Factors Affecting Oral Feeding Ability in Indonesian Preterm Infants

Round 1

Reviewer 1 Report

The manuscript has been substantially improved with the addition of more detailed methods and amendments to the introduction, results and discussion. It continues to require English language editing throughout (including the abstract).

Author Response

Dear Reviewer,

Sincerest thanks for your response.

We have reviewed and made some changes to the manuscript. We have paid special attention to the English editing. Please kindly check the edited version of the manuscript in the attachment.

Some changes in English editing that we have made are eliminating redundancy, improving grammar and word selection, and changing passive sentences to active ones.

We really appreciate your suggestions, as they were important to make the ideas clearer.

Thank you for your kind attention.

Author Response File: Author Response.pdf

Reviewer 2 Report

The authors have used most of available research to design the study. There are other studies including Thorye, McCain, McGrath that have described feeding readiness in more detail.  The finding from the study is not unexpected.  The behavioral state at the beginning of the feeding has been shown to be the most important variable for infant feeding or sucking organization (Medoff-Cooper).  What is most important about this study is that infants who appear to be showing signs of feeding readiness are not necessarily correlated with feeding success.   

Author Response

Dear Reviewer,

Sincerest thanks for your response.

We have modified the manuscript considering the extensive and insightful reviewers’ comments and suggestion. We also paid special attention in improving our English editing.

We really appreciate your suggestions, as they were important to make the ideas clearer.

I will respond to the comments point by point, please kindly check the attachment.

Thank you for your kind attention.

Author Response File: Author Response.pdf

Reviewer 3 Report

The author has shared the single unit cross-sectional study aimed to determine various factors affecting oral feeding ability in Indonesian preterm infants who have fulfilled oral feeding readiness criteria but still have not been able to feed orally. Although this study has a few limitations, such as single-center, non-randomization, and small sample size, it can be one of the few studies which can throw light on factors affecting oral feeding ability in Indonesian preterm infants. 

Some of the specific comments are:

Abstract:

The abstract is written well, and it reflects the facts in the article.

Introduction: 

The introduction is well written, and relevant references are cited. We have a few suggestions. 

Page 1 line 43: “...maintain physiological stability & behavioral state while...” 

Please consider writing it as “and”. 

Materials and Methods

The Materials and Methods section is written in detail. We suggest the following changes,

Page 2 line 91: “and using an endotracheal tube at the time of assessment..”

Can the author clarify if the Non-invasive ventilator and CPAP requirements were taken into consideration in the assessment?

Results

The results section is written nice and informative. However, we have a few suggestions as listed below,

Page 5 line 172: “ In infants born at 28 – 31 weeks gestational age, 31 (77.5%) were unable to feed orally. In 172 infants born at 32 – 34 weeks, 41 (51.2%) were able to feed orally (p = 0.003).” 

The author can consider writing both stats in a similar way for example “able to feed orally” in both conditions. This will improve the understanding. 

Discussion:

Overall, the discussion part is very well elaborated with an extensive literature search. 

All the references are relevant, recent, and readily retrievable. The tables and figures provided in the manuscript support the paper's discussion and conclusions. 

(Note: Page numbers cited in this letter refer to page number of the Manuscript PDF)

Author Response

Dear Reviewer,

Sincerest thanks for your response.

We have modified the manuscript considering the extensive and insightful reviewers’ comments and suggestion. We also paid special attention in improving our English editing.

We really appreciate your suggestions, as they were important to make the ideas clearer.

I will respond to the comments point by point, please kindly check the attachment.

Thank you for your kind attention.

Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Thank you for submitting your article and for carrying out a study with a significant number of infants involved across hospital sites in your country. I do not feel the study offers sufficient new information or findings to be of benefit to an international audience.

Introduction: It is interesting that OGT is the main form of non-oral feeding as in many countries, naso-gastric feeding would be the norm. For an international journal I think this difference could be highlighted and commonalities with other countries also noted. There are likely to be many countries who have a health system similar to Indonesia and I think this is important to make clear.

General fundamentals of oral feeding readiness are clearly stated, although references to 1995 are old and more recent nuanced references such as the SOFFI would be relevant to mention https://www.feedingfundamentals.com/research-using-the-soffi-method

Specific details of feeding readiness per feed e.g. is the infant awake, alert and physiologically stable and ready to feed in this moment seem to have been missed even though there is considerable research (see SOFFI website above and related links).

It would be wise to not use the word 'subject' but instead refer to participants or infants.

Method: if the "sucking mechanism evaluation system" is a specific protocol then it should be referenced as such and the specific device used to measure pressure stated. The manufacturer of the teat should be noted and wording corrected to 'teat' rather than pacifier.

Were there any similarities amongst the parents who did not participate - were they predominantly those who intended to breastfeed?

What experience of NNS did the infants have prior to the study feed?

It's not clear if the infants were fed on-demand or to a schedule - were they woken for a feed? Were there any interventions used such as swaddling? Who fed the infant - was it the parent? 

Results: There is text here that should be removed as it is part of the template. It is not clear whether 'readiness to feed' refers to the next feed, or to oral feeding in general. If it is referring to the next feed, then experience is important - how many oral feeds has the infant already tried and succeeded with? Otherwise I would make it clear that you were assessing their very first oral feed ever. 

Discussion: These comments need connecting to the current literature and it is not clear how they add to our existing knowledge.

Reviewer 2 Report

1. pg 3 line 113- female not women
2. no description of sucking mechanism system
3. The definition of feeding readiness- 30% volume in 5 minutes with rate 1.5 ml/minutes is not an  accepted definition by most feeding folks- see McGrath, PIckler, Thorye
4. No definitions of postural tone, physiologic stability , self regulation or behavioral state in methods- there are some definitions in the discussion section
5. Some results in the discussion 
6. NNS has not been shown to be a good indicator of feeding readiness