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Revista chilena de pediatría

versión impresa ISSN 0370-4106

Rev. chil. pediatr. vol.90 no.5 Santiago oct. 2019 


Standardization of Early Feeding Skills (EFS) scale in preterm infants

Abarzúa P. Constanza1 

Ana Godoy M.2  3 

Mariana Rubilar P.6 

María Silva Sch.2  3 

Mónica Velásquez Z.2  3  4 

Luis Bustos M.4  5 

1 Departamento de Administración de Educación Municipal, Ilustre Municipalidad de Vilcún, Chile.

2 Carrera de Fonoaudiología, Universidad de La Frontera, Temuco, Chile.

3 Departamento de Especialidades Médicas, Universidad de la Frontera, Temuco, Chile.

4 Departamento Salud Pública, Universidad de la Frontera, Temuco, Chile.

5 Centro de Excelencia CIGES, Universidad de la Frontera, Temuco, Chile.

6 Departamento de Administración de Educación Municipal, Ilustre Municipalidad de Loncoche, Chile.


Introduction: The Early Feeding Skills (EFS) scale assessed the neonate’s behavior before, during, and after the feeding process. Objectives: To determine the face and content validity, and to evaluate with this scale the feeding process in premature newborns comparing with relevant variables. Patients and Method: Premature newborns were evaluated; they were between 34 to 36 weeks of corrected age, without neurological damage or craniofacial malformations. Cross-sectional descriptive study. The data were obtained through the EFS scale, version corrected by face and content validation. The study variables were gender, breastfeeding achievement, and feeding skills during the feeding process, evaluated by two observers. Dispersion measures were analyzed, and the Fisher test was used at 5% significance, establishing the association of the obtained results with the variables. Results: 5 domains were evaluated: (1) Ability to stay focused on food, in which 75.3% have a poor performance level, and 28.6% equitable, with significant differences in the sex variable. (2) Ability to organize motor- oral functioning presents 10.5% deficient, 68.8% equitable, and 20.6% good. (3) Ability to coordinate swallowing 95.2% presents an equitable performance. (4) Ability to maintain physiological stability 96.7% was equitable; and (5) Evaluation of oral food tolerance presents 41.6% of poor performance. Conclusion: The EFS scale is a tool that provides relevant information to describe the oral feeding process in premature infants, allowing to identify the areas of greatest difficulty that require profes sional treatment, however, this tool is not enough by itself to carry a comprehensive evaluation of the newborn feeding process.

Keywords: Preterm; oral feeding; swallowing; evaluation


In newborns, oral feeding is a complex process that, in order to be successful, it depends on the anatomo-functional indemnity of the orofacial structures that favor the sucking-swallowing process. In cases of prematurity, this process is greatly affected.

A newborn is considered premature when born before 37 weeks, which leads to several comorbidities that can be observed in poor postural control, impai red oral-motor skills, immature gastrointestinal tract, and physiological control difficulties. All these diffi culties interfere with a safe, effective, competent, and comfortable oral feeding4,5. It is important to have gui delines for the evaluation and monitoring of the fee ding process in premature babies which ease the work of the Neonatal Critical Patient Unit team. Several authors suggest scales such as the Preterm Oral Fee ding Readiness Assessment Scale8,9 and the Neonatal Oral-Motor Scale10, which consider a predictor of oral- motor skills for oral feeding in infants8,10,11. In this arti cle we analyze the Early Feeding Skills (EFS) scale that assesses the newborn’s behavior before, during, and after the feeding process which also allows the identifi cation of impaired areas and to establish guidelines to subsequently provide speech therapy according to the needs and skills of the newborn5,12,13. The objective was to describe through the EFS scale the feeding process in preterm newborns. Specific objectives were: 1) To de termine the face validity of the EFS scale; 2) To deter mine the content validity of the EFS scale; 3) To assess the feeding process with the EFS observation scale, and 4) To analyze the outcomes of the items for each of the domains according to the study variables and perfor mance levels or score obtained in each domain (good, equitable, or poor).

Patients and Method

Between 2015 and 2016, 138 preterm newborns were included from the Neonatal Unit of the Dr. Her nán Henríquiez Aravena Hospital, Temuco, Chile. The corrected gestational age was 34 to 36 weeks, excluding those newborns with craniofacial malformations or neurological disorders. Data were obtained using the EFS scale, corrected version through the face and con tent validity.

