10 • 2022 • Developmental Observer A s early as 1974, it was reported that a deviant suck was a sign of neurological issues.1 Hill and Volpe reported in 1981 that, difficulty with neonatal sucking has been described as an early indicator of neurologic abnormalities.1 Typical sucking in the infant has been well described in the literature. It is generally accepted that, in the preterm infant, the immature pattern is characterized by short bursts of three to five sucks followed by a pause of equal duration. In the term infant, there is a continuous sucking burst of 10-30 sucks per burst with an average ratio of one suck-one swallow-one breath.2 In both cases, the infant is comfortable with coordi- nated respiration while feeding occurs effortlessly. When an infant is unable to coordinate sucking, swallow- ing, and breathing in a rhythmical and comfortable fashion, the suck pattern presents as disorganized.3 In this case it is usually caused by the infant’s inability to maintain adequate respiration while also sucking and swallowing. Such infants may experience apnea or oxygen desaturation during feeding.4 If feeding persists, the infant may show signs of stress such as finger splay, head turning, widening of the eyes, extension of the limbs, arching backward, or any of the many other be- haviors indicative of distress. It is important for the feeder to recognize these signs of stress in the infant, to respond quickly to alleviate the cause of stress which will calm the infant, and to assure feeding is a pleasurable experience.5 The Neonatal Oral Motor Assessment Scale (NOMAS) is a tool designed to assess neonatal sucking and distinguish be- tween disorganized and dysfunctional feeding. A recent study reported that infants who lack coordination of suck-swal- low-breathe and who also experience stress during feeding, as based on the NOMAS, have a longer transition time to full oral feedings than those infants who are not stressed during feeding. Infants with a disorganized suck who are stressed take 22 days to transition to full oral feedings, while those with no stress can transition in six days.6 Dr. Xianhong Zhang and colleagues in the Department of Neonatology at the Children’s Hospital of Chongqing Medical University in Chongqing, China used the NOMAS to identify abnormal sucking patterns in moderately and late preterm infants and to ascertain the relationship between these patterns and neurodevelopmental outcome at six months corrected age. This study did not enroll infants with neurologic disorders, so no infants were classified as having a dysfunctional suck. Infant feeding was classified as either normal or disorganized based on the NOMAS. The researchers reported that infants who demonstrated stress signs per the NOMAS, that is, incoor- dination of suck, swallow, and respiration which result in nasal flaring, head turning, and extraneous movement, along with arhythmical jaw and tongue movements, were at risk for adverse neurodevelopmental outcomes at six months corrected age.7 In addition to infants who present with both a disorga- nized suck and stress per the NOMAS, it is also possible to predict later developmental outcomes for infants who present with a dysfunctional suck.8 This suck pattern can be identified by abnormal movements of the tongue and jaw that occur during active sucking and that are never typical. These move- ments include the lack of a central tongue groove compared to a cupped tongue with a central tongue groove. The tongue in- stead presents as either flattened/flaccid with an absent tongue groove or is retracted with the posterior tongue humped against the palate.8 During a dysfunctional suck, the jaw may demonstrate an excessively wide excursion pulling the tongue away from the nipple and interrupting the intra-oral seal that is formed between the tongue and the palate. Another charac- teristic of a dysfunctional suck occurs when the jaw is unable to make an adequate downward movement due to a restriction of movement at the temporal-mandibular joint that inhibits smooth downward movement of the jaw. This restriction is secondary to the posterior humping of the tongue against the palate. In all cases