Babies born too early do not struggle only to breathe. They also struggle to swallow. Coordination between sucking, swallowing, and breathing generally matures at around 32 to 34 weeks of gestation, meaning that premature infants born before this milestone often have to rely on nasogastric tubes for weeks before they can feed independently. The question is: is there a way to accelerate this maturation?
A recent study from the Faculty of Dentistry, Universitas Gadjah Mada, offers a fairly convincing answer. This systematic review and meta-analysis, published in BMC Pediatrics (2026), concluded that structured oral motor interventions, particularly a protocol known as Premature Infant Oral Motor Intervention (PIOMI), consistently help premature infants achieve independent oral feeding more quickly than standard care alone.
The study was a collaborative work by drg. Putri Kusuma Wardani Mahendra, M.Kes., Sp.KGA., together with Rina Febriani Puspitasari and dr. Anrizandy Narwidina from the Department of Pediatric Dentistry, Faculty of Dentistry, Universitas Gadjah Mada.
Small Stimulation, Major Impact in the NICU
PIOMI is not a complicated procedure. The protocol involves structured tactile and proprioceptive stimulation of the infant's oral and perioral areas, specifically designed according to the anatomical and neurodevelopmental characteristics of premature infants. Sessions are brief, typically 15 minutes per day for 7 to 14 days, and are conducted by trained neonatal nurses, speech therapists, or occupational therapists.
The research team searched the literature in PubMed, the Cochrane Library, and Google Scholar, screening 62 articles published between 2014 and 2024. Following rigorous selection based on the PRISMA 2020 guidelines, ten randomized controlled trials (RCTs) met the inclusion criteria, all involving premature infants in neonatal intensive care units.
The results were striking. In an analysis limited to studies with a low risk of bias, PIOMI showed a mean reduction in the time required to achieve full oral feeding of nearly 10 days compared with standard care (mean difference = −9.90; 95% CI: −16.78 to −3.02; p = 0.005). In another analysis combining all studies, the effect remained evident, although with greater heterogeneity.
“Oral motor intervention has been shown to be clinically relevant in improving feeding readiness, suck-swallow coordination, feeding efficiency, and earlier achievement of full oral feeding compared with routine care.” — Puspitasari, Mahendra, and Narwidina, BMC Pediatrics (2026)
More Than Just Being Able to Feed
Why is this relevant to pediatric dentistry? The answer lies in the functional orofacial foundation established during the first days of life.
Orofacial muscles are not merely tools for eating. They establish a biomechanical balance that influences long-term craniofacial stability, lip posture, functional occlusion, and even the risk of temporomandibular joint disorders later in life. The concept of triangular force in orthodontics explains how balanced muscle-force distribution across the teeth, alveolar bone, and surrounding soft tissues determines the structural stability of the face.
Premature infants who experience delayed oral coordination are not only at risk of prolonged hospitalization. They may also develop dysfunctional oral patterns such as tongue thrusting and mouth breathing, which, if left untreated, may interfere with normal orofacial development. Oral motor intervention during the neonatal period, therefore, is not only about feeding today, but also about the functional architecture of the child's face for years to come.
By the age of 3 to 6 years, children should have developed orofacial motor control approaching that of adults, allowing them to eat a variety of textures, speak clearly, and breathe properly. This development begins with the sucking reflex in the NICU.
Strong Evidence, with Important Caveats
The researchers did not conceal the limitations of their findings. Of the 10 RCTs analyzed, three were assessed as having a low risk of bias, two raised some concerns, and five had a high risk of bias. The largest source of bias was the difficulty of blinding non-pharmacological interventions such as this one, since caregivers and treatment providers inevitably know which intervention is being administered.
The certainty of evidence (GRADE) for full oral feeding was rated as moderate. For feeding efficiency and feeding readiness, the evidence was based on only one RCT each, so its generalizability should be interpreted with caution.
Yet this is precisely where the strength of the systematic review lies: by following the prospectively registered PROSPERO protocol, using the Cochrane RoB 2.0 tool for risk-of-bias assessment, and rigorously adhering to PRISMA 2020, the FKG UGM research team built a methodologically grounded evidence-based argument rather than simply presenting an optimistic narrative.
From a health-system perspective, the implications are tangible. Delayed achievement of independent oral feeding is a major contributor to prolonged NICU stays, increased healthcare costs, and psychological burdens on parents. A non-invasive, low-cost intervention that can be implemented with relatively brief training, such as PIOMI, has considerable potential for scalability, particularly in developing countries with limited resources.
Every day that can be shortened from tube feeding to bottle or breastfeeding is one day earlier for an infant to begin building their own world—with their tiny mouth, which turns out to be training far more than simply swallowing.
Source DOI: https://doi.org/10.1186/s12887-026-06905-4
Authors: Nanda Ayu, drg. Achmad Zam Zam Aghasy, M.Kes.
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