Instrument validity

We requested scale manual and scores from author Suzanne Thoyre, then the face validity was ca rried out through the translation of the instrument from English into Spanish by a native English speaker. Afterward, an analysis from Spanish to English was made, ensuring that the instrument did not lose coherence12.

Once the instrument was translated into Spanish, it was assessed by six speech therapists who are experts in the field. These experts follow a guideline that con siders aspects of sufficiency, clarity, coherence, and relevance, scoring from 1 to 4, where values 3 and 4 (moderate and high scores) are considered optimal for the validation of each aspect. Those items scored with 1 and 2 (low and very low scores) by at least two of the experts were modified according to the sugges tions made by them. Finally, these modifications were revealed to all the expert speech therapists who agreed in all assessed areas with a high score (Graphic 1). Sub sequently, the level of agreement among the experts was assessed, estimating that each item should weigh at least 67% of the total responses. Then, all items groups were analyzed, finding in each group the description of different processes and moments of the feeding process of the newborn such as ability to maintain engagement in feeding, ability to organize oral-motor functioning, swallowing, physiologic stability, and feeding toleran ce. These groups are called domains. Afterward, cross checks were made between domains and the variables described in the methodology.

Graphic 1 Score assigned by each eva luator in each aspect. The average score obtained in the items is considered. 

This research followed a cross-sectional study de sign. Data obtained from the assessment with the EFS scale were analyzed through measures of dispersion (median, mean, and average). The Fisher test was used at a 5% significance, establishing the association of the results grouped into domains with the selected varia bles. The study variables and the assigned score to each of the options were:

1- Patient sex:

a. Male: 1 (Since males are more likely to have feeding difficulties at birth, it is considered a lower value)

b. Female: 2.

2- Achieve breastfeeding.

a. No: 1.

b. Yes: 2.

3- Feeding skills during the feeding process.

a. Declined: 1.

b. Maintained: 2.

c. Improved: 3.

The observation was made by two evaluators in pa rallel who then agreed on the scores assigned to each item. The evaluations were carried out during the fe eding periods established by the unit. The used milk was preferentially breast milk, and as a second option milk formula according to the physician’s indications. During the feeding process, the mother has to be pre sent to receive a detailed description of the procedure, reading the informed consent corresponding to the observation. Throughout the feeding, we provide sup port, guiding the mother and giving the pertinent su ggestions regarding the posture, necessary pauses and adequate grasp of the mother’s breast. In addition, the vital signs are monitored through the process which upon exceeding normal ranges, are sufficient reason to interrupt or end the process, fulfilling the necessary food intake by feeding tube.

The research work was approved by the Ethics Committee of the South Araucania Health Service, which was presented to the Director of the Dr. H.H.A. Hospital, obtaining the pertinent permits to carry out the evaluations in the Neonatology Unit.


Out of the assessed newborns, 50.7% were fema les and 49.3% were males which were observed by two evaluators, resulting in a total of 276 measurements. The Ability to maintain engagement in feeding with the sex variable showed that the poor performance level was higher in boys, and the equitable level was higher in girls. These differences are significant. The performance level in the Ability to organize oral-motor functioning did not show significant differences with the sex variable. Regarding the Ability to coordinate swallowing, it shows a performance mostly equitable, as well as the Ability to maintain physiologic stability domain. There were no significant differences between these two domains and the sex variable. Concerning the Oral feeding tolerance evaluation and sex, there was no association (Table 1).

Table 1 Comparison of performance levels of the SAI scale by sex. 

The five studied domains were measured with the Achieves breastfeeding variable showing significant di fferences in the performance levels. It is important to note that newborns have high percentages in the poor performance level in the Ability to maintain engage ment in feeding and Oral feeding tolerance evaluation domains (Table 2).

Table 2 Comparison of performance levels of the SAI scale according to breastfeeding ability. 

The Ability to maintain physiologic stability was no associated with the Skills during feeding. There were significant differences in the performance levels of the Ability to maintain engagement in feeding domain in each category of the Skills during feeding, where the poor performance level was higher in those newborns that have a decrease in the Skills during feeding. Regar ding the Ability to organize oral-motor functioning, the percentages of poor performance level were lower than the equitable and good ones, where these associations were significant. The Ability to coordinate swallowing domain was significantly associated with the Skills du ring feeding, where there was a lower distribution in the poor performance level than in the equitable one. In the Oral feeding tolerance evaluation, there were signifi cant differences in the three performance levels regar ding the Skills during feeding (Table 3).

