Hi Laura.

When to refer will in part depend on what exercises you know.  :)  In general, if you suspect the suck problem involves muscles beyond the tongue--orbicularis oris, mentalis, buccinator, masseter--and you don't know how to isolate and address those muscles, refer.  My personal rules of thumb:  do I see any improvement within two days of working with the baby with the skills I have? If not, I refer.  This means that everytime I suggest exercises I reassess the baby in two days (or so).  The exception for me is an older baby...I have found the age of the baby will influence the timing of outcome...a 4 week old baby will take longer to strengthen than a 4 day old baby.  But still, if there isn't improvement rather quickly, I refer.  Depending on where you live, the referral might be to an SLP or an OT.  Also, I often attend that appointment *with* the mom for support, clarification, etc. (unless you know and trust her already).  Plus your knowledge base will increase when you attend.  

Glad you found the info on bottle teats and flow useful.  Many (most?) lactation books suggest tipping a bottle over to determine flow.  My coauthor and I tested bottle nipples and found that this suggestion is not accurate (not even close to accurate).  My current favorite example:  the Medela Calma does not drip when turning it over, which sounds good.  But of the 37 slow flow nipples we have tested thus far, it flows the fastest.  For example, the Dr. Browns narrow dripped 46 times (avg) in 30 seconds, and the flow measured 3.03 mL after 20 cycles with a pump; the Medela Calma had zero drips in 30 seconds and the flow measured 14.2 mL after 20 cycles--it's 4.7 times faster than the other nipple, even though the other nipple drips.    

You asked, "How *do* I determine flow?"  A couple ways...first, yes, watch the baby use the bottle. Baby will be coordinated and calm with the right flow.  Second, let me email you our updated version of Appendix C from our book.  Our book is about to be reprinted with this revised appendix.  (for those who already have the book, you may contact me)  We do not give out flow information in general because flow is only one aspect of using bottles.  If mouth placement on the bottle is poor, breastfeeding is at risk regardles of the flow.  Also, we just did an interview with the Leaky Boob blog that talks more indepth about our bottle nipple flow testing.  You can read it here: http://theleakyboob.com/2012/03/bottle-feeding-breastfed-babies/

Warmly,
Amy Peterson, IBCLC
coauthor Balancing Breast and Bottle: Reaching Your Breastfeeding Goals--not a plug, just showing this is one of my areas of knowledge :)

   

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