Neonatal Feeding Performance is Related to Feeding Outcomes in Childhood

Abstract

Aim:

Define relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment.

Study design:

Ninety-one infants (44 preterm infants born ≤ 32 weeks at term-equivalent age and 47 full-term infants within 4 days of life) had feeding evaluated using the Neonatal Eating Outcome Assessment and the Neonatal Oral Motor Assessment Scale (NOMAS). At 4 years of age, 39 of these infants (22 preterm infants and 17 full-term infants; 43% follow-up rate) had parent-report measures of feeding conducted using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Pediatric Eating Assessment Tool (PediEAT).

Results:

Lower Neonatal Eating Outcome Assessment scores were related to higher PediEAT scores (p = 0.01; r = −0.44), but were not related to BPFAS scores (p = 0.17; r = −0.23). Relationships were not detected between the NOMAS and BPFAS (p = 0.35; r = 0.17), and relationships between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34). There was a relationship between the BPFAS and PediEAT scores at 4 years (p < 0.001; r = 0.66). Preterm infants performed poorer than full-term infants on the Neonatal Eating Outcome Assessment (p < 0.001) and NOMAS (p <0.001), but no differences were detected in preterm compared to full-term performance on the BPFAS (p = 0.87) and PediEAT scores (p = 0.27).

Discussion:

Neonatal feeding performance is an important predictor of feeding outcomes at 4 years of age. The Neonatal Eating Outcome Assessment has predictive validity, and the Pediatric Eating Assessment Tool has concurrent validity with relationships to another childhood feeding tool.

Introduction

Safe and successful oral feeding during the neonatal period is an important activity of daily living [1] with significant implications for long-term growth and development [2]. The ability to engage in feeding impacts the child’s sensory processing, motor function, as well as nutritional intake which fosters brain growth and development [3]. Feeding also creates one of the earliest social exchanges between the infant and caregiver, with early feeding experiences being foundational for strong parent-child relationships [4]. Ties between social exchange and feeding continue through childhood, as children engage in meaningful relationships during mealtimes and/or have shared experiences with others in relation to food [5].

Although feeding is a normal, programmed component of growth and development, neonatal feeding is a complex activity. Neonatal feeding relies on neurological maturation that drives cognitive and motor responses from sensory exposures in the environment [6]. Immaturity or poor acquisition of developmental skills can result in feeding problems [7, 8]. During the neonatal period, oral feeding difficulties can present as poor arousal to engage in the feeding process or sub-optimal oral motor reflexes (such as rooting, sucking and swallowing), impeding attainment of oral motor skills needed for feeding, and/or resulting in suck-swallow-breathe discoordination [9, 10]. Neonatal feeding problems can impact 75% of preterm and 23% of full-term infants [11]. Developmental skills related to feeding change as the infant transitions from a liquid diet to eating solids and table foods, and feeding problems also evolve throughout childhood. Childhood feeding problems can present as an inability to motorically manage a bolus of food, vomiting, avoidance, oral hypersensitivity, and/or drooling [12, 13]. Feeding problems in early childhood are common, impacting 20% of typically-developing children, 80% of children with developmental disabilities, and 85% of children with complex medical diagnoses [14]. Children with feeding difficulties also have a higher risk of comorbid developmental impairments, indicating that the problems related to feeding often do not occur in isolation [2, 15, 16].

Although there are many assessment tools available to evaluate early neurodevelopment [17], there are fewer assessments available to define the important function of feeding. There are some neonatal feeding tools that are designed to assess whether the infant is neurologically mature enough to engage in oral feeding [18, 19]. However, other assessment tools are designed specifically to detect abnormal feeding performance of bottle feeding or breastfeeding during the neonatal period.

The NOMAS is likely the most widely used and accepted neonatal feeding assessment tool for infants in the NICU [20, 21]. The NOMAS was developed in 1983 by Marjorie Meyer Palmer and consists of a 28-item observation checklist of infant tongue and jaw movement during the first two minutes of bottle feeding or breastfeeding [22]. There are mixed reports on reliability of the NOMAS [20, 23]. Some concurrent validity, with relationships between the NOMAS categorical score and early neurobehavior and cerebral structure at term equivalent age, have been reported [20, 24]. Early studies on the NOMAS demonstrated relationships between NOMAS scores and cognitive, language and motor outcomes at age 2 years [25]. However, these relationships were not supported in more recent work [20]. One study was identified that reports on the predictive validity, with early NOMAS scores related to subjective feeding performance at 6 and 12 months of age [26].

