al.11 examined feeding efficiency in preterm neonates using the NOMAS and determined that both nutritive and nonnutritive sucking scores are higher for efficient feeders than for inefficient feeders. These results indicate that the convergent validity of the NOMAS for PMA from 32 to 35 weeks is well supported. By contrast, convergent validity for those infants of PMA of at least 36 weeks in both the normal category (Spearmans rs=0.23) and the disorganized category (rs=0.26) was not supported in this study. This finding might be accounted for by two observations. First, as infants get older, their oralmotor performances start to differentiate and diverge. Many other factors such as endurance, range of state, or regulation of state may start to affect feeding performance at later developmental stages,23 but these behaviors are not assessed by the NOMAS. Second, in this study, infants of PMA of at least 36 weeks were close to being discharged, and one of the criteria for discharge is that infants transitional rate (drinking speed) has reached a stable point regardless of their oralmotor skills. Therefore, the nearly plateau transitional rate might also result in a weak association with the scores of the NOMAS. Responsiveness is important for any measurement tool designed to measure change over time.24 The NOMAS demonstrated moderate responsiveness in detecting infants oralmotor changes from PMAs of 32 weeks to 36 weeks or older. A high responsiveness level was found from 32 to 34 weeks PMA (SRM=1.08). This result was expected because the oralmotor skills were reported to become more functionally coordinated over this time period.3 A lower responsiveness level at later weeks (from 3536wks or older, SRM=0.26) might be interpreted as showing that the oralmotor functions have stabilized at this age.25 Mizuno and Ueda26 reported that sucking behaviors of preterm infants with ages ranging from 32 to 36 weeks PMA demonstrated significant improvements in oralmotor function between all weeks except 35 to 36 weeks PMA. These results are in agreement with the low responsiveness level from PMAs of 35 to 36 weeks or older found in the current study. In addition, we also observed that the magnitudes of changes of oralmotor skills in each corresponding period

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between the normal and disorganized categories were symmetrical despite the directions of changes. Items describing same behaviors were listed in both the normal and disorganized categories with opposite directions. For example, consistent degree of jaw depression was listed in the normal category versus inconsistent degree of jaw depression in the disorganized category, and rhythmical excursions was listed in the normal category versus arrhythmical jaw movements in the disorganized category. Therefore, the symmetrical patterns were expected because of the symmetrical construct of items in the normal and disorganized categories. Psychometric properties of the dysfunction category were not examined because of insufficient data. The dysfunction category of the NOMAS was designed to differentiate infants with neurological problems.27 The insufficient data obtained under the dysfunction category were expected, because infants with documented abnormal neurological findings, who may exhibit abnormal jaw and tongue movements (i.e. listed in the dysfunction category), were not included in the data collection. In addition, PMA was used as a grouping criterion, and only a few infants with GA greater than 34 weeks (2/147 infants) had been observed in this study. Therefore, caution should be exercised when interpreting the results of our findings for infants with GA greater than 34 weeks. Conclusion In summary, the normal and disorganized categories of NOMAS demonstrated acceptable levels of convergent validity and responsiveness in a cohort of preterm infants from 32 to 35 weeks PMA. However, the NOMAS had modest internal consistency and poor convergent validity with transitional rate for preterm infants of PMA of at least 36 weeks in both the normal and disorganized categories. Further validation research is needed to investigate the internal consistency of later PMA and to include infants with abnormal oralmotor skills in order to examine items in the dysfunction category.
Accepted for publication 31st July 2007. Acknowledgments We express our appreciation to Dr Ian R Holzman and the NICU staff at the Mount Sinai Medical Center for their assistance and support. We also thank Tara Wilhelm Forstrom for her editorial assistance. References 1. Conway A. (1994) Instruments in neonatal research: measuring preterm infant feeding ability. Part I. Bottle feeding. Neonatal Netw 13: 7175. 2. Hill A, Volpe J. (1981) Disorders of sucking and swallowing in the newborn infant: clinical pathological correlations. In: Korobkin R, Guilleminault C, editors. Progress in Perinatal Neurology, vol. I. Baltimore, MD: Williams & Wilkins. p157181. 3. Medoff-Cooper B, McGrath JM, Bilker W . (2000) Nutritive sucking and neurobehavioral development in preterm infants from 34 weeks PCA to term. MCN Am J Matern Child Nurs 25: 6470. 4. Ingram TT. (1962) Clinical significance of the infantile feeding reflexes. Dev Med Child Neurol 4: 159169.

