Research Article

Establishing Normative Values for Healthy Term

Infant Feeding Performance: Neonatal Eating
Assessment Tool-Mixed, Oral Feeding Scale, and
Early Feeding Skills Assessment
Katlyn Elizabeth McGrattan,a,b Alicia Hofelich Mohr,c Ellen Weikle,a Kayla Hernandez,d
Katie Walsh,e Jinhee Park,f Sara E. Ramel,g Michael K. Georgieff,g Kelly Dietz,h Kyle Dahlstrom,i
John Lindsay,i and Suzanne Thoyrej
a
Department of Speech-Language-Hearing Science, University of Minnesota, Minneapolis b Department of Rehabilitation, Masonic Children’s
Hospital, Minneapolis, MN c College of Liberal Arts, University of Minnesota, Minneapolis d Department of Otolaryngology and Communication
Enhancement, Boston Children’s Hospital, MA e Department of Speech Language Pathology, Ann and Robert H. Lurie Children’s Hospital of
Chicago, IL f Connell School of Nursing, Boston College, Chestnut Hill, MA g Department of Pediatrics, Division of Pediatric Neonatology,
University of Minnesota, Minneapolis h Department of Radiology, University of Minnesota, Minneapolis i nuBorn Medical, Eden Prairie, MN
j
School of Nursing, University of North Carolina at Chapel Hill

ARTICLE INFO ABSTRACT

Article History: Purpose: Infants with perceived feeding problems are frequently referred for
Received November 22, 2022 assessment of their feeding abilities. However, little is known regarding how
Revision received February 27, 2023 healthy nondysphagic infants perform on commonly used assessments, making
Accepted July 15, 2023 determination of impairment difficult. The aim of this investigation was to eluci-
date the characteristics of healthy term infant feeding performance using three
Editor-in-Chief: Katherine C. Hustad commonly employed clinical assessments: Neonatal Eating Assessment Tool-
Editor: Georgia A. Malandraki Mixed (NeoEat-Mixed), Oral Feeding Scale, and Early Feeding Skills (EFS).
Method: In this prospective case–control study, we recruited 30 infants without
https://doi.org/10.1044/2023_AJSLP-22-00372 feeding impairments to undergo video-monitored bottle feeds under their normal
feeding conditions. Caregiver perception of infant feeding was evaluated using
the NeoEat-Mixed. Milk ingestion was monitored real time using the Oral Feed-
ing Scale for rate of milk transfer and modified proficiency as characterized by
the total volume consumed out of the total volume the caregiver provided.
Videos were analyzed by two speech pathologists using the EFS assessment.
Descriptive statistics were used to characterize performance.
Results: Participants underwent feeding monitoring at an average chronological
age of 4 ± 2 months. Caregivers primarily reported normal, nonconcerning feed-
ing patterns across all of the NeoEAT-Mixed outcomes. Infants consumed milk
at an average rate of transfer of 7 ± 3 ml/min, a modified proficiency of 50 ±
21%, and achieved the highest OFS score of 4 (93%, n = 28). The majority of
infants scored the best EFS score (mature-3) as it related to the absence of
color changes during the feed (97%, n = 29), although commonly scored in the
worst EFS score (immature-1) in their presentation of one or more compelling
stress cues (63%, n = 19).
Conclusion: Establishing healthy term infant normative values for commonly
used feeding assessments is critical in accurately distinguishing infants with
feeding impairments from those with normal developmental variants.

Concerns regarding an infant’s feeding abilities are

Correspondence to Katlyn Elizabeth McGrattan: kmcgratt@umn.
common among caregivers of both healthy and medically
edu. Disclosure: The authors have declared that no competing financial fragile neonates. Work by Hung (2006) indicates maternal
or nonfinancial interests existed at the time of publication. concerns about their infant’s coughing and choking during