The Neonatal Eating Outcome Assessment, developed in 2014 by Roberta Pineda, has been adopted by many NICUs for neonatal feeding assessment and used for research investigating early feeding performance in newborns [27]. This standardized feeding assessment tool defines feeding skills in infants based on the observation of a 20-minute bottle feeding or breastfeeding attempt, and appropriate feeding performance is determined in relation to what is expected at the infant’s postmenstrual age (PMA) [28]. Good to excellent inter-rater reliability and concurrent validity have been defined [29, 30], but the predictive validity of the Neonatal Eating Outcome Assessment has yet to be evaluated.

This study aims to define the relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment. The concurrent validity of the Pediatric Eating Assessment Tool (PediEAT), a childhood parent-report measure of feeding performance, was also evaluated.

Methods

Study design

This prospective longitudinal study was approved by the Human Research Protection Office at Washington University in St. Louis. Written informed consent was obtained from the infants’ mothers.

Participants

One hundred and one infants were prospectively enrolled (50 preterm infants and 51 full-term infants) as part of two overarching studies. Feeding was assessed during the neonatal period (at term equivalent age for preterm infants and within 4 days of life for full-term infants) using the Neonatal Eating Outcome Assessment and NOMAS. Feeding performance at 4 years of age was determined using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and the PediEAT.

Fifty preterm infants born ≤ 32 weeks estimated gestational age (EGA) were prospectively enrolled prior to oral feeding initiation from the 85-bed level IV neonatal intensive care unit (NICU) at St. Louis Children’s Hospital in St. Louis, Missouri. Infants were recruited between January 2015 and June 2015 as part of an overarching study investigating feeding progression across PMA [31]. Exclusion criteria included documented congenital anomaly (such as Trisomy 21, VACTERL sequence, cardiac anomalies, and cleft lip and palate) or birth > 32 weeks EGA.

Fifty-one full-term infants born ≥ 37 weeks EGA were consecutively enrolled within the first 4 days of life from the 35-bed labor and delivery floor at Barnes-Jewish Hospital in St. Louis, Missouri. Infants were recruited between May 2016 and August 2016 as part of an overarching study of full-term infant experiences and development [27]. Infants were excluded if they had a congenital anomaly, hospitalization in the NICU, or birth < 37 weeks EGA.

The sample size was predetermined, due to samples coming from two overarching studies. However, analyses for the current study with a sample of n=32 provides 80% power to detect relationships when the true linear correlation between the neonatal feeding measures and the childhood feeding measures is 0.48 based on α = 0.05.

Infant and demographic factors

Infant and demographic information collected from the medical record included maternal age, maternal marital status, race (Black or non-Black), mode of delivery (vaginal or Caesarean section), insurance type (public or private), infant sex, EGA at birth (based on dates or Ballard exam, when dates could not be determined with accuracy), infant birth weight, and length of hospital stay after birth.

Study procedures

Once the preterm infants reached term equivalent age (between 35- and 41-weeks PMA) and had full oral intake of their nutritional volume for at least 24 hours, an oral feeding was video recorded. For the recording, parents and healthcare professionals were instructed to feed the infant how they normally would, and a full feeding was recorded for 20 minutes. Infants were fed by their parents when they were present, and the mode of feeding (breast or bottle) was selected by the parents. A member of the nursing staff, an occupational therapist, or a speech-language pathologist fed the infants by bottle when parents were unavailable, which is common practice within the NICU setting.

For the full-term infants, prior to discharge from the hospital and within 4 days of birth, an oral feeding was video recorded for 20 minutes. For the recordings, parents were instructed to feed their infant as they normally would using their preferred mode of feeding (breast or bottle). No instructions were given during the recording.

