The Development of Sucking Patterns in Preterm, Small-for-Gestational Age Infants Saakje P. da Costa, PhD, Cees P. van der Schans, PT, CE, PhD, Mar J. Zweens, MD, Sarai R. Boelema, MSc, Eva van der Meij, BH, Mieke A. Boerman, MA, and Arend F. Bos, MD, PhD Objective To determine whether the development of sucking patterns in small-for-gestational age (SGA) preterm infants differs from appropriate-for-gestational age (AGA) preterm infants. Study design We assessed sucking patterns in 15 SGA and 34 AGA preterms (gestational age #36 weeks) lon- gitudinally from 34 to 50 weeks postmenstrual age (PMA) using the Neonatal Oral-Motor Assessment Scale (NOMAS). At each measurement, we scored sucking as normal, dysfunctional, or disorganized. We examined the development of their sucking patterns in relation to clinical characteristics. Results SGA preterms developed a normal sucking pattern later than did AGA preterms (median, 50 versus 44 weeks PMA, P = .002). At term-equivalent age, none of the SGA and 38% of the AGA preterms showed normal suck- ing (P < .05); at 48 to 50 weeks PMA this was 54% and 81%, respectively (P = .064). Abnormal sucking including ‘‘incoordination’’ and dysfunctional sucking were more prevalent in SGA preterms than in AGA preterms (median, 11% versus 0% per infant, P < .05). A higher gestational age and z-score for birth weight were predictive of normal sucking at 50 weeks PMA. Conclusions SGA preterms developed a normal sucking pattern later than AGA preterms. Many AGA preterms also developed a normal mature sucking pattern only after they had reached term age. (J Pediatr 2010;-:---). N ewborn infants rely on their ability to suck and swallow liquids effectively for nourishment. An increase in the rate of sucking and swallowing, longer sucking bursts, and larger volumes per suck with increasing postmenstrual age (PMA) are characteristic of the development of sucking and swallowing in healthy term infants. 1-4 Preterm infants, and small- for-gestational age (SGA) preterms in particular, are at increased risk for impaired sucking and swallowing. They have 2 dis- advantages: prematurity and increased nutritional needs for catch-up growth. Both factors may affect the development of their sucking patterns. During the neonatal period, the neurobehavioral organization of SGA preterms is poor compared with that of their appropriate-for-gestational age matched peers. This is expressed as unstable state organization, poor motor maturity, and lower orientation to social and nonsocial stimuli. 5 During follow-up, former SGA preterms are at increased risk for subtle mo- tor, cognitive, and behavioral developmental deficits. 6 Feeding disorders are also more prevalent in these children. 7 In a study of a cohort of 465 children under the age of 10 years who were referred to a multidisciplinary eating disorder clinic, children with eating disorders had significantly lower birth weights for gestational age. 7 Eating disorders caused by gastrointestinal or neu- rological pathology were related to lower birth weights for gestational age. Therefore, deviant development of sucking and swal- lowing might be the basis of persistent eating problems in former SGA preterm children. 7 It is not known whether the development of sucking and swallowing is impaired or delayed in SGA preterm infants. The Neonatal Oral-Motor Assessment Scale (NOMAS) 8 is a method that can be used to investigate sucking patterns in young in- fants from birth to several months old (Appendix; available at www.jpeds.com). The aim of our study was to investigate the development of sucking patterns from birth to 50 weeks PMA (10 weeks post-term) in SGA preterms compared with appropriate-for-gestational age (AGA) preterms. We hypothesized that SGA preterm infants would develop a normal sucking pattern later, would need to rely on tube feeding longer, and would be hindered by a dysfunctional sucking pattern more often than AGA preterms. In particular, we hypothesized that SGA preterms would have more difficulty initiating sucking movements and that sucking and swallowing would be arrhythmic as a result of their poor state organization. Moreover, abnormal jaw and tongue movements, as a component of the poor motor maturity of these infants, would probably interfere with effective sucking. From the Research and Innovation Group in Health Care and Nursing (S.P.d.C., C.P.v.d.S. E.v.d.M.), Hanze University Groningen, University of Applied Sciences, Groningen, The Netherlands; the Department of Pediatrics (M.J.Z.), Martini Hospital Groningen, Groningen, The Netherlands; Faculty of Social Sciences (S.R.B.), Department of Interdisciplinary Social Science, Utrecht University, Utrecht, The Netherlands; Center for Rehabilitation (M.A.B.), Martini Hospital Groningen, Groningen, The Netherlands; and the Department of Pediatrics (A.F.B.), Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright Ó 2010 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2010.04.037 AGA Appropriate-for-gestational age BPD Bronchopulmonary dysplasia GMH Germinal matrix hemorrhage NBRS Nursery Neurobiologic Risk Score NOMAS Neonatal Oral-Motor Assessment Scale PMA Postmenstrual age PVL Periventricular leukomalacia SGA Small-for-gestational age 1