2792 American Journal of Speech-Language Pathology • Vol. 32 • 2792–2801 • November 2023 • Copyright © 2023 The Authors
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
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feeding was one of the top 10 sources of postpartum perception of their infant’s feeding performance while tak-
maternal stress among caregivers of healthy term infants ing case history is the Neonatal Eating Assessment Tool-
(Hung, 2006). Similar findings were observed by Fuhrman Mixed (NeoEAT-Mixed; Pados et al., 2019, 2020). The
and Ross (2020), where they found 30% of caregivers who NeoEAT-Mixed was initially validated in a heterogenous
attended a feeding support clinic expressed concerns sur- group of infants between the ages of 0 and 7 months
rounding infant coughing, choking, and gulping during including infants with and without known feeding
feeds (Fuhrman & Ross, 2020). impairments (Pados et al., 2019). Infants with known
feeding impairments were found to score significantly
The clinical swallow evaluation is the first-line
worse (higher) than those without known feeding impair-
assessment to elucidate whether these concerns are rooted
ments, leading developers to develop interpretation mate-
in a true feeding impairment that warrants more invasive
rials that categorizes infants into one of three groups indi-
assessment and treatment or if they solely reflect normal
cating the likelihood of a feeding impairment (high concern
immature neuromuscular feeding variants. This is done by
for deficit to no concern for impairment) based on their total
taking a thorough case history and then monitoring the
score (Pados et al., 2019). Subsequent work in healthy
infant as they feed for correlates of milk ingestion, and
infants without feeding impairments demonstrated that,
sucking, swallowing, and respiratory physiology (Arvedson,
while these cutoffs provide a good reference for identifying
2008). Unfortunately, the ability to accurately identify an
potential impairments worth monitoring, high scores are
impairment based on clinical findings is significantly limited
not always indicative of impairment as reflected by some of
by the lack of specificity in clinically applicable data relat-
the healthy infants without reported feeding impairments
ing to healthy nondysphagic infant-feeding performance.
scoring with high scores (Pados et al., 2020).
Specifically, it is well established that infants should feed
by alternating between suck bursts, characterized by a The only validated measure of milk ingestion is the
period of active sucking and swallowing, and suck burst Oral Feeding Scale (OFS; Lau & Schanler, 2000; Lau
breaks, characterized by a period of sucking and swallow- et al., 1997; Lau & Smith, 2011). This tool, which catego-
ing cessation. Likewise, it is also established that, during rizes an infant’s feeding abilities into levels ranging from 1
suck bursts, infants breathe at reduced respiratory rates as (worst) to 4 (best) based on how much they consume and
the infant alternates between breathing and swallowing how quickly they consume it, has only been validated in
approximately once every second. Previous work has pro- preterm infants. Although this work demonstrated that
vided information on general trends relating to milk inges- OFS score is associated with a preterm infant’s time to
tion as well. This indicates that infants increase their suck- achieve full oral feeds, the fact that it has never been vali-
ing rate to enable more milk ingestion to meet growing dated in term infants makes interpretation of results out-
metabolic demands in the initial months of life. Although side of preterm infants difficult (Lau & Schanler, 2000;
making clinical determinations about the presence or absence Lau et al., 1997; Lau & Smith, 2011).
of these and other physiologic processes can be easily
achieved, determining if the manner that they are being exe- The Early Feeding Skills (EFS) assessment is one of
cuted is normal or indicative of impairment is much less clear. the only standardized assessments for the clinical assess-
This is due to the combined effects of a scarcity of clinical ment of infant feeding physiology (Thoyre et al., 2018).
instrumentation capable of quantifying feeding physiology, Although its construct validity has been demonstrated in
as well as to the fact that the specifications of how these pro- preterm infants by correlations with the Preterm Infant
cesses are linked vary based on infant age, time into the feed, Driven Feeding Assessment and postmenstrual age, the
and rate of milk flow. For example, Bamford et al. (1992) characteristics of healthy term infant performance has
demonstrated that breaths are not always inserted between never been elucidated (Thoyre et al., 2018).
swallows during the initial suck bursts of a feed, but that they
The determination of how healthy nondysphagic
become more regularly inserted in a coordinated pattern as
infants perform in these outcomes is critical in delineating
the feeding progresses (Bamford et al., 1992). Unfortunately,
infants with normal performance from those with impair-
the lack of associated cut-point delineating normal variability
ments (Goday et al., 2019). This includes characterizing
in this, and other physiologic patterns, makes the identifica-
not only how infants perform in a single feed but also the
tion of impairment highly subjective and a source of variation
stability in their performance across multiple feeds given
across clinicians.
some variability in infant feeding performance is generally
Appreciating the need for standardized metrics appreciated among clinicians. Such information is critical
quantifying physiology and clearly delineating impair- in a setting where the presence or absence of impairment
ment, investigators have developed standardized assess- is often made from a single time point. The aim of this
ments to evaluate these feeding domains. One of the more pilot investigation was to take the first step in filling this
commonly used intake questionnaires to evaluate parent’s void by characterizing healthy term infant feeding

