Kathy Boggs wrote:
<Catherine writes: Again, many premies have immature ability to
coordinate
swallowing and breathing, and that might make even a normal supply
difficult to handle initially.

This is very true, Catherine, but if we let supply regulate to baby's
need
before s/he is fully breastfeeding many premies are unable to transfer
milk well
at all. It's certainly a dilemma. The way we handle it in the hospital is
to
have mother partially pump before putting baby to breast.>

I can see how this would help, perhaps not so much because of removing
some excess milk near the front of the breast, but because it might well
trigger the MER and allow the "big push" to dwindle down before latching
attempts. IME, it takes about 2 full minutes for the "big push" to
subside, once the first sign appears of the MER having been activated.
Subsequent MER's during the feeding appear to be less powerful than the
first one, perhaps due to initial reduction of "pent-up" milk waiting in
the ducts, or perhaps some lower level of subsequent oxytocin surges (???
just musing about a possible 'refractory' effect).

Some NICU's have furniture in a private nursing area that might allow the
mother to assume an "anti-gravity" position when nursing (this might be
accomplished with pillows and infant in a semi-prone position or
carefully propped football position). Besides using gravity to reduce the
speed of the emerging milk, it positions the infant's posterior
nasopharynx above the level of the flow (like a drinking fountain)
instead of underneath it (like Niagra Falls) as happens in standard
positions.

This preserves some space for unobstructed air passage and might reduce
effort to coordinate sucking and swallowing to keep from choking. This
works very well in term babies who also often experience the same
difficulty at home when mother has an oversupply.

I would like to suggest the possibility of using Reverse Pressure
Softening for 3-4+ minutes before attempting to latch. This triggers the
MER within 1-2 minutes, and would allow the "big push" to subside before
latching, so the baby could remove milk at a speed he could handle
better, especially if in an anti-gravity position. Stimulating the MER
this way might eliminate some time and trouble spent in pumping a.c., and
by somewhat reducing the # of ounces pumped out daily, work toward a
better eventual balancing of supply.

I have also heard that some people think a silicone nipple shield might
modify the rapid flow during MER. RPS can be applied as part of the
process of applying the shield too.

Cotterman, KJ, Too swollen to latch on?: Try Reverse Pressure Softening
first, Leaven Apr. May 2003, pp. 38-40.

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

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