I am delighted that there is beginning to be more discussion of infant
state, stress and satiety cues in lecture that LCs attend.  In my Infant
Assessment lecture, I always review the work of  Heidi Als.  Dr. Als was a
student of Brazelton's and she carefully studied infant state behavior and
expanded it beyond the typical understanding of sleepy, drowsy, quiet alert,
active alert, crying, etc.  She described what stable and unstable states
look like in infants (esp. in prematures) in terms of autonomic and motor
behaviors.  While sneezing and hiccoughing are described (in the premature,
at least) as stress cues, they are less severe than gagging or vomiting, or
than crying -- which is an intense cue.  She also points out that the timing
of behavior can tell you what has caused the event.  There may be a
perfectly good reason for the event (i.e. vomiting because baby has mucus,
etc) but it is still stressful to throw up.

It is impt. to remember that birth is traumatic for some infants, and even
when not particularly difficult, is prob. a pretty heavy duty experience for
all infants.  Therefore, some stress may be inevitable in the aftermath of
birth. Goodness knows babies get poked a bunch, which would stress me out.
Like vomiting to clear mucus, getting poked may be inevitable and even
necessary, but that doesn't make it fun.  I think that anticipatory guidance
for staff and parents about how to recognize and comfort stressed babies is
very appropriate.  Skin-to-skin care and holding help.  Breastfeeding is
analgesic in newborns, so assisting babies in effective bfg is critical.

  When I do exams of babies, I am always watching for stress cues,
describing them to parents in a casual, but hopefully informative manner.  I
might say as we are weighing, "Oh look at how she is splaying her fingers
and grimacing.  She doesn't like being on this hard surface and perhaps
feels as if she may fall."  Then when we pick her up, I will say:  "She
really likes being held close and reassured."  If a baby begins to hiccough
or sneeze while we are practicing latch, I may say:  "The baby is telling us
she needs a short break.  This learning period can easily be broken up into
short teaching moments that are comfortable for her."  If a baby falls
asleep early in the feeding, I may say:  "Tuning out is a stress cue.  This
means that feeding is somehow still a bit difficult for your baby.  Let's do
like athletic trainers do and run a lap, walk a lap.  While the baby is
recovering for a lap, let's talk about the plan and how to recognize when
your little athlete is getting stronger and can do more repetitions before
needing a break."

I think Al's work is just fascinating, and, along with Marie Ramsey's and MM
Palmer's and Wolf and Glass's, it has really informed my practice.  We have
a ch. on infant state in the Breastfeeding Atlas, which lists a bunch of
refs that people can read in the original, but I include a few here.

Als,H:  Toward a Synactive Theory of Development:  Promise for the
Assessment and Support of Infant Individuality, Infant Mental Health J 1982,
3(4):229-243.



Palmer,M and Heyman,M.  Assessment and treatment of sensory-versus
motor-based feeding problems in very young children. Infants and Young
Children  1993, 6(2):67-73.



Ramsey,M and Gisel,E:  Neonatal Sucking and Maternal Feeding Practices, Dev
Med and Child Neurol 1996, 38:34-47.





Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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