McGrattan et al.: Normal Values for Healthy Infant Feeding 2793

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performance for characteristics of parent-perceived feeding was intended for use in infants less than 7 months old and
impairments using the NeoEAT-Mixed, milk ingestion our investigation included infants up to a year, there is no
using the OFS, and physiology using the EFS Assessment. other tool available with this level of rigor that enables
assessment and standardized reporting throughout the first
year of life. The study team therefore determined that,
Method even though the conclusions that could be drawn from
NeoEAT-Mixed scores on infants > 7 months would be
Participants limited by validation data, its inclusion had the potential
to provide valuable insight into the sample characteristics
Thirty infants, 0–12 months old, without feeding that would be better than not reporting anything at all.
impairments were recruited from Masonic Children’s Hos- See Statistical Analysis section for specifications on how
pital postpartum unit as well as through postings on social the one infant exceeding the 7-month cutoff was scored.
media. Infants were included if they were born full term
(≥ 37 weeks gestation) without any underlying medical Following intake, infants were monitored during
conditions known to influence feeding performance. As two feeds that took place in their home or the research lab-
bottle nipple has the potential to influence feeding perfor- oratory based on caregiver preference for correlates of milk
mance, and flow rates differ across brands, only infants ingestion and feeding physiology. Both feeds occurred within
fed with the Dr. Brown’s bottle and nipple system were 7 days of each other to control for maturation effects and
included in this phase of the investigation. Exclusive bottle were completed at the infant’s scheduled feeding time, while
feeding was not required for study inclusion, although all the infant was fed by their caregiver using a Dr. Brown’s bot-
infants were required to have been bottle fed at least once tle equipped with their typically used Dr. Brown’s nipple flow
prior to the assessment. Infants were excluded from the rate. The same nipple flow rate and feeder was used across
investigation if they had a history of feeding impairments both feeds. If caregivers determined that their infant was
requiring supplemental alternative nutrition (e.g., nasogas- not hungry at the scheduled feeding time, the assessment
tric tube), poor weight gain resulting in a diagnosis of fail- was held until the caregiver indicated the infant was show-
ure to thrive, or parent-perceived feeding impairments. ing hunger cues. Feeds were video-recorded using a Canon
The study was approved by the University of Minnesota VIXIA HD camera with the visual field including the
Institutional Review Board. infant’s face, arms, and upper torso for post hoc analysis of
oropharyngeal physiology using the EFS assessment tool as
Data Collection described below. All files were stored on secured Box drive.

Milk ingestion was measured real time and reported

Prior to enrollment, parents were screened through a using the OFS (Lau & Schanler, 2000; Lau et al., 1997;
series of yes/no questions pertaining to the presence of Lau & Smith, 2011). The OFS is a standardized assess-
comorbid conditions or feeding impairment that would ment of milk ingestion that requires the clinician to record
prohibit the infant’s inclusion. Enrolled infants underwent the amount of milk the infant consumes in the first 5 min
a thorough case history obtained by parent interview for of the feed, the total milk they consume at the end of the
demographics, birth history, and feeding history. Intake of feed, and the total feed duration. From this, composite
caregiver-perceived feeding performance was then com- outcomes reflecting the rate of transfer (RT; total milk
pleted using the NeoEAT-Mixed feeding assessment consumed/feed duration) and proficiency (PRO; milk con-
(Pados et al., 2019). The NeoEAT-Mixed is an 89- sumed in first 5 min/total milk prescribed) can be gener-
question parent questionnaire that asks caregivers to rank ated and used to categorize an infant’s feeding abilities
the frequency that their infants display desirable and trou- into levels ranging from 1 (worst) to 4 (best) based on
blesome feeding behaviors on a 6-point Likert scale rang- published cutoffs (OFS 1: PRO < 30%, RT < 1.5 ml/min;
ing from Never to Always. The tool is designed for use in OFS 2: PRO < 30%, RT > 1.5 ml/min; OFS 3: PRO >
infants who are less than 7 months old and achieving the 30%, RT < 1.5 ml/min; OFS 4: PRO > 30%, RT > 1.5
majority of their nutrition by milk. Scores can be used to ml/min; Lau & Schanler, 2000; Lau et al., 1997; Lau &
categorize infants into one of three categories indicating Smith, 2011).
the likelihood of a feeding impairment (high concern to
no concern for impairment). In doing so, infants receive As it relates to this investigation, a stopwatch was
an overall categorization for their risk for feeding impair- used to allow precise monitoring of time throughout the
ment, as well as categorizations within each of the specific feed. The stopwatch was started once the infant began
domains of function (infant regulation, energy and physio- sucking on the nipple, with the bottle checked after 5 min
logic stability, gastrointestinal tract function, sensory to record the amount of milk the infant had consumed to
responsiveness, and feeding flexibility). Although the tool the nearest milliliter by referencing the VoluFeed value.