Table 3 Comparison of performance levels of the SAI scale according to abilities during feeding. 


From this study, we can observe that the EFS scale is a predictor of the feeding skills in the studied pre term newborns. Crossover domains with the variables, depending on the performance of the newborns during the feeding process, indicates that they have a high per centage of equitable performance in the Ability to orga nize oral-motor functioning and the Ability to coordinate swallowing domains. This allows them to initiate oral feeding through the mother’s breast. However, this does not mean that they can receive all the necessary food orally. Sometimes, it is necessary to fulfill their nutrition through an alternative feeding route such as the nasogastric or orogastric tube. This situation can be observed in the Ability to maintain engagement in feeding and the Oral feeding tolerance evaluation doma ins which present a higher poor performance level. On the other hand, it is worth to mention that the Ability to maintain physiologic stability domain has a higher equitable performance level. The research team asso ciates this result to the fact that the newborn was fed by the mother’s breast, being protected by the mother and for a limited time since the energy level of the new born does not allow him/her to be fed orally for more minutes. In 2005, Thoyre et al. described the EFS scale as an instrument for the identification of the strength areas and those areas in which a preterm baby requires support to achieve a safe and effective feeding, agreeing with this study12. In addition, it indicates that babies frequently experience episodes of oxygen desaturation, increased energy expenditure in response to stress, and fatigue, which can be observed in the data mentioned above.

The EFS scale has been analyzed in other studies. In 2017, in Brazil, the validity and reliability of the scale was studied through the ‘Validation of the Early Fe eding Skills Assessment Scale for the Portuguese population’14, which considers a sample of 698 newborns of gestational age between ≥ 24 and < 37 weeks, con cluding that it is a sensitive, valid, and reliable scale to observe the early skills of the newborn during oral fe eding, allowing to develop an intervention plan and to work along with the families.

Another study that stands out is the ‘Validation of a clinical nutritional sucking scale’15 that considered a sample of 179 infants < 6 months old and 86 infants at high risk of impaired sucking, which has face and psychometric validation, establishes a relation between the sucking performance and the volume ingested, swallowing and peripheral oxygen saturation, and ven tilation with respiratory rate. With this scale, alteration patterns were fixed according to neurological condi tion history, hemodynamic stability, and immaturity.

Notwithstanding the above, the evaluation team considers that the scale should complement the as sessment with the objective observation of the non nutritive sucking skills, the mother-child attachment, and the breast anatomy since these aspects may di rectly affect the feeding performance in newborns. In the literature, the instrument ‘Oral Feeding Readiness in Preterm Infants’ by Fujinaga et al. stands out9, which has content validity in Brazil and allows an evaluation to initiate the oral feeding of the preterm newborn, scoring orofacial tonicity, adaptive reflexes, non-nu tritive sucking and signs of stress11. Each one of the se scales can be complemented in order to assess the infant comprehensively, however, they should be used by specialized and competent professionals in the area who can observe through a common guideline all the important aspects of the complex feeding process in this population.


The EFS scale is a tool that provides important information to describe the oral feeding process in preterm infants allowing to identify the most difficult areas that require professional treatment, however, this tool is not enough by itself to carry out a compre hensive evaluation of the newborn feeding process. Therefore, it is important to carry out an adequate evaluation by a professional speech therapist before hand who, using his/her knowledge in the area, also observe the anatomical and functional aspects of the oral cavity, the adaptive reflexes, and can scored the infant’s non-nutritive sucking performance before observing the nutritive sucking performance through the EFS scale.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regu lations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This docu ment is in the possession of the correspondence author.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

Aknowledgments: We thank Suzanne Thoyre, author of EFS for provi ding the scale, manual and scale scores. To Dr. María Angélica Belmar, head of the Neonatology unit of Dr. HHA Hospital, who jointly allowed and facilitated the unit’s staff, the application of the scale. And finally to the experts who participated as evaluators, contribu ting with their knowledge and experience in the con tent validity.


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Received: January 28, 2019; Accepted: May 07, 2019

Correspondence: Abarzúa P. Constanza. E-mail:

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