Working in both the role of Lactation Consultant and Nurse Feeding
Specialist, I am confronted with this situation all too often.  I am
many times heart broken (watching the heart ache of mom and dad) when
the medical treatment is in conflict with the normal mother-baby
breastfeeding dyad.  You are on target when you are referring to the
medical issues as very separate and distinct.  On the first subject of a
very serious heart defect and intestinal bleeding, there may be upcoming
surgeries that the infant needs to maximize growth and nutrition.  They
may be concerned about the absorption of protein due to allergies.
Protein is very important to the repair of tissue post surgery.  The
other thing with the bleeding issue is that the levels of hemoglobin are
even more critical with infant heart defects since the cardiac perfusion
is impaired.  Unrepaired cardiac defects may have different oxygenation
requirements that are being maintained.  Normal is usually 98 to 100%,
and the infant with Tetralogy of Fallot may be maintained at 70 to 85%.
So the normal healthy infant with milk protein allergy that has a lower
level is not affected as much as the infant with a cardiac defect that
is already having a difficult time perfusing the organs and extremities.
The other issue is the aspiration on thin liquids.  My understanding
that rice cereal is used in the pediatric community instead of the
'thick-It' type products, they are a sugar based carbohydrate base and
contains sodium.    The infant rice cereal is a lower allergenic food
and has about 9 to 10 calories per tablespoon.  Infant oatmeal may also
be used in older babies but is harder on the younger ones digestion than
rice.  Based on experience, the thicker liquid most likely will decrease
the volume of food taken per feeding.  The rationale for thickening the
liquid is that it gives more time to organinze the suck swallow breathe
coordination.  A (MBS)(VFSS)modified barium swallow study or a (FEES)
fiberoptic endoscope evaluation of swallow may be tools that allow the
physician and speech pathologist to view the safety of thin and thicker
liquids.  When studies are showing aspiration, benign changes may help
with VERY mild coordination issues that can be solved with breastfeeding
position changes, slow flow nipples, slower external pacing of EBM
bottle, position changes in baby and bottle.  Severe situations of
aspiration would not allow ANY oral feedings.  Mild and moderate cases
of aspiration may not be solved easily with breastfeeding changes,
position changes or pacing of thin liquids.  There may be multiple
issues that may be causing the discoordination of suck swallow breathe
in the critically ill infant.  While breast milk is almost always best,
the results of aspiration are most likely much more detrimental than
supplementation of mom's milk with rice cereal, some ABM or using
artificial nipples/bottles.  Again, I am not speaking of normal healthy
newborns or babies that have innocent heart murmurs.  I am referring to
the most complicated and critical.  Each mom and baby should be
evaluated individually.  Is there any reason that Mom could not start
reestablishing her milk supply while they are waiting for the cow's milk
to be eliminated?, store at home for a later date to be used when the
bleeding or aspiration concerns are in the past?  Or even use it later
on to mix with infant cereal for spoon feedings?  This would allow mom
to begin her breastfeeding plan.  Could the cow milk eliminated
expressed breast milk be given via feeding tube and thickened formula by
bottle for oral feeds?  If mom is educated as to the texture needed for
safe bottle feeding, she can add more rice cereal to the expressed
breast milk as it begins to break down being very careful of maintaining
the required texture.  The more concerning the results of the aspiration
on the swallow study, the less flexible the plan for feeding may be.  

Angie Kirkwood RN, BSN, IBCLC

Nurse Feeding Specialist and Certified Lactation Consultant
Children's Hospital of Pittsburgh

Office  412-692-5036



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