Paula,

I just attended a seminar dealing with gastric reflux and hyperlactation
that may provide some helpful ideas.  Stimulating breastmilk by pump
often (deliberately) produces an overabundant milk supply since the
infant's demand is not what's regulating the supply.

Overactive letdown reflex is almost always present in the case of
overabundant milk supply. This, and it's tendency to overfill the baby's
tummy, and not the "thinness" of breastmilk, is more than likely one
major source of the baby's problem.

This is not to say there might not be other problems in addition, but it
is sad to see that this aspect has apparently been so mismanaged. Sounds
like sacrificing breastfeeding on the altar of ignorance, as Dr. Jack
would say. At the very least, the breastmilk could have been given by a
slow-flow nipple or alternate feeding method.

The Medela thin silicone nipple shield, small size for a premie,
discussed very positively on Lactnet the last few days, is an excellent
tool to deflect the force of an overactive let-down reflex and slow the
flow so the baby doesn't overfill it's stomach capacity by gulping too
large a quantity too quickly.

Also, triggering the reflex by hand expression, slight nipple twisting
and/or massage 3-4 minutes prior to latching usually gives the surge time
to subside so that many babies can deal with the subsequent trickling
flow at their own pace. However, with an oversupply, subsequent MER's
might again overwhelm the child. Using only one breast at a feeding, or
offering the same breast for 2, or even 3 feedings, is often helpful.
"Tames" the MER and less likely to result in temporary lactose overload.

Also helpful is the use of "anti-gravity" positions, where the mom is
leaned comfortably back, as in a recliner chair and/or the baby is
propped up at a level above mom's nipple, and rolled over somewhat above
the mom's chest.

This position seems to "subtract" the force of gravity from that of the
MER because milk is moved  in the opposite direction of gravitational
pull, making it much easier on the baby.

This works well because the baby's posterior pharygeal air passage is
then above the nipple. He also receives a slower, less powerful "uphill"
flow of milk as if from a drinking fountain. This allows his tongue a
chance to organize a bolus and transfer it around the epiglottis with a
coordinated suck,swallow, breathe pattern.

Positioning baby "downhill" from nipple puts his nasopharynx in a
dependent position and permits gravity to have an additive effect to the
MER. This results in  his receiving the milk as if from under Niagra
Falls, flooding straight downward toward the posterior pharynx, causing
choking, gulping and bradycardia.

A sidelying position, where gravitational forces play less of a role,
also has less tendency to cause difficulty with suck, swallow, breathe
coordination.

Also, feeding smaller amounts (more frequently than scheduled 3 hour
feeds) at least during the mom's waking hours, and keeping the baby as
upright as possible all the time, are helpful.

Diaper changes while the baby is semi-upright may be challenging, but
this is one of the most important times, and it's also important to avoid
extra intra-abdominal pressure from the knees being bent back on the
abdomen during diaper changes.

Carefully aligned body support in a car seat was also identified as a way
to reduce reflux.

I hope these ideas are helpful for "fixing the breastfeeding" and getting
mother and baby much closer together soon.

Jean
*****************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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