Early

Feeding Skills Assessment Tool (EFS)

to the age of 6 months. The EFS is intended to be completed by a clinician who understands the

development of early feeding skills and is familiar with indicators that skills are not yet developed.

Disclosure: The EFS is not intended to provide a diagnosis, but instead may provide the healthcare

provider with an objective assessment of the child’s current skills in order to facilitate diagnosis and

treatment decisions.

Referencing Information:

Please give appropriate credit to the authors when presenting, publishing, or otherwise referencing the

Early Feeding Skills Assessment Tool (EFS).

Thoyre, S. M., Shaker, C., Pridham, K. F. (2005). The Early Feeding Skills assessment for preterm infants.

Neonatal Network, 24(3), 7-16. doi: 10.1891/0730-0832.24.3.7

Thoyre, S., Pados, B., Shaker, C. Fuller, K., & Park, J. (in development). Psychometric field test of the Early

Feeding Skills (EFS) assessment tool.

Please check the Feeding Flock website for updates to references: www.feedingflock.web.unc.edu
 EARLY FEEDING SKILLS ASSESSMENT (EFS)
Respiratory Regulation 3 2 1
1. Each time the nipple is received, Consistently stable Instability for at least one Instability for most or all
transitions to sucking without behavioral transition transitions
a
or cardio-respiratory instability
2. Times the length of the sucking burst to Consistently Occasionally sucks too long Frequently sucks too long
remain stable before stopping to breathe before stopping to
breathe
3. Integrates breathing within the sucking Consistently Attempts to add breaths but No or rare breaths during
burst is not yet fully integrated the sucking burst
4. Organizes long sucking bursts (7+ sucks) Consistently takes long Occasionally long sucking Frequently long sucking
without signs of behavioral or cardio- sucking bursts and bursts lead to instability bursts lead to instability
respiratory instability remains stable OR no long sucking bursts
b
5. Increased work of breathing Never or rarely Occasionally Frequently
Oral-Motor Functioning 3 2 1
6. Actively opens mouth and drops tongue to Consistently Inconsistent Never
receive the nipple when lips are stroked
7. Promptly starts sucking once nipple is Consistently Inconsistent Never or rarely
received
8. Sucks with steady and strong suction Consistently Occasional compression- Frequent compression-
only sucking only sucking
9. Loss of milk at lips No or rare loss of milk Occasional loss of milk Frequent loss of milk
Swallowing Coordination 3 2 1
10. Gurgling/rattle sounds created by fluid in No or rare gurgling Occasional gurgling Frequent gurgling
the nose or pharynx
11. Gulping or effortful hard swallows No or rare gulping Occasional gulping Frequent gulping

12. High-pitched “yelping” sound when No or rare “yelping” Occasional “yelping” Frequent “yelping”
transitioning from swallowing to breathing
13. Coughing or choking sounds Never One event observed More than one event
Engagement 3 2 1
14. State Awake Becomes drowsy late in the Becomes drowsy early in
feeding the feeding
c
15. Energy Sustains motor Late loss of tone/energy Early loss of tone/energy
tone/energy
Physiologic Stability 3 2 1
d
16. Stress No or rare Occasional Frequent
17. Color change No color change Occasional color change Frequent or prolonged
color change
18. Stable oxygen saturation Stable, remains close to Occasional dips below Frequent or prolonged
pre-feeding level clinical standards dips below clinical
standards
19. Stable heart rate Stable, remains close to Occasional rise or dips 20% Frequent rise or dips 20%
pre-feeding level above or below pre-feeding above or below pre-
feeding
a
Instability is evidenced by behavioral (eyebrow raise, eyelid flutter, furrowed brow, worried look, moving away from nipple, extending
fingers or arms, pushing nipple away) or physiologic cues (apnea, desaturations, heart rate drops).
b
Increased 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.
c
Energy is expressed through motor tone, postural control, midline feeding position, and flexion.
d
Eyebrow raise, eyelid flutter, furrowed brow, worried look, moving away from nipple, extending fingers or arms, pushing nipple away

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EFS Scoring

Each subscale is scored individually. Each item can score 1, 2, or 3 with 1 representing the least skill or high frequency
of problem (right hand column) and 3 representing mature skill or absence of problem (left hand column). Scores of 2
indicate skills that are emerging/occasionally observed or problems that are occasionally observed. Provide total
scores and an “X” in the appropriate box to the right of the total score for each subscale.

Every item scores At least one item scores At least one item scores
“3” “2” “1”

Skill is consistently Skill still emerging Skill not yet evident
Total observed and/or problem is and/or significant
Score indicated problem is evident
Respiratory Regulation
(Range 5 – 15)
Oral-Motor Organization
(Range 4 – 12)
Swallowing Coordination
(Range 4 – 12)
Engagement
(Range 2 – 6)
Physiologic Stability
(Range 4 – 12)
Total EFS
(Range 19 – 57)

10/8/2017 © 2017 Suzanne Thoyre Page 2