Hope you are not all getting sick of my comments on this thread, which I
find fascinating. I promise I will shut up about it after this post.
The reading I have done suggests that the gag reflex protects the airways
from large objects. In very young, normal infants it is an exaggerated
reflex which can be triggered by contact about midway back on tongue. As
baby matures a bit, it retreats and takes up "residence" (in normal kids) at
the rear of the tongue. It is not really much involved in protecting the
airways from fluids. That is the role of the cough reflex. (There are refs
for this in the OT, PT, Speech Path lit.)
When I saw Wolf and Glass present, I also watched numerous videofluoscopic
films of infants aspirating. There are many ways of aspirating fluids, and
many times it is silent. Aspiration can take place during the swallow
cycle. If baby can't form milk into an organized bolus, it can leak and
spill over the sides of the tongue into airways before baby can lift
posterior tongue and soft palate to seal off for a swallow. If baby has
difficulty with regularizing or timing respirations, fluid can be sniffed up
into nasal pharynx where it will result in a sound of "wet" breathing. Some
babies aspirate reflux. Apirating babies often become quite aversive to
feeding due to the distress this causes.
I saw a baby like this last week. Born 6.5, down to 5.7 by the time I saw
him at 1.5 wk pp. Mother had flaccid breasts, and we couldn't figure out
where the milk was. It never really seemed to have come in . We didn't
have much breast milk to work with, so began immed. steps to bolster
production with pump, frequent nursing with excellent positioning, and
fenugreek. This might have looked like a milk supply cause for SWG if it
weren't for how aversive baby was to supplemental feeding. You'd expect a
starving baby to be glad to get some food. Test weighing revealed baby who
essentially hung out at the breast doing non-nutritive sucking. We heard
swallows, but turned out it must have been baby swallowing own saliva (or
reflux) because it produced no discernable intake.
Baby looked very stressed when I tried to cup feed pumped milk to see what
he could handle in way of alternative feeding. He also looked very
distressed when I tried to feed him milk from a bottle or off my finger. In
fact the only thing that didn't stress him was hanging out and doing NNS.
Due to lack of available milk, MD recommended formula to try to get some
weight on baby. Baby immed. began episodes of projectile vomiting and
didn't stool for 5 days. My report to the MD had emphasized how many
motoric stress cues baby evidenced when feeding. MD made referal for barium
swallow study and discovered baby has a partially blocked valve at entrance
to duodenum. No wonder baby won't eat! Everything he eats backs up,
causing painful reflux. He has very wet breathing from all this backed up
fluid, a worried look, and cries a lot.
The issue of the WAY food was delivered is not this baby's main problem, but
it illustrates my point that ill infants don't feed normally. The risk to
them of proceeding without more information can be significant. These
infants need evaluation in person, not over the ph. management, and they
probably need more testing than an LC would be able to obtain. Clearly the
LC role here is interpreting the infant's feeding distress to the pedi in
order to get the pedi's attention on behalf of further investigation.
Current status of the infant described above: mom's supply is slowly
increasing allowing more of his diet to be human milk. Formula has been
switched to "hypoallergenic" until we can get him exclusively on human milk.
Surgeon is looking at test results. Baby is being nursed at breast with
supplemental bottles and is essentially in holding pattern while decision is
made about whether surgery is nec. Mom understands that her milk will be
best if baby does have surgery, and is relieved to have some answers -- not
just the fear it is her incompetancy causing the distress.
Human milk IS more physiologic if it comes in contact with mucus membranes.
The cleft palate lit. supports this. However, infants with clefts who are
fed human milk still are often chronically ill with respiratory infections
and otitis media. We MUST ask the question: can it be good for fluids --
even human milk -- to be in the lungs or nasal passages? I have had
exclusively bfed infants in my practice who have had many upper and lower
respiratory infections -- not a normal presentation for the breastfed. Some
have later been discovered to have swallowing probs. In fact, my middle
daughter was my only infant to have chronic, repeated ear infections during
the time she was breastfed exclusively. (She bfed partially to age 4.5)
Today as a 16 yr. old she has exercised induced asthma. She has been
extensively tested for allergies and has never reacted positively to any
allergen. Yet, her respiratory function is not normal. Is there a
connection between early silent aspiration, ear infections and the current
lung issues? Who knows?
The point: Babies who WON'T eat normally are generally babies who CAN'T eat
normally. Care must be taken to separate out the infants who can be safely
fed just about any old way from infants who may not be safe unless great
care is taken. And if we are to be taken seriously as breastfeeding experts,
we need to obtain continuing education in anatomy and physiol. of oral-motor
function. An LC is more than a cheer-leader. S/he must constantly use very
critical thinking to refine an ever deepening understanding of how the
process works. We can't extrapolate that what works for the normal can work
the same way for the abnormal situation. In fact, there are probably some
babies we may see who cannot be safely fed, and need gavaging. Individual
case planning is the key.
Barbara
Barbara Wilson-Clay, BS, IBCLC
Private Practice, Austin, Texas
Owner, Lactnews On-Line Conference Page
http://moontower.com/bwc/lactnews.html
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