I am hoping some of you will be able to make some suggestions to help me
with a client.

Baby (3rd) is 7 weeks and gaining well, thanks to mum's copious milk supply
(always been an oversupplier, with all 3 lactations).

In early days, baby cracked mum's nipples, and lost 14% of bw, so mum
reluctantly resorted to nipple shield, which she used for last baby (long
story, but last baby couldn't handle fast flow and needed shield to cope,
and had trouble keeping breast in mouth - also had receding chin, fed on
shield for 9 months, then weaned). Once using shield, this baby gained
weight in leaps and bounds, so she kept using it. Feeding seemed OK, but
not perfect, for a couple of weeks, then got worse and worse with sucking
air and windy behaviour. Now sucks better without shield than with it, but
not well at all.

Baby cannot maintain a seal on the breast, or nipple shield, or even a
bottle teat for that matter. She sucks lots of air and was very windy and
unsettled. This is complicated by a very forceful let-down, which means
baby only has to hang off the end and swallow (along with the air!). When I
did a digital assessment, she had a very strong gag reflex with my finger
only just past her upper gum. Mum reports that she frequently gags (and dry
retches) while feeding, and she interpreted this as baby being full and not
wanting to feed anymore. I have never seen a baby gag like this before.
It's almost like baby has an aversion to anything in the back, or even the
middle of her mouth. Baby *can* attach well for variable amounts of time
(from a couple of sucks to several minutes), but doesn't stay there - just
slides gradually down nipple and eventually hangs off tip, sucking milk and
air together. Nipples have not been sore, but with all the "on and off"
feeding, they are starting to suffer. When I saw her feed on the shield,
she actually pushed out shield after every couple of sucks, in between
gulping the fast flow. Milk poured out from under shield while feeding on
it. She now (a week later) refuses to feed on the shield, so feeds are a
series of attachments and re-attachments. She is still getting plenty of
milk.

After I saw her last week, I referred her to a chiropractor who treats lots
of babies. He found her neck was out to the extent that she could turn her
head one way OK but not the other. Chiropractic treatments seem to have
made a big difference to her unsettled, windy behaviour, but has not made
any difference to her feeding behaviour.

I also saw this mum with her 2nd baby, and on reading back through my
notes, this other baby was very similar the way she attached well then slid
off, and would only feed on the nipple shield. She also showed the
overactive gag.

Do you know who might deal with this sort of problem (ie overactive gag
reflex)? Can speech pathologists treat this at all? What about others, such
as OT's? Do you have any suggestions of things we could try that might
help?

I would be very grateful for any ideas, suggestions.

Joy Anderson IBCLC
Perth, Western Australia

P.S. Congratulations to Jay on finally getting your certificate. We have
all been waiting along with you, Jay, all these months. Great news!