2794 American Journal of Speech-Language Pathology • Vol. 32 • 2792–2801 • November 2023

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The bottle was then returned to the caregiver to continue monitoring equipment not commonly utilized in most out-
feeding the infant until they determined the infant was patient feeding clinic settings (stable oxygen saturation
done. At this time, the clinician recorded the total feed and heart rate), 17 of the 19 EFS outcomes were the focus
duration and the total milk consumed. From these mea- of this investigation. After clinicians had completed train-
sures, RT was calculated by dividing the total milk con- ing, interrater reliability was evaluated using 20% of the
sumed by the total feeding duration and reported as ml/ exams that were randomly selected for testing. Discrepan-
min. PRO, the other calculated OFS outcome, is designed cies were resolved by consensus. Only outcomes achieving
to be calculated in the preterm population by dividing the agreement coefficients indicative of fair agreement or bet-
amount of milk consumed in the first 5 min of the feed by ter were reported in this investigation. Benchmarking was
the total volume the infant was prescribed to take by the determined using cumulative membership probability on
physician. Such practice was not possible in this investiga- the Landis–Koch scale, as recommended by Gwet (2014).
tion due to the fact that healthy nondysphagic infants in Rather than a static cutoff being used to determine
the home setting do not have a “prescribed” volume that whether an agreement coefficient was fair or above, both
they must take each feed. To circumnavigate this, the pre- the magnitude of the coefficient magnitude and its vari-
scribed milk volume in this study was determined as the ability were used. See Statistical Analysis section below
amount of milk the caregiver provided them to drink dur- for further information on the reliability analysis.
ing that feed. This was referenced as “modified profi-
ciency” to reflect this variant in the intended definition, Statistical Analysis
and corresponding implications relating to its lack of psy-
chometric study, RT, and modified proficiency were used NeoEat-Mixed percentiles were calculated according
to categorize infants into OFS Levels 1–4 using published to ages and rankings in the NeoEat-Mixed scoring man-
values. ual. Domain scores for Feeding Flexibility and Infant Reg-
ulation domains, which include questions regarding breast-
Following data collection, video recordings of bottle feeding, were calculated only for those infants who breast
feeds were evaluated for physiology using the EFS and bottle fed outside of the study (n = 19). Scores were
(Thoyre et al., 2018). The EFS assessment is a 19-item compared to the age-based reference values for each
ordinal rank metric designed for use in preterm infants domain and total score. One participant (age 8 months)
that evaluates oral feeding skills across five domains was above the 0- to 7-month age range provided in the
throughout the duration of a bottle feed: respiratory regu- manual, and, therefore, scores were compared to the refer-
lation, oral-motor function, swallowing coordination, ence values for the oldest 6- to 7-month group. Descrip-
engagement, and physiologic stability (Thoyre et al., 2005; tive statistics summarized results relating to the proportion
Thoyre et al., 2018). Each item is scored on a 3-point of infants who demonstrated desirable or undesirable feed-
scale with 1 representing the least mature skill and 3 repre- ing presentations. Desirable behaviors were indicated by a
senting the most mature skill. Each score variant has a score of always, almost always, or often present on desir-
corresponding definition delineating observations indica- able outcomes, or the absence of a score of never or
tive of that rating to maximize reliability. Table 1 provides almost never on undesirable outcomes. Characteristics of
a full listing of EFS outcomes and score variant criteria. OFS and EFS performance were analyzed using descrip-
The rater reliability of the tool has not previously been tive statistics and reported as M ± SD and the proportion
evaluated, and, therefore, a core component of its utiliza- of the sample with each score variant, respectively. As
tion for this investigation was focused on conducting the each infant had two feeds as part of data monitoring, the
necessary rater training and testing to ensure validity and first monitored feed was used to characterize their perfor-
reliability of the results. To do this, two licensed speech- mance, with the second feed used to elucidate variability
language pathologists, each with 11 years of experience in in performance within infants. Due to the small sample
working in infant feeding, underwent a 4-hr training in size, nonparametric tests were used for all inferential anal-
analysis of infant feeding using the EFS by the scale yses. EFS outcomes that required auditory feedback (e.g.,
developer (Suzanne Thoyre, PhD). Training included gulping or effortful hard swallows) could not be analyzed
review of the scoring manual, with operational definitions in 13 participants due to insufficient audio integrity in the
for each domain, with associated video recordings to recordings, and, therefore, proportions of these outcomes
depict score variants, and practice videos with trainer are reflective of the smaller sample. Interrater reliability
feedback on correct scoring to clarify any unclear scoring was calculated using Gwet’s agreement coefficient (Gwet,
guidelines. Once training was complete, the de-identified 2014) due to data being skewed with many outcomes hav-
videos of the infant feeds were disseminated to clinicians ing low variability in scores across infants. This coefficient
for independent scoring. As two of the EFS outcomes can- has been shown to be more stable when outcome preva-
not be evaluated without the addition of systemic lence is skewed as compared to Cohen’s kappa

McGrattan et al.: Normal Values for Healthy Infant Feeding 2795

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Table 1. Proportion of infants scoring Each Early Feeding Skills (EFS) score.

