We also see fussiness with feeding and feeding refusal with babies who 
are having difficulty swallowing. They act as if there is an oversupply, 
but the flow is normal. They are incapable of handling a normal flow. So 
far, we've always found a reason for the swallowing difficulty - 
posterior tongue-tie, velopharyngeal dysfunction. 
laryngomalacia/tracheomalacia. The baby's normal weight gain and the 
mother's normal pumped volume make it more likely that one of these 
issues or something similar is making the baby unhappy.

If you have a neonatal stethescope, try putting it to the underside of 
the baby's chin while he/she is feeding. A clean swallow sounds like a 
rapid biphasic click - cuh-lick. If it's drawn out cuuuuhhhhhh----lick, 
the volume swallowed is likely small. If there's rare bouts of stridor 
(squeekiness) the baby is trying to breathe while still swallowing, or 
closing the vocal folds because milk got too close to the airway 
(laryngeal penetration). If you hear air bubbling, there are problems in 
the pharygeal phase of the swallow. You will hear nasal congestion 
(wetness in the breathing sounds) if the baby is getting milk up the 
back of the nose (nasopharyngeal backflow), it will get worse as the 
feeding progresses. If there's almost constant stridor, the airway is 
collapsing. Cervical auscultation (this technique) is a really good one, 
you can listen to the baby's coordination of swallowing and breathing. 
If the baby breath-holds while swallowing (swallows several times 
without breathing) that's a sign that he's struggling, as are too-long 
sucking bursts (there should be respiratory pauses of 2-5 seconds every 
10-20 sucks in newborns/young babies), up to 30 sucks per burst in older 
babies.

There's some info in Supporting Sucking Skills in Breastfeeding Infants 
on this, you can get a  preview on Google Books, so this is not a sales 
commercial.

If you find swallowing difficulty, then a prone position for feeding 
with some head extension is often helpful. Have mom lean way back, and 
let baby be in a straddle or diagonal position, and teach mom NOT to 
hold baby's head, not to push baby to feed if he or she rests to 
breathe, etc. Some babies can feel much safer this way, and I've had 
some with dysphagia (difficulty swallowing) who went back to bf with 
this positioning.

Catherine Watson Genna BS, IBCLC  NYC  cwgenna.com


On 1/20/2011 4:08 PM, Laurie Wheeler wrote:
> Hi Jannette,
> My first thought is reflux. This can seem to be overdiagnosed, but some babies do have it.
> I calculate the weight gain at average 4.8 oz per week, which is normal, though not stellar.
> As my other thought is oversupply/overactive letdown, often we see a large wt gain with that. Sometimes not.
> Also it would seem that at this point in time, the overactive symptoms would have tamped down. Not
> necessarily though. You did say mother has lots of milk, though if she pumped 5 oz and that is a typical
> volume (what is typical, right?) then that doesn't fit oversupply to me.
> So back to my first thought of reflux, and then perhaps letting baby have more control over feeding positions?
> Does baby have *any* respiratory symptoms or odd sounds?
> Laurie Wheeler RN MN IBCLC
> Mississippi USA
>
>
>
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