I have just seen a mother with a baby (4.5 wks old) that we suspect has
mild-moderate form of laryngomalacia (floppy larynx).  What makes me wonder
if this might be the situation with this baby is when you stated <Within
moments he was gulping and making high pitched noises and clearly
struggling>.   We recently had a talk on laryngomalacia at our College of
Lactation Consultants Western Australia meeting by Diane Tomlinson (IBCLC)
and Rebecca Shaw (Speech Pathologist) which helped to identify the symptoms
and they gave suggestions and ideas to help reduce them.  

When she came for the consult she stated many possible problems:  unsettled
baby, baby that keeps coming on and off the breast, candida, nipple pain,
reflux .....  The thing that was absolutely identifiable was the extremely
noticeable INSPIRATORY stridor during feeding and also when she was supine.
The mother described this as sounding like 'a mule' or 'a goose'.  This baby
is thriving but some babies with severe laryngomalacia I believe can have
problems with weight gain.   

The main strategies the mother has used for the last week has been:
*Expressing the first rush before feeding (on the days she did this
religiously at every feed she said it was like a miracle) - some feeds she
expressed 60ml and others 20-40mls.
*Helping the baby to pace the flow - allowing baby to rest when showing
signs of incoordinate suck or pulling or pushing off.  Helping baby to have
a more pleasant experience and reorganising herself when she became
disorganised seems to have been useful.  
*Using long piece of fabric as sling to tie baby onto her body to keep the
baby upright - this mother carries baby in sling for 4-5 hours a day.
Reflux is often associated with Laryngomalacia so by keeping baby very
upright after feeds seems to have helped this mother and baby.  
*I have suggested she visit a Physiotherapist to help baby gain good neck
and head control.  

It appears that this self corrects itself within first year of life but
helping the mother to understand there is a reason why her baby behaves the
way she does seems to help.

May not be the problem Chayn but thought it might be useful to discuss!

Shaughn Leach, RM IBCLC DipT
Perth, Western Australia



  

 

 

-----Original Message-----
From: Lactation Information and Discussion
[mailto:[log in to unmask]] On Behalf Of Fogelmans
Sent: Friday, 11 April 2008 5:36 AM
To: [log in to unmask]
Subject: baby gulping and choking

Dear Friends,
Please help.  I have practically promised the mother that I would get at
least a second opinion from the best and brightest LCs around the globe, so
someone please reply....

The mother called complaining that she has too much milk and her baby is
unable to cope with the flow, making nursing miserable.  As she needs to fly
with him to England on Tuesday (5 hour flight) she needs help fast.

Baby is a bit less than 6 weeks old.  Birthweight was 3.130, discharge
weight, 2 days old 3.060.  Today he weighs 4.420 (5 weeks, 5 days)

Mother reports that the baby nursed decently in the hospital except that he
didn't open his mouth wide enough.  She was in a bit of pain but nothing
terrible.  Baby got one bottle at night per mom's request.  Day 3, they went
home and the mom's milk came in and she had to pump to relieve herself of
engorgement.  Baby became fussy on the breast, choking sputtering and
pulling off.  The mother discovered that if she pumped 80 ccs from her
fuller side that the baby could eat for 15 minutes peacefully and then need
second side.  Mom would pump off 40 ccs from that side and finish nursing.
Mom grew tired of pumping and cut back to 40 ccs and 20 ccs from fuller and
less full breast before each feed.  Baby nurses 5 minutes, gulping, comes
off, gets burped, goes back on, back and forth for a while until he is
finally satisfied.  

Today I went to see her.  She tried to put the baby on without pumping
first.  Positioning was beautiful! Baby went on well but closed up quickly.
Within moments he was gulping and making high pitched noises and clearly
struggling.  Mom took him off and there were no spray, not even drips.  Her
nipple is a bit pinched but doesn't hurt at all.  

We tried side lying and baby just lied there with the breast in his mouth,
sucking here and there for about a minute and then again started gulping and
struggling.  This time when he came off Mom's breast was dripping.  We tried
with Mom on her back but the baby was miserable and wouldn't even try.  We
even tried with a nipple shield, thinking that if she could slow the flow
down with the sheild, she may be able to nurse the baby on the plane without
too much hassle.  We soaked the sheild in ebm, dripped it on as he was
latching but the baby would have nothing to do with it and screamed
miserably.  He wouldn't even suck those few sucks that would get mom's milk
flowing.

Baby has normal bowel movements and does not spit up. Mother tried feeding
him with ebm from both a terrible fast flow nipple that she brought home
from the mother - baby rest home and a MAM nipple for newborns.  She said
that he choked on both.

The mother pumped  with an Avent hand pump to have milk to drip on the
sheild and she did not pump especially quickly.  Before that she tried to
squeeze some milk out with her hand but got almost nothing, maybe a drip.
She is not uncomfortably full.  

Watching baby cry I noticed that his tongue stays perfectly flat in his
mouth.  Upon oral exam, his palate felt higher than normal, like a dome.
While he was resting, he put his tongue up against his palate, in the dome.
He did not lateralize when I ran my fingers across his bottom biting
surface. No visible frenulum.  Unfortunately I had run out of tubes and
could not check his suck with a flow.   

So I'm thinking that the baby has a submucosal tongue tie and lousy bolus
formation coupled with Mom's ample suppy and he can't handle it. I explained
to the mother what I thought but she is reluctant to take him to be clipped
so I told her that I would check it out with a 'few' collegues.  Perhaps he
has some kind of sucking disorder.  The mom also claims that he has had a
cold since he was born.

I hope that this is clear.  
Thank you so much,
Chayn in Israel IBCLC 


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