Background The relationship between behavioral states (alert, sleep, drowsy, and crying) and oral feeding efficiency in preterm infants is not well understood. Purpose To determine the relationship between behavioral states and feeding efficiency in preterm infants. Method This correlational study was conducted as a secondary analysis from a randomized controlled trial (RCT). Medically stable preterm infants born between 29 and 34 weeks gestational age participated. Baseline data from the RCT (week 0), 1-minute prior to feeding were used. Behavioral states were coded by two blinded coders. Oral feeding efficiency (ml/min) was calculated as the amount of intake over the first 10 minutes of feeding. Results Data from 147 infants were included. The proportion of time spent in alert states (β = .76, F = 11.29, p ≤ .05), sleep states (β = −1.08, F = 25.26, p ≤ .05), and crying (β = 1.50, F = 12.51, p ≤ .05) uniquely predicted oral feeding efficiency. Implications for Practice Comprehensive assessment of behavioral states and infant characteristics for oral feeding readiness is crucial. Alert states are optimal for oral feeding. Forced oral feeding when infants are sleeping should be avoided. Infants in crying or drowsy states prior to feeding should be closely evaluated. Sleeping or drowsy infants may benefit from interventions (e.g. oral sensory stimulation, non-nutritive sucking, or multisensory intervention) to support transition to alert states prior to feeding. Implications for Research Future research should evaluate behavioral states prior to and during feeding and their relationship to oral feeding efficiency.

Background. To investigate the influence of early life pain/stress and medical characteristics on neurobehavioral outcomes in preterm infants. Methods. A prospective cohort study was conducted with 92 preterm infants (28–32 weeks gestational age [GA]). Early life pain/stress was measured via the Neonatal Infant Stressor Scale (NISS) during the first 28 days of NICU hospitalization. Neurobehavioral outcomes were evaluated using the NICU Network Neurobehavioral Scale at 36–38 weeks post-menstrual age. Functional regression and machine learning models were performed to investigate the predictors of neurobehavioral outcomes. Results. Infants experienced daily acute pain/stress (24.99±7.13 frequencies) and chronic events (41.13±17.81 hours). Up to 12 days after birth, both higher acute and chronic NISS scores were associated with higher stress scores; and higher chronic NISS scores were also related to lower self-regulation and quality of movement. Younger GA predicted worse neurobehavioral outcomes, GA < 31.57 weeks predicting worse stress/abstinence, self-regulation, and excitability; GA < 30.57 weeks predicting poor quality of movement. A higher proportion of maternal breastmilk intake predicted better self-regulation, excitability, and quality of movement in older GA infants. Conclusion. Preterm infants are vulnerable to the impact of early life pain/stress. Neurobehavioral outcomes are positively associated with increased GA and higher maternal breastmilk intake.

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