when a dysfunctional suck is diagnosed, there is a neurological issue that has been identified or soon will be identified.9 These may include diagnoses such as, grade III intraventricular hemorrhage (IVH),9 periventricular leu- komalacia (PVL), perinatal hypoxic ischemic encephalopathy (HIE), seizure disorder, hydrocephalus, meconium aspiration, meconium staining, congenital anomalies, placenta abruptio with decreased muscle tone, chromosomal abnormalities, and neonatal encephalopathy of unknown etiology, to name a few. It has been reported that in addition to an association with dysfunctional sucking, severe IVH negatively impacts the suck-swallow-breathe rhythm. The independent effect of neurological injury in the form of IVH on early neonatal feed- ing coordination suggests that a closer analysis of feeding may reflect and predict neurological sequelae.9 Early diagnosis of the neonatal suck pattern is important because of the complexity of the neuronal network needed to suck and neuroplasticity in infancy. Because of this, the skill of sucking has the unique ability to give insight into areas of the brain that may be damaged either during or before birth.10 In 2009, it was hypothesized that a standardized instrument Predictability of Neonatal Sucking for Later Developmental Outcomes Marjorie Meyer Palmer MA, NLP, CC-SLP, Neonatal/Pediatric Feeding Specialist, Speech-Language Pathologist, Founder/Director, NOMAS® International DOI: 10.14434/do.v15i1.33788 2022 • Developmental Observer • 11 for neonatal sucking could offer a cost-effective early screen- ing tool for preterm infants at greatest risk for developmental delay,11 and the NOMAS provides such a tool. The NOMAS can be administered at the bedside within two to three minutes by the trained examiner observing a routine feeding offered by the assigned caregiver in the intensive or special care nursery. The examiner first observes the non-nutritive suck during the first burst, first pause, and second burst to rule out sen- sory conditions such as habituation and perseveration. This is followed by a two-minute observation of nutritive sucking starting once the nipple is adequately and properly placed in the infant’s mouth. The number of sucks per burst and the type of pattern (continuous or burst-pause) is observed and recorded. A disorganized sucking pattern occurs when an infant exhibits too much variability in the number of sucks per burst (sucking bursts have between 5-10 sucks per burst), or the infant demonstrates an inconsistent suck-swallow-breathe ratio. The NOMAS may also be used for breast feeding infants but will require the examiner to spend more time observing the infant because of the variability of flow that occurs with breast feeding.12,13 NOMAS-based assessments for neonatal feeding perfor- mance have been considered helpful tools to predict neuro- developmental outcome at six and 12 months corrected age.14 The NOMAS has been identified as the only neurobehavioral assessment that specifically measures preterm sucking behav- ior.15 Slattery reports in a review article that, early sucking and swallowing measures predicted neurodevelopmental out- come in later infancy in five of the six studies reviewed.16 Thus studies show that sucking and swallowing disorders in early infancy serve as potential markers of neurodevelopmental problems and abnormal sucking patterns may reflect neurolog- ic developmental issues in preterm infants.17 The NOMAS provides predictability for later developmen- tal outcomes for both disorganized and dysfunctional sucking patterns and is a screening tool that can be administered by observation at the bedside by a trained examiner. Trained examiners demonstrate reliability in the administration and scoring of the NOMAS to distinguish between disorganized and dysfunctional sucking patterns to assure the subsequent intervention strategies, therapeutic techniques, and treatment plans are appropriate. Currently there are NOMAS Licensed Professionals in 46 U.S. States and 40 foreign countries. References 1. Hill Al, Volpe JJ. Disorders of sucking and swallowing in the newborn infant: Clinicopathologic correlations, Progress in Perinatal Neurology. Philadelphia. WB Saunders, 1981,157-181. 