Project Summary: A major challenge-facing the 500,000 preterm infants born each year is the transition from gavage to oral feedings. Most preterm infants are bottle fed either formula or expressed breast milk while in the hospital. Thus, management of bottle feedings in preterm infants is a key aspect of hospital care. As there are few evidence-based protocols to guide clinicians in achieving competence at oral feeding, already vulnerable infants are subject to a trial-and-error approach to this complex and critical life-sustaining activity. This study builds on a National Institute of Nursing Research (NINR) funded study in which morbidity, maturity, and feeding experience predicted feeding outcomes. This study will prospectively test four different approaches to the transition to full oral feedings. The proposed study will provide important information about ways to assist preterm infants to make the transition from gavage to full oral feeding and how the transition may affect longer term development. The specific aims of this application are to: 1)Test four approaches to oral feeding introduction and progression;2) Test the effect morbidity, maturity, experience and behavior state on feeding outcomes in preterm infants;3) Estimate the effect of feeding approaches on clinical outcomes;and 4) Estimate the effect of feeding approaches on feeding transition outcomes after discharge. The study aims are consistent with the NINR's efforts to establish a scientific basis for care of individuals across the life span. Specifically, the study will improve clinical care of preterm infants and will promote better clinical and health related outcomes of these children. A prospective, randomized, experimental design will be used to test four different approaches to the transition to full oral feedings. Data will be collected from infants during the 14 day approaches, at discharge, and 2-weeks post-discharge. Data will be analyzed using a mixed-models approach. Relevance: Over 500,000 preterm infants are born each year and feeding these infants is a major clinical challenge while they are in the hospital. How infants are fed during their hospitalization has long term consequences on health and development. This study will help nurses and families in neonatal intensive care units provide feeding care that may result in shorter hospital stays and improved developmental outcomes.