Impact of early oral-motor intervention combined with kangaroo mother care on feeding outcomes in extremely preterm infants

Feeding intolerance (FI) and immaturity hinder nutritional advancement in extremely preterm infants. While kangaroo mother care (KMC) and early oral-motor intervention (EOMI) show individual benefits, evidence for their combined effect on FI via improved oral-motor function remains limited. This retrospective observational study included 428 infants (gestational age < 28 weeks) admitted between June 2021 and June 2024. Infants were grouped by exposure to EOMI + KMC (at least one 60-minute session by the first oral-feeding training day) versus EOMI-only. Outcomes included FI, time to 50% and 80% oral intake, and feeding efficiency. Firth penalized logistic regression and linear regression were used. Counterfactual mediation analysis assessed the role of Neonatal Oral-Motor Assessment Scale severity (0-2) as a mediator. After full adjustment, EOMI + KMC was associated with lower odds of FI (odds ratio [OR] 0.73, 95% confidence interval 0.53-0.99) and higher odds of achieving the 80% intake milestone (OR 1.43, 95% confidence interval 1.01-2.04). Among achievers, EOMI + KMC reduced the time to reach 50% (ratio 0.90) and 80% (ratio 0.89) oral intake. Feeding efficiency (mean difference + 0.18 mL/min) and intake ratio (mean difference + 0.022) were significantly higher. Mediation analysis revealed a significant natural indirect effect through Neonatal Oral-Motor Assessment Scale (OR 0.92), accounting for 26.5% of the total association. Effect modification was observed by gestational age and ventilation status. Sensitivity analyses confirmed robustness. In this retrospective observational study, EOMI combined with timely KMC was associated with improved feeding outcomes and lower odds of FI, with early oral-motor function explaining a meaningful portion of this association. These findings support integrating KMC into structured EOMI protocols.