In response to Cindy Curtis' post four areas come to mind
- suck
- oral anatomical variation
- organic cause
- floundering
I'd like to pick up on Linda Smith's suck thread.  In my experience babies
sometimes get into improper sucking patterns from the SNS.  It becomes a
cycle of what came first, the problem or the SNS, and is almost impossible
to determine the original cause.  However, many babies suck SNSs like straws
creating a negative suck.  Cheek dimplings is a clue to this.  The tongue
interacts with the tubing preventing a correct peristaltic wave-like motion.
Unless the mother has been stimulating her milk supply in yet another manner
her milk supply is compromised.  Just the baby at breast with the SNS is not
enough unless the baby has a perfect suck.

You responded to Linda that the L-O and positioning was correct.  Sometimes
a visual assessment is not enough.  A baby may look great from the outside
but may be doing all sorts of oral gymnastics on the inside.  An oral
digital assessment may give some clue as to what is happening on the inside.
It can assess the suck and also palatal variations.  With a palatal
variation the baby can look great visually but not be effectively sucking.
Example - a high arched palate and a short nipple.  This baby would have to
be latched on more deeply than what is generally good to make it work.

Organic causes can be surprisingly ellusive.  I worked with a baby whose
frenulum was tight then clipped, still had problems was clipped a second
time because the first clip wasn't deep enough and ultimately CMV
postnatally contacted was diagnosed.  This baby exhibited anorexiant
behavior which had to be strenuously monitored.

Some babies flounder being switched in feeding methods and just need
adjustment. This is tough when the MD is weight watching.  Slow withdrawal
of ABM is necessary for all parties.  Effectient sucking must be maintained
with the withdrawal.

Hope this helps.
Joanne Burke Snyder, MA, CLE, IBCLC
Latch-On Services, A Private Practice in Indianola, Iowa
LLL APL Iowa