3 2 1 Interrater
Variable Mature Emerging Immature reliability
Respiratory regulation
1. Each time the nipple is 70% (21) 17% (5) 13% (4) 0.69
received, transitions to Always At least once but not Never Moderate
sucking without behavioral or always
cardiorespiratory instabilitya
2. Times the length of the 83% (25) 13% (4) 3% (1) 0.60
sucking burst to remain stable Always Sucks too long before Sucks too long before Fair
stopping to breathe at stopping to breathe > 1
least once sucking burst
3. Integrates breathing within the 100% (20) 0% (0) 0% (0) 0.90
sucking burstb Consistently adds regular, Predominantly adds Predominantly holds Substantial
full breaths throughout breaths within the sucking breath during the sucking
the sucking burst burst, but they are burst
irregular, shallow, or
interrupted
5. Work of breathingc 100% (30) 0% (0) 0% (0) 0.83
No work of breathing On at least 1 occasion, a On > 1 occasion, a series Substantial
series of breaths is of breaths is labored with
labored with work of work of breathing
breathing
Oral-motor functioning
6. Actively opens mouth and 93% (28) 7% (2) 0% (0) 0.74
drops tongue to receive the Always At least once but not Never Moderate
nipple when lips are stroked always
7. Promptly starts sucking once 83% (25) 13% (4) 3% (1) 0.62
nipple is received Always At least once but not Never Fair
always
9. Loss of milk at lips 33% (10) 13% (4) 53% (16) 0.56
Never Loss of milk once Loss of milk > 1 time Fair
Swallow coordination
10. Gurgle/rattle sounds created 85% (17) 0% (0) 15% (3) 0.89
by fluid in the nose or Never Once > 1 event Substantial
pharynxb
12. High-pitched “yelping” sound 75% (15) 10% (2) 15% (3) 0.63
when transitioning from Never Once > 1 event Fair
swallowing to breathingb
13. Coughing or choking 70% (14) 10% (2) 20% (4) 0.89
soundsb Never Once > 1 event Substantial
Engagement
15. Sustains motor tone, energyd 100% (30) 0% (0) 0% (0) 1.0
All the time Loss of muscle tone/ Loses muscle tone/energy Almost Perfecte
energy after 5 min, but within 5 min
within the feeding
Physiologic stability
16. Stressf 30% (9) 3% (1) 67% (20) 0.71
0 or 1 mild distress cue 2 or more mild distress At least 1 compelling Fair
cues distress cue
17. Color change 100% (30) 0% (0) 0% (0) 1.0
Never 1 episode > 1 episode Almost Perfecte
Note. Physiologic Process 4 was not included as it did not meet interrater reliability criteria. Values in cells represent the proportion (N) of
participants achieving each score variant during the initial feed.
a
Instability is evidenced by behavioral (eyebrow raise, eyelid flutter, furrowed brow, worried look, moving away from nipple, extending fingers
or arms, and pushing nipple away) or physiologic cues (apnea, desaturation, and heart rate drops). bN reflects a subset of participants with
intact audio recordings. Interrater reliability reflects Gwet’s correlation coefficient, and the corresponding Landis–Koch reliability category using
Gwet’s (2014) cumulative membership probability approach to benchmarking. cIncreased work of breathing is evidenced by nasal flaring and/or
blanching, chin tugging/pulling head back/head bobbing, suprasternal retractions, grunting/prolonging the exhale, or use of accessory breathing
muscles. dEnergy is expressed through motor tone, postural control, midline feeding position, and flexion. eTop reliability category is used as
probabilities could not be calculated due to complete rater agreement. fMild: Eyebrow raise, eyelid flutter, furrowed brow, worried look,
splaying/extending fingers, or arms; Compelling: moving away from nipple and pushing nipple away.

