Effects of Swaddling During Bottle Feeding in Infants Born Preterm: A Randomized Crossover Study

BACKGROUND AND PURPOSE: Due to fragile physiological stability, decreased state regulation, and low tone, infants born preterm may not demonstrate organized and coordinated feeding skills, affecting length of hospital stay. Swaddling has been found to improve pain and stress responses, neurobehavioral state regulation, and physiological stability in the neonatal intensive care unit (NICU) in infants born preterm. Swaddling during bottle feeding could support preterm infant behavioral organization by supporting the infant’s body for maintaining appropriate arousal and focus on feeding skills. Despite potential benefits, swaddling is used inconsistently during feeding in the NICU and has not been critically examined as an occupational therapy intervention to improve quality in preterm infant’s feeding skills. This study addressed the research question, What are the effects of swaddling on feeding quality and feeding efficiency in infants born preterm?

DESIGN: An experimental, randomized crossover design was used with infants serving as their own controls. A convenience sample of 30 infants was selected from the NICU at New York University Langone Medical Center. Infants born before 34 wk of gestation were considered for inclusion in the study. Infants with Grade III or IV intraventricular hemorrhage, necrotizing enterocolitis, cardiac conditions, genetic syndromes, craniofacial abnormalities, or exclusive breastfeeding were excluded.

METHOD: Each infant was swaddled for one feeding and unswaddled for another feeding with randomization of the starting condition. When the infant was able to attempt two bottle feedings per nursing shift for 2 days, the infant was assessed for feeding readiness according to NICU policies and completed two consecutive bottle feedings as part of the study. Feeding efficiency was measured by rate of volume consumed and percent of physician-prescribed volume consumed. Feeding quality was measured with the Early Feeding Skills Assessment (EFS) and frequency of significant physiological changes, including bradycardia and oxygen desaturations. Data analysis was completed using dependent t tests for data that met the assumptions of parametric testing and Wilcoxon signed-rank test for data that were skewed.

RESULTS: When swaddled, participants demonstrated improved feeding quality indicated by significantly better scores on all subtests of the EFS (p ≤ .001) except oral feeding readiness, as this was not affected by the swaddling condition. Infants demonstrated significantly more oxygen desaturations (p = .048) when swaddled and no difference in frequency of bradycardia. Participants demonstrated no differences in feeding efficiency outcomes when swaddled compared to unswaddled, with no statistically significant differences in volume consumed, length of feeding, volume lost, rate, or percent of physician-prescribed volume consumed.

CONCLUSION: Swaddling is an intervention that can be used by occupational therapists in the NICU to improve feeding quality in infants born preterm. Given neuronal group selection theory, infants need to practice coordinated feeding skills in order to develop the proper motor patterns for future coordinated feeding performance; therefore, swaddling should be used to provide infants born preterm the opportunity to be more coordinated and less stressed during bottle feeding. However, skilled observation for subtle infant stress cues for coregulated pacing should be used to prevent physiological instability.

IMPACT STATEMENT: Occupational therapists in the NICU can use swaddling as an evidence-based intervention to improve feeding quality in infants born preterm. This study provides early evidence for the therapeutic use of swaddling to improve behavioral organization and engagement in age-appropriate occupations.