2. Gryboski JD. Suck and swallow in the premature infant. Pediatrics. 1969, 43(1):96-102. PMID: 5764074. 3. Palmer MM, Crawley K, Blanco IA. Neonatal Oral-Motor Assessment Scale: A Reliability Study. Journal of Perinatology. 1993, 13, 28-35. 4. Hanlon MB, Tripp JH, Ellis RE, Flack FC, Selley WG, Shoesmith HJ. Deglutition apnoea as indicator of maturation of suckle feeding in bottle-fed preterm infants. Developmental Medicine and Child Neurology. 1997, 39(8):534-42. doi: 10.1111/j.1469-8749.1997. tb07482.x. 5. Als H, Lawhon G, Duffy FH, McAnulty GB, Gibes-Grossman R, Blickman JG. Individualized developmental care for the very low-birth-weight preterm infant. Journal of American Medical Association. 1994, 272 (11): 853-858. 6. Yi YG, Oh BM, Shin SH, Shin JY, Kim EK, Shin HI. Stress signals during sucking activity are associated with longer transition time to full oral feeding in premature infants. Frontiers in Pediatrics. 2018, 12, (6):54. doi: 10.3389/fped.2018.00054.  7. Zhang X, Zhou M, Yin H, Dai Y, Li Y. The predictive value of early oral motor assessments for neurodevelopmental outcomes of moderately and late preterm infants. Medicine (Baltimore). 2017, 96(50):e9207. doi: 10.1097/MD.0000000000009207. 8. Palmer MM, Heyman MB. Developmental outcome for neonates with dysfunctional and disorganized sucking patterns: Preliminary findings. Infant-toddler Intervention. The Transdisciplinary Journal. 1999, 9, (3): 299-308. 9. Gewolb IH, Sobowale BT, Vice FL, Patwardhan A, Solomonia N, Reynolds EW. The effect of severe intraventricular hemorrhage on the biorhythms of feeding in premature infants. Frontiers in Pediatrics. 2021, 23, (9):673152. doi: 10.3389/fped.2021.673152. 10. Shandley S, Capilouto G, Tamilia E, Riley DM, Johnson YR, Papadelis C. Abnormal nutritive sucking as an indicator of neonatal brain injury. Frontiers in Pediatrics. 2021, 12;(8):599633. doi: 10.3389/fped.2020.599633. 11. Medoff-Cooper B, Shults J, Kaplan J. Sucking behavior of preterm neonates as a predictor of developmental outcomes. Journal of Developmental and Behavioral Pediatrics. 2009, 30(1):16-22. doi: 10.1097/DBP.0b013e318196b0a8.  12. Palmer MM. Identification and management of the transitional suck pattern in premature infants. Journal of Perinatal and Neonatal Nursing. 1993, 7(1):66-75. doi: 10.1097/00005237-199306000-00009. 13. Palmer MM. Developmental continuum of neonatal sucking performance based on the NOMAS (Neonatal Oral-Motor Assessment Scale). Developmental Observer. 2015, 8(1): 11-15. 14. Tsai SW, Chen CH, Lin MC. Prediction for developmental delay on neonatal oral motor assessment scale in preterm infants without brain lesion. Pediatrics Int. 2010, 52(1):65-8. doi: 10.1111/j.1442-200X.2009.02882.x. 15. Slattery J. Preterm sucking behavior and later neurodevelopment. Developmental Medicine and Child Neurology. 2017, 59, (8): 784-785. 16. Slattery J, Morgan A, Douglas J. Early sucking and swallowing problems as predictors of neurodevelopmental outcome in children with neonatal brain injury: a systematic review. Developmental Medicine and Child Neurology. 2012, 54(9):796-806. doi: 10.1111/j.1469- 8749.2012.04318.x 17. Poore MA, Barlow SM. Suck predicts neuromotor integrity and developmental outcomes. Perspectives Speech Science Orofacial Disorders. 2009; 19: 44-51. doi.org/10.1044/ ssod19.1.44 I really like the new layout of the Developmental Observer - my compliments for all the work and the professional appearance. There is a lot of content and I like the use of quotes from people in between the articles. – Monique Oude Reimer Sophia NIDCAP and APIB Training Center It was really a pleasure to read the article writ- ten by Jeff Alberts and his review regarding “The effect of gentle human touch during endotracheal suctioning“ from the last issue of the DO. I really like the way he analysed it. It is not only his excellent English and the ability to write in an interesting way, but it is the way he sees and thinks about the subject. I was amazed how he referred to my review. I would like to express my thanks. – Ita Litmanovitz Israel NIDCAP Training Center Letters to the Editor Continued on p. 18