The video recording of the feeding was initiated before the nipple was placed in the infant’s mouth, when possible, and included a lateral view of the jaw and lips. The videos of the preterm and full-term oral feedings were scored using the Neonatal Eating Outcome Assessment and NOMAS by an evaluator trained and certified, when appropriate, in the use of each measure. When the infant did not show readiness for oral feeding with adequate arousal, sucking, and engagement in the oral feeding process, neonatal feeding scores were not considered in data analysis.

Once the preterm and full-term infants reached 4 years (± 1 year; from 3-5 years) of age, their parents were sent a questionnaire that included standardized parent-report measures of oral feeding. A waiver of written informed consent was granted from the institutional review board for this portion of the study. The questionnaire was completed in paper format and mailed back, and parents were also given the option to complete the questionnaire online via a Research Electronic Data Capture (REDCap) survey [32, 33]. The questionnaire, which contained the BPFAS and the PediEAT, took approximately 15-minutes for parents to complete. Questions that were similar across the two measures were combined on the questionnaire to decrease parent burden (e.g., likes to eat [PediEAT] and enjoys eating [BPFAS]; prefers to drink instead of eat [PediEAT] and would rather drink than eat [BPFAS]). Written copies of the questionnaire were sent to the home address for parents to return in a self-addressed, pre-stamped envelope. After several attempts (a minimum of 2) at encouraging participation with reminder phone calls, an abbreviated questionnaire, which only contained the BPFAS measure and took approximately 5 minutes to complete, was mailed to the home address with a request for completion.

Measures

Feeding performance was assessed during the neonatal period (Neonatal Eating Outcome Assessment and NOMAS) and at 4 years of age (BPFAS and PediEAT).

Neonatal Eating Outcome Assessment

Feeding performance for the preterm and full-term infants during the neonatal period was assessed using the Neonatal Eating Outcome Assessment [30]. The Neonatal Eating Outcome Assessment is appropriate to assess bottle feeding or breastfeeding from approximately 32 weeks PMA until 4-6 weeks corrected age and consists of 18 scored items in three sections (Pre-feeding Behaviors, Oral Feeding, and Observations at the End of Feed). Scoring of each item is based on the expected performance at each PMA. The total raw score of the Neonatal Eating Outcome Assessment ranges from 18 to 90. Higher scores indicate better feeding performance. Based on established ranges, raw scores can also be categorized as normal (77-90), questionable (58-76), or feeding challenge (18-57). For this study, the raw score was used in analysis. The Neonatal Eating Outcome Assessment has good to excellent inter-rater reliability, and concurrent validity has been established with relationships to the NOMAS [29, 30].

Neonatal Oral Motor Assessment Scale (NOMAS)

Neonatal feeding performance was also assessed using the NOMAS, which is appropriate for assessing bottle feeding or breastfeeding once oral feeding is initiated in the newborn. Using the NOMAS, feeding performance is categorized as either normal, disorganized or dysfunction based on the presence and/or absence of observed jaw and tongue movements during the first 2 minutes of oral feeding. The NOMAS has mixed reports on reliability, some established concurrent validity, mixed reports on predictive validity of neurodevelopmental impairment [20, 22-24], and one study demonstrating predictive validity of subjective feeding performance at 6 and 12 months corrected age [26].

Behavioral Pediatrics Feeding Assessment Scale (BPFAS)

The BPFAS is a 35-item parent-report assessment that defines patterns of mealtime and feeding behaviors in young children aged 9 months to 7 years. The first 25 items describe the child’s feeding behaviors (e.g., has problems chewing food, comes readily to mealtime), and the last 10 items describe the parental feelings and strategies used to address mealtime behaviors (e.g., I coax my child to get him her to take a bite, I feel that my child’s pattern hurts his her general health). For each item, parents indicate how often the behavior occurs on a five-point Likert scale, which ranges from 1 (“Never”) to 5 (“Always”). Scores range from 35 to 175 with higher overall scores indicating more problems in mealtime behaviors and feeding [34]. The BPFAS has good test-retest reliability and established content and concurrent validity [35, 36].