5. Ross ES, Browne JV . (2002) Developmental progression of feeding skills: an approach to supporting feeding in preterm infants. Semin Neonatol 7: 469475. 6. Sharrack B, Hughes RAC, Soudain S, Dunn G. (1999) The psychometric properties of clinical rating scales used in multiple sclerosis. Brain 122: 141159. 7. Aaronson N, Alonso J, Burnam A, Lohr KN, Patrick D L, Perrin E, Stein REK. (2002) Assessing health status and quality-of-life instruments: attributes and review criteria. Qual Life Res 11: 193205. 8. Wade DT. (1992) Measurement in Neurological Rehabilitation. Oxford: Oxford University Press. 9. Kirshner B, Guyatt G. (1985) A methodological framework for assessing health indices. J Chronic Dis 38: 2736. 10. Palmer MM, Heyman MB. (1999) Developmental outcome for neonates with dysfunction and disorganized sucking patterns: preliminary findings. Infant Toddler Interv Transdisciplinary J 9: 299308. 11. Case-Smith J, Cooper P , Scala V . (1989) Feeding efficiency of premature neonates. Am J Occup Ther 43: 245250. 12. Palmer MM, Crawley K, Blanco IA. (1993) Neonatal OralMotor Assessment scale: a reliability study. J Perinatol 13: 2835. 13. Hawdon JM, Beauregard N, Slattery J, Kennedy G. (2000) Identification of neonates at risk of developing feeding problems in infancy. Dev Med Child Neurol 42: 235239. 14. Case-Smith J. (1988) An efficacy study of occupational therapy with high-risk neonates. Am J Occup Ther 42: 499506. 15. Howe TH, Sheu CF, Hinojosa J, Lin J, Holzman IR. (2007) Multiple factors related to bottle-feeding performance in preterm infants. Nurs Res 56: 307311. 16. Ware JE, Snow KK, Kosinski M, Gandek B. (1993) SF-36 Health Survey: Manual and Interpretation Guide. Boston, MA: The Health Institute, New England Medical Center. 17. Colton T. (1974) Statistics in Medicine. Boston, MA: Little Brown. 18. Cohen J. (1988) Statistical Power Analysis for the Behavioral Science. Hillsdale, NJ: Lawrence Erlbaum Associates. 19. Duhachek A, Lacobucci D. (2004) Alphas standard error (ASE): an accurate and precise confidence interval estimate. J Appl Psychol 89: 792808. 20. Medoff-Cooper B, McGrath JM, Shults J. (2002) Feeding patterns of fullterm and preterm infants at forty weeks postconceptional age. J Dev Behav Pediatr 23: 231236. 21. Daniels H, Casaer P , Devlieger H, Eggermont E. (1986) Mechanisms of feeding efficiency in preterm infants. J Pediatr Gastroenterol Nutr 5: 593596. 22. Lau C, Alagugurusamy R, Schanler RJ, Smith EO, Shulman RJ. (2000) Characterization of the developmental stages of sucking in preterm infants during bottle feeding. Acta Paediatr 89: 846852. 23. Medoff-Cooper B, Ratcliffe SJ. (2005) Development of preterm infants: feeding behaviors and Brazelton neonatal behavioral assessment scale at 40 and 44 weeks postconceptional age. Adv Nurs Sci 28: 356363. 24. Guyatt G, Walter S, Norman G. (1987) Measuring change over time: assessing the usefulness of evaluative instruments. J Chronic Dis 40: 171178. 25. Gewolb IH, Vice FL, Schwietzer-Kenney EL, Taciak VL, Bosma JF. (2001) Developmental patterns of rhythmic suck and swallow in preterm infants. Dev Med Child Neurol 43: 2227. 26. Mizuno K, Ueda A. (2003) The maturation and coordination of sucking, swallowing, and respiration in preterm infants. J Pediatr 142: 3640. 27. Palmer MM. (1993) Identification and management of the transitional suck pattern in premature infants. J Perinat Neonatal Nurs 7: 6675.

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