Tracy writes about a rather complicated (in my opinion) situation regarding
a mom with a small baby (birth weight under 6lbs) who is just now 6lb2oz and
experiencing apnea during feeding.  Mother was upset by early delivery of
supplements to baby and also doesn't want to increase feed frequency due to
belief that frequent feeding was the source of her baby's early fussiness.

I often seen parents and health professionals who seem unaware of the fact
that the research literature describes these smaller babies as high risk for
poor early feeding (see refs below).  There are physiological reasons for
this.  These babies are often neurologically immature (if born prior to 38
weeks).  They have thin cheeks (which de-stabilizes feeding.) Prematures
typically have low tone (which affects safe swallowing -- esp. as the baby
fatigues.)  These babies are vulnerable to what is termed "fatigue
aspiration."  Fatigue aspiration can happen during feeding by any method,
altho is slightly less likely during breastfeeding because it is more under
the control of the baby. However, regardless of the feeding method, as the
baby starts to get tired, he/she becomes disorganized in terms of being able
to manage the fluids they are trying to swallow.  The cough reflex (by which
babies protect their airways from fluids) is often immature in babies who
are early and small.  They don't cough, but rather hold their breath (apnea)
and try to manage to swallow the fluids that are pooling up in their mouths.
When they can't manage to swallow the accumulated fluids (which are usually
being too swiftly delivered) and they run out of breath, and can aspirate.
This is sometimes called "silent aspiration" due to the lack of a cough
occurring prior to the apena event.  Wolf and Glass describe these
mechanisms thoroughly in their book, Feeding and Swallowing Disorders of
Infancy.

It is tricky to manage these babies, but parents are quite capable of
understanding the challenge the baby is facing once the situation is
carefully explained.  While we want to have these  babies exclusively breast
MILK  fed, they often aren't strong or well-developed enough to access
enough milk on their own.  This may be what the nurses thought and may be
the reason why they supplemented.  Tracy doesn't say what baby was
supplemented with.  It's too bad the nurses didn't explain their reasoning
to the parents.   If such a baby needs to be supplemented, it should be with
mother's own milk, and should be delivered with pacing techniques so as not
to set up a cascade of events that can include becomming aversive to being
orally fed.  These babies also are often temporarily unable to stimulate an
adequate milk supply.

 I work with such  babies all the time, and their outcomes are generally
excellent (my definition of a good outcome is that the baby returns to
exclusive breastfeeding and continues for many months.)  However, the mother
needs to be informed of the reasons why these babies are initially so
vulnerable and must be given real concrete reasons for the interventios that
are proposed. Once the parents understand the issues -- and understand how
short-term these interventions are, they are usually on-board with the idea
of sticking it out until the infant stabilizes.

In such a case, here are the interventions I would propose:
1.  Educate the parents about the challenges such small babies experience by
pointing out the facial features (thin cheeks, deep creases under the eyes,
etc).  Educate on the distinctive differences between nutritive and
non-nutritive suck so mom can identify the point during feeds when the baby
starts to fatigue (closed eyes during breastfeeding, flat affect, choppy,
dys-rhythmic suck.)
2.  Suggest several options to assist the baby's intake which take into
account the risk of fatigue aspiration. These might include postfeed pumping
and delivery of hindmilk back to the baby  (with pacing techniques taught by
return demonstration).  This would protect infant intake and simultaneously
protect the milk supply until baby is more capable of taking over the job.
Or, the mom can do very frequent feeding using breast compressions, allowing
baby to pull off when he/she needs a breathing break.
3  The baby needs to continue to have weight checks to make sure the
interventions are successful in terms of helping baby achieve good gains and
protect the milk supply-- esp. if the mom is not pumping or supplementing.
4.  Mom needs to have the information that as baby gains above 7lbs and
reaches the real due date, feeding behavior will become much more competant
and the interventions can be gradually withdrawn.

The pediatrician of record needs the information that a baby with
demonstrated poor breastfeeding ability and apenea during feeding has been
released home. (See reporting tool ref. below.) These babies need
watchfulness during the first month of life -- much as would the runt of a
litter of pups.  I always remind worried familes that the runt is always the
pick of the litter -- probably because they are handled more tenderly:)

Because all our management should be evidence-based, I cite the following
articles as the basis for these suggestions:

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.



Glass,R. and Wolf,L: Incoordination of Sucking, Swallowing, and Breathing as
an Etiology for Breastfeeding Difficulty, J Hum Lact 1994, 10(3):185-189.


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


Ramsey,M and Gisel,E:  Neonatal Sucking and Maternal Feeding Practices, Dev
Med and Child Neurol 1996, 38:34-47.



Valentine C, Hurst N, and Schanler R:  Hindmillk Improves Weight Gain in
Low-Birth-Weight Infants Fed Human Milk, J Ped Gastroent & Nutr 1994;
474-77.



Wilson-Clay, B. and Maloney,B:  A Reporting Tool to Facilitate
Community-Based Follow-up for At-risk Breastfeeding Dyads at Hospital
Discharge, in Current Issues in Clin Lact 2002, ed. Kathleen Auerbach, Jones
and Bartlett, Boston.  Pg.59-66.





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