Pediatric Eating Assessment Tool (PediEAT)

The PediEAT is a 78-item parent-report assessment that measures symptoms of feeding problems in young children aged 6 months to 7 years. The questionnaire includes four subscales (Physiologic Symptoms, Problematic Mealtime Behaviors, Selective/Restrictive Eating, and Oral Processing). Parents report how often the problematic mealtime behavior described in each item occurs on a six-point Likert scale, which ranges from 0 (“Never”) to 5 (“Always”). Total scores range from 0 to 390, with higher scores indicating more symptoms of problematic feeding. The PediEAT total score has excellent internal consistency, good to excellent test-retest reliability, and established construct validity [14, 37].

Statistical Analysis

Statistical analyses were conducted using Statistical Package for the Social Sciences Statistics, Version 23.0 (IBM Corporation, USA). All statistics were conducted and/or reviewed by biostatistician and author Michael Wallendorf. Descriptive statistics were used to define infant and demographic characteristics of the sample as well as neonatal and childhood feeding scores. Pearson correlation statistics were used to determine differences between continuous scores on the Neonatal Eating Outcome Assessment and the continuous scores on the BPFAS and PediEAT. Relationships between the NOMAS scores, considering them as ordinal in nature, and the continuous scores on the BPFAS and PediEAT were also explored using Pearson correlation statistics. The relationship between the BPFAS and PediEAT, both completed at 4 years of age, was also explored using correlation. Significance during correlation analyses was defined as p < 0.05 and r > 0.30. Differences in the Neonatal Eating Outcome Assessment, PediEAT, and BPFAS scores among preterm and full-term infants were investigated using independent samples t-tests. Differences in NOMAS among preterm and full-term infants was explored using chi-square analysis. Significance was defined as p < 0.05.

Results

Refer to Figure 1 for a flow diagram of infants enrolled in the study. One hundred and one infants (50 preterm infants and 51 full-term infants) were enrolled. One full-term infant was excluded after enrollment due to an identified congenital anomaly. Neonatal oral feeding performance using the Neonatal Eating Outcome Assessment and NOMAS was not defined in 9 infants (6 preterm infants and 3 full-term infants) due to lack of feeding readiness at the time of assessment. Therefore, 91 infants (44 preterm infants and 47 full-term infants) were followed longitudinally, with attempts made to obtain feeding outcome measures at 4 years. At 4 years of age, 39 parents of infants (22 preterm infants and 17 full-term infants) completed the questionnaire to define feeding outcome in childhood, with a questionnaire return rate of 43%. Of these, 39 questionnaires (22 preterm infants and 17 full-term infants) included both the BPFAS and PediEAT, and 32 questionnaires (17 preterm infants and 15 full-term infants) included only the BPFAS.

Figure 1.

Participant flow diagram.

Among the sample of infants with neonatal and childhood feeding measures, 21 (96%) preterm infants were bottle-fed (instead of breastfed), compared to 5 (29%) full-term infants (p < 0.001) being bottle-fed (instead of breastfed) during the neonatal feeding assessment. The average age at the time of neonatal feeding outcome measure was 38.6 ± 2.1 weeks PMA and was not significantly different between preterm and full-term infants (p = 0.56). The average age at the time of childhood feeding measures was 45.3 ± 7.8 months chronological age. Parents of preterm infants completed the questionnaires later than the full-term group (51.3 ± 4.5 months for preterm infants compared to 37.5 ± 2.4 months for full-term infants; p < 0.001).

Table 1 provides infant and demographic characteristics of each group.

Table 1.

Infant and demographic characteristics.

	Total sample (n = 39)	Preterm (n = 22)	Full-term (n = 17)	*p value
	Mean ± SD or N (%)
Maternal factors
Maternal age	30.8 ± 6.5	31.7 ± 6.8	29.5 ± 6.1	0.30
Maternal marital status: Single	16 (41%)	10 (46%)	6 (35%)	0.52
Race: Black	17 (44%)	6 (27%)	11(65%)	0.02
Mode of delivery: Caesarean section	26 (67%)	20 (91%)	6 (35%)	<0.001
Insurance Type: Public	21 (54%)	12 (55%)	8 (47%)	0.92
Infant factors
Sex: female	24 (62%)	12 (55%)	12 (71%)	0.31
EGA (weeks)	32.5 ± 6.0	27.6 ± 3.0 (range 23-32)	38.8 ± 1.2 (range 37-41)	<0.001
BW (g)	2124.1 ± 1237.6	1119.1 ± 454.0	3424.7 ± 425.4	<0.001
LOS (days)	51.3 ± 53.0	88.1 ± 42.5	3.5 ± 1.2	<0.001

