Appropos of the twins who were delivered slightly early, one who was breech,
and who both were having breathing difficulties.  In my experience, you
can't manage babies who are in the NOT NORMAL assessment category the same
way you manage babies who are. While these babies are probably only
temporarily in the NOT NORMAL categoy, they have some real red flags for
poor feeding.  Unstable breathers must stabilize respiratory function before
they can feed dependably.  Early babies must sometimes mature and may have
different energy requirements.  Breech babies often have range-of-motion
issues that impede normal motor control until they "thaw" a bit in terms of
muscle tension.  Intubation creates risk of conditioned dysphagia.
Dyskinesia can lead to early feeding resistence.  These weak babies are
notoriously poor stimulators of maternal milk supply, need extra postural
assistance while feeding, may need supplemental calories (hopefully from
pumped hind milk) and lots of monitoring to make sure they remain medically
stable.  It is great to have cheer leaders for lactation, but the support of
such at-risk babies requires acute, individualized observation of each baby
and what ever realistic assistance appropriate to ensure normal growth.  The
references documenting these issues are lengthy, and have been posted many
times.
Heres a few:

Abadie V, Andre A, Zaouche A, et al: Early feeding resistance:  A possible
consequence of neonatal oro-oesophageal dyskinesia,  Acta Paediatr 2001;
90:738-45.



Alper,B. and Manno,C:  Dysphagia in Infants and Children with Oral-Motor
Deficits:  Assessment and Management, Seminars in Speech and Language 1996,
17(4):283-309.



Chen,D. Nommsen-Rivers,L. Dewey,K. Lonnerdal.B:  Stress during labor and
delivery and early lactation performance, Am J Clin Nutr 1998, 68:335-45



Kramer M, Demissie K, Yang H, Platt R, et al:  The Contribution of Mild and
Moderate Preterm Birth to Infant Mortality, JAMA 2000, 284:843-849.



Palmer,M.  Identification and management of the transitional suck pattern in
premature infants, J Perinat Neonatal Nurs  1993, 7(1):66-75.



Powers,N:  Slow Weight Gain and Low Milk Supply in the Breastfeeding Dyad,
in Clinics in Perinatology, 1999, ed. by C. Wagner and D. Purohit,
26(2):399-430.



Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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