These are the mystery babies, and I see quite a few of them.  They present
with marginal weight gain, and have what I call a "worried look."  Sometimes
mom's milk production is fabulous -- esp. if I get involved early on when
supply is still essentially hormonally driven.  Poor draining of accessible
milk generally results in supply problems later, so that if I get involved
at 6 weeks pp or so, I may wonder if I am looking at a slow-gainer due to
primary milk production problems.  These are not FTT babies, but children
who put on weight  painfully slowly, barely making 2-3 oz gain a week
(although they may occasionally have a rather good week for no apparant
reason.)  They may suck fairly well for a few min. but often close their
eyes and fade out, and seem to have stamina problems.  If I try to
supplement them, I find they do the same thing even with an augmented flow:
fingerfed, or cup or bottle or sns, they close their eyes and tune out.
They spit up a lot, seeming to do much better with very small amounts.  If
the doctor intervenes and says: " You must give x amount  per 24 hrs"  the
mother spends the whole day trying to get this amount in the baby, and often
says the baby won't accept it.  Hence my perception that the baby is
self-limiting intake.

Now, why would a baby do that, programmed as they are to grow rapidly and
with gusto in those early weeks?

 I have frequently  seen it with reflux and with babies with respiratory
distress.   I had a pediatric nurse client with the most bountiful supply of
milk and a baby who was almost starving.  Neither weaning down, nor special
positioning, nor alternative feeding methods helped.  The only time baby was
happy was when NOT feeding.  I had suggested swallowing evals. sev. times,
but it wasn't until ulcers in the throat were dx at 6 mo pp from acid reflux
that baby got treated.  She cont. to have feeding prob. and needed thickened
fluids for 3-4 yrs.

I have seen babies with heart defects self-limit.  They can only handle
small vol. feeds for physiologic and stamina related reasons.  Cleft palate
babies often do it.  I suspect they find nasal aspiration very disquieting.
I saw a baby recovering from botulism self-limit.  He was so floppy that he
just lost control and began sputtering after a few min. of feeding.

I am working with a very interesting baby right now, who self-limited
intake.. 35 week Preemie -- NICU a short time -- now  9  lbs.  I saw this
baby about 6 wks ago about 2 weeks post-discharge.  Baby had so much nasal
congestion that to fill his mouth caused him to panic ( he had to mouth
breath due to blocked nares.)  When mom  forced him to breast, he went
crazy. He wasn't much happier with a bottle of pumped milk.  He literally
held his breath, gulped as fast as he could to get some food, then went nuts
flailing his arms, stiffening, so mom would take bottle away.  Then he
panted until he caught his breath, vomited from the gulping and the stress,
and aspirated some more. This was typical at each feed.  It was painful to
watch. He could do this for only so long, and then just shut down on eating.
His growth and certainly his feeding enjoyment was horribly compromised.

Plan to remediate included:  teaching mom how to pace his bottle feeds,
pulling the nipple out every 2-3 swallows,  teaching him to trust the
feeding process wouldn't drown him. Her milk supply was very depressed, so
we instituted pumping with good pump and fenugreek so she could dc all
formula.   I showed her how to bottle feed him in a sort of flexed, seated,
upright position. I communicated with the pedi about the stress cues,
feeding behavior and labored breathing.  MD prescribed saline nasal spray to
clear the accumulated milk debris from the nasal passages. Reducing the
stress of bottle feeds produced reduction of reflux, better organization of
respirations, improved growth.

  Mom cont. to report baby being very stressed when bfg was attempted, so I
went back today.  We worked with an upright, seated stradle position with
baby's head very unfettered (support only at shoulders so he could pull away
as needed.)  We calmed him with a sip of bottle delivered pumped milk, and
then he did very well at breast in this more up-right position. He has more
maturation, better organization, altho he still doesn't have a good
suck-swallow-breathe rhythm.  But it is better.  He has learned that if he
is calm, he can get more  breath.. The saline solution and reflux meds have
helped a lot.  He took in .6 oz from one an .7 oz from the other breast. Not
a full feed, but a good start.  Both mom and I were so encouraged and happy.
Baby has had so much stress, he really deserves a normalized feeding situation.

I have seen babies with very sore mouths, from viral infections esp.
self-limit.  Also injured babies -- esp. broken collarbones.  These babies
all find feeding painful, so they begin to have an aversive reaction to the
process, and just take in enough to stay even -- rarely achieving that
robust appearance we generally associate with normal feeding.

Hope this gives a sense of what I meant when I referred to the baby who
deliberately self-limits intake. Sorry it's so long.

Barbara

Barbara Wilson-Clay, BS, IBCLC
Private Practice, Austin, Texas
Owner, Lactnews On-Line Conference Page
http://moontower.com/bwc/lactnews.html