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(Wongpakaran et al., 2013). Outcomes were judged to be from caregivers who both breast and bottle fed their infant
reliable if raters achieved fair agreement, as defined by a revealed all infants but 2 scored within the 90th percentile
cumulative membership probability calculated with the irr- for each domain, indicating no concerning feeding behav-
CAC package in R (Gwet, 2014). ior. In one case, the infant’s sensory responsiveness score
was in the 90th–95th percentile, indicative of some concern
for feeding impairment, and in the other case, the infant’s
Results energy and physiology stability score was above the 95th
percentile and feeding flexibility score was in the 90th–95th
Background Information percentile, indicating high concern for feeding impairment
and some concern for feeding impairment, respectively.
Participants were evenly distributed by sex (50% Despite these categorizations, these infants were left in the
male) and underwent feeding monitoring at an average subsequent analysis as the caregivers did not perceive a
chronological age of 4 ± 2 months (range: 1–8 months). functional impairment in their child’s feeding patterns as
All but two infants, whose caregivers requested monitor- indicated by caregiver report during eligibility screening for
ing in the lab, underwent monitoring in their home envi- study inclusion, which is the underlying gauge for the sig-
ronment. Both monitored feeds occurred on the same day nificance of physiologic presentations in otherwise healthy
for all but one infant, whose monitored feeds occurred infants without impairments in systemic health.
3 days apart. Sixty-three percent (N = 19) of infants
enrolled in the investigation were both breast and bottle OFS
fed, with all others strictly bottle fed. All infants were con-
sidered by parents to be experienced bottle feeders prior Infants consumed an average of 104 ± 52 ml in
to the assessment session. The majority of the infants were 16 ± 6 min, although volumes and feed durations varied
fed using a Dr. Brown’s Level 1 nipple (67%, 20), with largely across infants (volume 20–210 ml; duration 8–
the remainder fed by a Level 2 (30%, 9) or newborn/ 32 min). This equated to an average RT of 7 ± 3 ml/
transitional (3%, 1; see Table 2). min. The RT was greatest during the first 5 min of the
feed (9 ± 3 ml/min) during which time infants con-
sumed 50% of their total milk ingestion (modified pro-
NeoEAT-Mixed Breast and Bottle Feeding ficiency). As a result, the majority of infants scored the
highest OFS score of 4 (93%, 28) with the other two
NeoEat-Mixed results revealed caregivers primarily scoring 2 and 3. See Table 3 for a full report of OFS
reported normal, nonconcerning feeding patterns across all outcomes.
of the NeoEAT-Mixed outcomes. When suboptimal feeding
The examination of how infants varied in their OFS
behaviors were reported, they were most frequently in
correlates of milk ingestion across feeds revealed that
reports of their infant getting the hiccups (36%, 11) and
infants showed high variability in performance across
gulping when eating (23%, 7). Cumulative section results
feeds. Feeding duration was the least variable, changing
an average of 28% (4.6 min) from the first (16 ± 6 min) to
Table 2. Participant characteristics (N = 30).
Table 3. Oral Feeding Scale (OFS) scores.
Variable M ± SD and N (proportion)
M ± SD and N
Gestational age (weeks) 39 ± 0.98 Variable (proportion)
Chronological age (months) 4 ± 1.88
Milk consumed in 5 min (ml) 44 ± 15 ml (15–80)
Sex
Total milk consumed (ml) 104 ± 52 (20–210)
Male 15 (50%)
Feed duration (minutes) 16 ± 6 (8–32)
Female 15 (50%)
Rate of transfer (ml/min) 7 ± 3 (1–12)
Race Total milk consumed/feed duration
Asian 2 (7%) Modified proficiency (%) 50 ± 21 (23–100)
White 25 (83%) 5-min intake/total intake
Other 3 (10%) OFS level
Bottle nipple used 1 0 (0%)
Newborn/transitional 1 (3%) 2 1 (3%)
Level 1 20 (67%) 3 1 (3%)
Level 2 9 (30%) 4 28 (94%)
Note. All bottle nipples are Dr. Brown’s brand. Note. Values reflect M ± SD and N (proportion).

McGrattan et al.: Normal Values for Healthy Infant Feeding 2797

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the second feed (14 ± 5 min). Greater variability was seen common for them to score immature (worst) on others;
in the amount of milk consumed during the feed (40% and (c) some variation in performance across OFS and
change, 30 ml), modified proficiency (40% change, 17% EFS outcomes may be normal.
modified proficiency), and RT (54% change, 2.7 ml/min).