Abbreviations: Estimated Gestational Age (EGA); Birth Weight (BW); Length of Stay (LOS)

^*p value is from investigations of differences in maternal and infant factors across the preterm and full-term groups using independent sample t-tests for continuous variables and chi-square analyses for categorical variables. Bold values are those that reached significance (p < 0.05), indicating a difference in the preterm and full-term groups.

Refer to Figure 2 for relationships between neonatal feeding assessments and childhood feeding outcome measures. Lower scores on the Neonatal Eating Outcome Assessment were associated with higher scores on the PediEAT (p = 0.01; r = − 0.44; Figure 2A). No association was detected between the Neonatal Eating Outcome Assessment and the BPFAS (p = 0.17; r = −0.23; Figure 2B). Relationship between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34; Figure 2C), and no relationships between the NOMAS and BPFAS scores were detected (p = 0.35; r = 0.17; Figure 2D).

Figure 2.

Relationships between neonatal and childhood feeding assessments. (A) Relationship between Neonatal Eating Outcome Assessment and PediEAT; (B) Relationship of Neonatal Eating Outcome Assessment to BPFAS; (C) Relationship between NOMAS and the PediEAT; (D) Relationship between NOMAS and the BPFAS; p values from investigating relationships using Pearson correlation

Bold values are those that reached significance (p < 0.05; r > 0.30).

Relationships between the two childhood feeding outcome measures, PediEAT and BPFAS, were observed (p < 0.001; r = 0.66).

Table 3 displays neonatal and childhood feeding scores for both preterm and full-term infants. While differences between preterm and full-term infant feeding skills at term equivalent age have previously been reported [11], this subset of infants also demonstrated significantly more feeding problems among preterm infants during the neonatal period compared to the full-term group (p < 0.001 for Neonatal Eating Outcome Assessment and p < 0.001 for NOMAS). However, no differences in feeding outcome at age 4 years were detected in children born preterm compared to children born full-term for the BPFAS (p = 0.87) and the PediEAT (p = 0.27). However, a sample of 20 per group (preterm and full-term) would provide 80% power when the true mean difference is 18 for BPFAS and 35 for PediEAT, meaning there is a higher chance of a Type II error due to inadequate sample size.

Discussion

The key finding of this study is that early feeding performance during the neonatal period (using the Neonatal Eating Outcome Assessment) is related to feeding outcomes in childhood (using the PediEAT). Furthermore, our findings established the predictive validity of the Neonatal Eating Outcome Assessment, with its relationship to the PediEAT at 4 years of age. Finally, concurrent validity of the PediEAT, with its relationship to the BPFAS, was established.

While relationships of early feeding performance to neurodevelopmental outcomes are well understood [2, 38, 39], there is a paucity of studies evaluating the relationship of neonatal feeding performance with later feeding outcome. Hawdon et al. found that infants who were dysfunctional on the NOMAS during the neonatal period were 6 times more likely to have negative responses to feeding at age 6 months and less likely to enjoy mealtimes and tolerate textures at age 12 months [26]. However, our study is the first, that we are aware of, to define relationships of neonatal feeding performance with standardized parent-report measures in childhood at age 4 years. Thus, our study contributes to our understanding of how neonatal feeding performance can be an important predictor of childhood feeding outcome. It will be important to continue to follow this cohort, as other studies have identified that feeding performance at age 4 years is not related to feeding outcome at 16 years [40]. Feeding is a dynamic function that evolves over time [12, 41]. Discriminating function across the continuum of development may necessitate standardized measures that assess a wide range of feeding domains across time, however, there are currently few standardized feeding assessments available. Additionally, this study appears to have been appropriately powered to investigate relationships between early neonatal feeding assessments with the childhood feeding outcomes, but there is a chance of a Type II error.

