I would look for anything that interferes with the baby's ability to
coordinate sucking, swallowing and breathing; as well as oral structural
issues. I have seen tongue tied babies unable to handle the milk flow
at breast let go repeatedly because it was the only way to pace the
feeding at all. If mom has a faster MER than baby can handle (even if
it's a *NORMAL* MER), baby will let go often, perhaps cough and sputter,
and become fussy from the stress of feeding.
Babies with tracheomalacia, laryngomalacia, velopharyngeal
insufficiency, submucous clefts, etc will have difficulty sustaining
enough negative pressure to stay on the breast, or will find feeding
sufficiently challenging to their ability to breathe that they will let
go.
Perhaps this baby performs better at night because he or she is just too
tired to complain by then.
Things I'd assess:
coordination of sucking, swallowing and breathing - swallowing sounds,
stridor (inspiratory for laryngomalacia, expiratory for tracheomalacia;
timing of suck:swallow:breathe triad (should be one per second,
significantly faster means the baby is having trouble keeping up);
sucking burst length (short sucking bursts indicates a respiratory or
cardiac challenge); oral anatomy (tongue tie or submucous cleft can lead
to difficulty maintaining the breast in the mouth); and when the baby
starts to become fussy in the feeding. If later in the feeding, it
might be a respiratory or endurance issue, if earlier, it may be that
the baby is putting out too much effort to get milk flowing.
Catherine Watson Genna, BS, IBCLC NYC
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