EFS Healthy Infants Typically Scored the

Highest OFS Score
Interrater reliability of fair or greater was achieved
on 13 of the 17 attempted EFS items (see Table 1). Our results indicating that the majority of the tested
Results from those processes not meeting reliability crite- term infants scored an OFS Level 4 is consistent with pre-
rion (4, organizes long sucking bursts; 8, sucks with strong vious work completed in preterm infants taking all nutri-
steady suction; and 11, gulping or effortful swallows; 14, tion by mouth (Lau et al., 1997; Lau & Smith, 2011). Pre-
state) will therefore not be reported in this investigation term infants who continued to require supplemental nutri-
(see Table 1). tion commonly scored OFS 1, whereas the majority of
infants who had obtained full oral intake achieved an
The majority of infants scored the best EFS score
OFS level of 2 or 4 (Lau et al., 1997). Although categori-
(mature-3) as it related to their consistent integration of
zation of milk intake into OFS levels based on thresholds
breathing within the suck burst (100%, 20), maintenance
for RT (1.5 ml/min) and proficiency (30%) provide one
of steady respiration without increased work of breath
method of feeding characterization, examination of the
(100%, 30), opening of their mouth in response to the nip-
specifics of these correlates may have greater clinical sig-
ple (93%, 28), maintenance of motor tone and energy
nificance for term infants who require faster rates of
throughout the feed (100%, 30), and absence of color
intake to keep up with increasing nutritional needs. Feed-
changes during the feed (100%, 30). Despite this high per-
ing at a rate of 1.5 ml/min would only result in consump-
formance among these items, infants commonly scored in
tion of 45 ml over 30 min; a volume far below what the
the worst EFS score (immature-1) for others. This was
healthy term infant needs as they progress throughout the
characterized by loss of milk at their lips more than one
first year of life. In fact, Lau and Smith (2011) found the
time (53%, 16), coughing or choking sounds (20%, 4), and
average RT among preterm infants in OFS 4 was 2.6 ml/
one or more compelling stress cues (67%, 20) as defined
min. In our sample of healthy term infants, we found an
by the infant moving away from the bottle nipple or push-
average rate of 7 ml/min, with some infants consuming
ing the nipple away. Table 1 provides a full listing of EFS
milk at rates as fast as 12 ml/min (Lau & Smith, 2011).
scale outcomes with the associated proportion of infants
Interestingly, the rates of milk transfer found in our inves-
scoring within each score level.
tigation are notably slower than those reported in the past
Examination of an infant’s stability in EFS perfor- among healthy term infants. Specifically, Pollitt et al.
mance across feeds revealed that, while some variation in (1981) reported RT ranging from 14 to 19 ml/min,
performance within physiologic processes did appear to be McGowen et al. (1991) reporting values ranging from
normal, the majority (73%) of infants scored the same 24 to 25 ml/min, and Mathew et al. (1992) reported values
within each parameter across feeds. If changes in perfor- ranging from 13 to 23 ml/min (Mathew et al., 1992;
mance did occur, there were approximately equal propor- McGowen et al., 1991; Pollitt et al., 1981). One source for
tions of infants whose score improved for any given com- these differences may be differences in age of tested
ponent (14%) compared to those whose score declined infants, with some previous work suggesting older infants
(13%). consume milk at faster rates of transfer (McGowen et al.,
1991). What does not fully align with this theory is that
the ages of infants studied in these past investigations
Discussion were typically younger, with data collected within the first
weeks of life, than the infants who were studied at an
This pilot investigation is the first to elucidate nor- average of 4 months old in the current investigation.
mal infant feeding performance as measured by the Another source may be in the timing that measures were
NeoEat-Mixed, OFS, and the EFS assessments. Key find- made. Our values report the average RT throughout the
ings from this investigation indicate (a) the overwhelming entire feed. However, Pollitt et al. (1981) calculated these
majority of healthy term infants without functional feed- during the initial 3 min of the feed (Pollitt et al., 1981).
ing impairments achieve an OFS score of 4 with an aver- We demonstrated that the volume of intake was greatest
age RT of 7 ml/min and modified proficiency of 50%; (b) during the initial 5 min of the feed during which time
although it was common for infants to score mature (best) infants consumed an average of 44 ml, yielding a RT of 9
performance for select EFS scale outcomes, it was also ml/min. It is plausible that our rates of transfer would be