Feeding is an important area of function that is not defined from traditional neurobehavioral [42-44] and neurodevelopmental [45, 46] assessments. There are a few feeding assessments available for clinicians [18, 19, 22, 47-52], with most in early childhood being parent-report measures [53, 54]. The Neonatal Eating Outcome Assessment is a new measure of neonatal feeding, that now has demonstrated predictive validity with its relationship to the PediEAT at age 4 years. Reliability and concurrent validity of the Neonatal Eating Outcome Assessment have previously been reported [29, 30, 34, 55-57], and this study adds to the psychometrics of this tool. The PediEAT is also a new childhood feeding tool, and this study establishes concurrent validity of the PediEAT, with its relationships to the BPFAS, which has been cited as the most reliable questionnaire available to measure feeding disorders in preschool age children [36, 58]. Further, these findings contribute to other studies supporting the reliability, content validity, and construct validity of the PediEAT [14, 37]. However, our study is the first study, that we are aware of, to support the concurrent validity of the PediEAT, with its relationships to the BPFAS.

Although we were able to identify poorer neonatal feeding performance in preterm infants compared to full-term infants, we did not observe differences in childhood feeding performance (at age 4 years) across preterm and full-term groups. However, we may not have had adequate power to detect differences. Results of research investigating childhood feeding outcome in children born preterm compared to full-term is mixed. Some studies identify that prematurity increases the risk of feeding impairment in childhood through age 6 years [2, 59-61], while others identify no differences in later feeding outcomes among prematurely born children [62, 63]. Our findings are consistent with Sanchez et al., who reported no observed differences in BPFAS scores between preterm and full-term groups at age 3 years [62]. It is possible that there are complexities related to the stressors of parenting and the impact of having a child who has overcome medical obstacles, that could influence parent-report measures of feeding in childhood, specifically in the preterm group. The stress of parenting a preterm infant can change parenting behaviors, with parents of preterm infants being more intrusive, strict, and controlling [64], which could impact their reports of feeding challenges. There also is some evidence to support that the experience of having a preterm infant also could impact parent-reporting of what is developmentally appropriate versus problematic [65, 66]. Other factors that could impact study findings include the timing of the assessment and whether there was time for resolution, medical complexity with the potential impact of medical influences, different populations studied including some with infants born extremely low birth weight, different feeding outcome measures used with some potentially not being able to discriminate childhood feeding outcomes, and different environmental or cultural influences on feeding behaviors [40, 59, 61, 63, 67]. Comparisons across culturally and medically similar infant cohorts could aid our understanding of factors that impact long-term feeding performance. Also, better defining therapy interventions and environmental influences on feeding could increase our understanding of how feeding is impacted by moderators.

In early infancy, feeding assessments measure feeding constructs that are specific and appropriate to this early developmental stage, such as state regulation, arousal, rooting, and suck-swallow-breathe coordination [68]. In childhood, problematic feeding behaviors are determined by the presence or absence, as well as frequency, of specific eating-related behaviors such as vomiting, drooling or difficulty with mastication [37]. Although feeding evolves across development, with the child largely consuming milk from a nipple and transitioning to eating table foods and solids, early feeding performance is a good predictor of feeding problems in later childhood. Valid and reliable feeding assessments can be used to differentiate normal versus abnormal neonatal feeding performance to aid in early identification of feeding alterations and inform targeted interventions to optimize outcome. Most importantly, problematic early feeding behaviors during the neonatal period are important areas for attention by Certified Neonatal Therapists [69], who are recognized inter-professional experts in neonatal therapy practice, possessing the knowledge and skills to safely and effectively work with high risk infants in the NICU [69].

