Exquisite coordination is necessary for correct closure of the airway 
during swallowing. The infant's normal respiratory rate allows about a 
swallow per second while providing sufficient airway open time to keep 
blood oxygen optimal.

When the flow is fast, it interrupts breathing. The baby then runs low 
on oxygen, and has to gasp in a breath as best he can, sometimes 
resulting in milk in the airway. Or he has to swallow a little more 
sloppily, and this can let milk into the airway as well.

A demonstration I often use when I speak about respiratory disorders and 
breastfeeding:

Tap your hands on your knees about 40-60 times a minute. That represents 
breathing at a normal infant respiratory rate. Now, while keeping a 
steady rhythm, touch your nose with your fingertips briefly. That 
represents swallowing. You will see that you can easily touch your nose 
(swallow) and then go right back to touching your knees (breathing) 
without any break in rhythm. BUT, if you speed up your tapping (try 
about 100-120 per minute) you will find you cannot touch your nose 
without missing breaths. The inverse happens when you have to keep 
touching your nose (swallowing), your hands are not free to tap your 
knees (breathing).

Try it and see for yourself.

You can also use a stethoscope under your baby's chin near his throat 
while he breastfeeds, and listen to his swallowing. Swallow sounds 
should sound crisp (glunk) and then the baby should breathe. If you hear 
multiple swallows with no breathing in between, the baby is 
breath-holding to try to keep up with the flow rate. A tiny bit of this 
may happen during the first MER and still be okay, but if it happens a 
lot, the baby can aspirate (draw fluid into the airway). You will hear 
that with the stethoscope as a wet, gurgly or bubbly sound to the 
breathing right after the swallow. If you hear a high pitched tiny bit 
of stridor during swallowing, the vocal folds are snapping shut to keep 
milk from going further down the airway. This happens when the baby 
tries to breathe and swallow simultaneously. Fluid at the level of the 
vocal folds is called penetration. Fluid can also leak into the nasal 
airway if the soft palate does not close it off tightly. Look at the 
archives for posts including the word velopharyngeal dysfunction or 
insufficiency for more on that.

Carol Chamblin has a great trick for reducing milk flow during strong 
MERs: she has mom place a hand flat on the breast to close off some 
surface ducts until the MER receeds a bit. I've tried it, it works very 
well. Thanks to Flossie Rollhauser for teaching it to me. Dontcha love 
our profession?

Catherine Watson Genna, IBCLC  NYC

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