2798 American Journal of Speech-Language Pathology • Vol. 32 • 2792–2801 • November 2023

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even faster if only including the initial 3 min as was done their lips likely does not draw significant concern. Quanti-
by Pollitt et al. (1981). Another potential source for these fying physiologic performance is of great clinical impor-
discrepancies is the differences in the bottle systems used. tance; however, considering the significance of this perfor-
Our investigation used a vented Dr. Brown’s bottle with mance in the context of the infant’s ability to achieve
nipples ranging from newborn to Level 2. In contrast, functional feeding outcomes is critical. Specifically, clini-
nipples used by Mathew et al. (1992) and Pollitt et al. cians must consider if the infant is obtaining adequate
included single-use, hospital-grade nipples that were nutritional needs orally to support adequate growth while
designed to flow faster than current versions on the mar- concurrently maintaining respiratory stability in the acute
ket, as well as a free flow milk system. Nipple and bottle (apnea) and long-term (respiratory infections) period.
attributes have been shown to influence rate of milk flow Infants who are meeting these functional outcomes do not
under simulated and real clinical feeding conditions necessarily require invasive testing or treatment unless
across different populations. Future investigations char- they are medically fragile and at high risk for dysphagia-
acterizing normal values for RT and other outcomes induced sequalae. It is notable that an infant’s perfor-
while controlling for bottle nipple and infant age are crit- mance during a bottle feed is not only strictly an indica-
ical to further delineate parameters of normal function tion of their skill but also of the feeder and apparatus
across development. used. Although all infants were feeding with the bottle sys-
tem and feeding methods selected by their caregiver to be
“functional” for their feeding needs, it is possible that per-
formance would change if these variables were altered and
Healthy Infants Do Not Always warrants further investigation.
Demonstrate Mature Feeding
Physiology on the EFS Assessment Another explanation for this dichotomy in scores
lies within components of the psychometric construct of
In contrast to our results demonstrating infants con-
the tool. A critical component in developing a reliable
sistently achieved the maximum score on the OFS were
assessment that utilizes subjective metrics is clearly delin-
our results demonstrating inconsistent achievement of the
eating a priori cut points for each categorical ranking
maximum score on the EFS assessment. Although almost
(Lefton-Greif et al., 2017; Martin-Harris et al., 2008,
all infants scored mature physiology (best) in their ability
2019). Although such practice is critical to ensure repro-
to consistently integrate breathing within the suck burst
ducibility in findings within and across clinicians, estab-
without increased work of breathing or color changes, a
lishment of these thresholds without a thorough under-
high proportion of infants also scored immature physiol-
standing of normal performance can lead to overidentifi-
ogy (worst) in their exhibition of greater than one occur-
cation of impairment. A central component of this lies
rence of milk escape from their lips and one or more com-
within frequency of a behavior. For example, the defini-
pelling stress cue. It is notable that the current investiga-
tion of compelling stress cues warranting a score of imma-
tion did not screen infants for minor illnesses such as
ture (worst) is characterized by the infant “directing
nasal congestion that may negatively influence their feed-
energy away from the feeding, actively moving away with
ing quality. Although such screening was intentionally
the head or swiping the arms, pushing, pulling away, turn-
avoided to capture “normal” infant feeding conditions
ing away one time.” Research in preterm infant popula-
including feeding during mild congestion caused by a cold,
tions demonstrates the association of these nonverbal
it may have influenced the results. Interestingly, some
communication attempts with periods of neonatal stress
domains appeared to be more predisposed to performance
and pain induced by diaper changes and heel pricks
deemed as “immature” such as oral motor functioning,
(Bigsby et al., 1996; Holsti et al., 2005). Due to their
whereas others such as respiratory regulation appeared
immature neurologic and vascular systems, preterm
more predisposed to “mature” performance. Future work
infants are postulated to be at increased risk for negative
is needed to determine if this reflects differences in oral
long-term effects arising from these encounters, warranting
motor development across these physiologic parameters.
conservative management approaches aimed at limiting
One explanation for the aforementioned dichotomy their occurrence (Sweeney & Blackburn, 2013). Although
in scoring is that it reflects the minimum physiologic past research has demonstrated term infants exhibit these
capacities that infants require for “functional” oral feed- behaviors less frequently than their preterm counterparts
ing, with the others not posing functional impairments. (Bigsby et al., 1996), little is known regarding the short- and
Becoming hypoxic and turning blue during a feed, for long-term significance of their presence. This is a critical
example, would likely cause most caregivers to deem their need, as the generalization of more conservative para-
child’s feeding as impaired to a level that warrants medi- digms to these nonverbal communication attempts is likely
cal attention, whereas dripping milk occasionally from not necessitated to the same extent for term infants at low

McGrattan et al.: Normal Values for Healthy Infant Feeding 2799

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risk for resulting neurovascular sequalae. In fact, complete assessments. Characterizing these correlates, however,
elimination of these presentations in term infants is likely provides just one piece to the assessment puzzle. The
not feasible or developmentally appropriate as infants con- true marker of the significance of aberrations to feeding
tinue to grow in their communication abilities and likely performance lies within their functional implications. A
utilize the nonverbal communication methods to indicate central focus of all examinations and treatment decisions
benign events such as the need to stop feeding to burp or needs to be not only on parameters of feeding perfor-
satiation. This highlights the limitations of utilizing assess- mance but also on parameters that are impeding the
ments designed for preterm infants to term populations. infant’s ability to consume full oral nutrition with cardio-
Although efforts to utilize evidence-based validated pulmonary stability without inflicting significant infant or
assessments to guide clinical exams are applauded, our feeder stress.
results highlight the need to thoroughly evaluate the psy-
chometrics behind the population the tool was validated
on prior to widespread utilization. As the previous vali- Data Availability Statement
dation studies on the EFS were strictly completed in pre-
term infants, utilization on other populations may cause The data used in this investigation are not available
the clinician to interpret the significance of a patient’s upon external request due to specifications of granted
presentation, such as a stress cue, incorrectly. Future institutional review board approvals.
research is needed to help differentiate between stress
cues and early nonverbal communication, as well as the
frequency that such behaviors may be normal in the term Acknowledgments
infant.
This research was supported by the Eunice Kennedy
Shriver National Institute of Child Health & Human
Healthy Infants Exhibit Variability in Development and the National Institute of Environmental
Feeding Performance Across Feeds Health Sciences under Award Number R41HD104305
(awarded to Katlyn Elizabeth McGrattan). The content is
Last, our results pertaining to the normal variation solely the responsibility of the authors and does not neces-
in feeding behaviors are of specific clinical significance. sarily represent the official views of the National Institutes
OFS outcomes were found to vary an average of 41% of Health. The authors would like to express their deepest
across feeds, with greatest variation in RT and lowest var- gratitude to the caregivers and infants who participated in
iation in feeding duration. In contrast, the majority of the investigation, as well as the study staff who assisted in
infants (73%) performed similarly within each EFS com- the investigation including Abigial Spoden, Abigial Ster-
ponent across feeds. Although it is unclear how much of kowtiz, Kristina Klein, and Abbey Hammell.
the observed variability is a result of the presence of
research equipment and the study team, similar “distrac-
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