There are several limitations to this study. This exploratory study was conducted using an overarching cohort of preterm and full-term infants, therefore the sample size was set prior to the study. This small sample size appears to have provided enough power to investigate differences in early feeding to childhood feeding, but may not have been adequate to detect differences in preterm compared to full-term infant feeding at 4 years of age. There was only a 43% follow-up rate, significantly reducing the sample of infants having measures at both time points and increasing the risk of bias related to who returned questionnaires. Variability in the infant medical factors, including whether medical issues resolved by the time of the neonatal feeding assessment, may have impacted the study findings. There was variability in the number of infants who were breastfed versus bottle-fed, and it remains unclear how this may have impacted neonatal and childhood feeding experience. The preterm group was older than the full-term group at the time of the early childhood feeding assessments. Therefore, it is possible that preterm infants had more time to resolve earlier feeding problems, potentially impacting why no differences in childhood feeding performances were observed in preterm infants compared to full-term infants. Childhood feeding outcomes were defined between 3 to 5 years of age, which represents a range of developmental stages and environmental exposures. Variability in what is developmentally appropriate or expected at different time frames across this continuum could have affected parents’ perceptions of problematic feeding behaviors and confounded the interpretation of our study findings. Likewise, neonatal feeding assessment was limited to a single time point and may not be generalizable to the infant’s overall feeding performance. Childhood feeding outcomes were measured using parent-report surveys, and it is possible that the child’s problematic feeding behaviors could have been under or over reported due to the potential for parent bias [70], The follow-up questionnaire was lengthy, and parents may have experienced question fatigue, impacting accuracy in reporting as well as potentially leading to lack of participation with the full-length questionnaire. Finally, there was a large time frame between the neonatal and childhood feeding measures, among which time the infant/child may have been exposed to therapy or experiences that could impact outcome, and this was not collected or accounted for in this study.

Despite these limitations, this study explored relationships between neonatal feeding performance and childhood feeding outcome and was able to identify that neonatal feeding is predictive of later feeding outcome extending to age 4 years. The concurrent validity and predictive validity of different neonatal and childhood feeding assessment tools are also reported. More research beyond this exploratory study is needed to aid in identifying which tools have the best predictive validity. The relationships between the NOMAS and the PediEAT failed to reach significance at p = 0.06, however, further investigation into this relationship is warranted. Further investigation is also warranted to define the predictive power of different assessment tools in addition to their combined power. Finally, further investigation using a properly powered sample is indicated to investigate differences in childhood feeding among those born preterm and full-term. Few valid and reliable feeding assessments exist to evaluate neonatal feeding, and feeding assessments are important, because they provide necessary information to enable early identification of feeding problems and initiation of targeted interventions to improve feeding experiences and developmental outcomes. This study sets the stage for future studies, that are properly powered, that can aid our understanding of the relationship between neonatal and early childhood feeding performance and improve our understanding of the trajectory of feeding performance across different developmental stages.

Table 2.

Neonatal and childhood feeding scores among preterm and full-term groups.

	Total sample (n = 39)	Preterm (n = 22)	Full-term (n = 17)	*p value
	Mean ± SD or N (%)
Neonatal Eating Outcome Assessment Total Score	73.7 ± 15.6	65.0 ± 15.5	85.1 ± 4.6	<0.001
NOMAS				<0.001
Normal	15 (38%)	0 (0%)	15 (88%)
Disorganized	12 (31%)	10 (45%)	2 (12%)
Dysfunctional	12 (31%)	12 (55%)	0 (0%)
BPFAS Total Score	66.2 ± 19.3	65.7 ± 15.2	66.8 ± 24.1	0.87
PediEAT Total Score	59.8 ± 37.0	66.7 ± 39.2	51.9 ± 34.1	0.27

Bold values are those that reached significance (p < 0.05). A sample of 20 per group (preterm and full-term) would provide 80% power when the true mean difference is 18 for BPFAS and 35 for PediEAT, meaning there is a higher chance of a Type II error due to inadequate sample size. Abbreviations: Behavioral Pediatrics Feeding Assessment Scale (BPFAS); Pediatric Eating Assessment Tool (PediEAT)

^*p value is from investigating differences in preterm and full-term infants using independent samples t tests for continuous variables and chi-square analyses for categorical variables.

Highlights.

• Neonatal feeding is an important predictor of feeding outcomes at age 4 years.

• The Neonatal Eating Outcome Assessment has established predictive validity.

• The Pediatric Eating Assessment Tool has concurrent validity.