These are the kids we lug those heavy scales around for! The loud, 
uncoordinated swallowing sounds can be either tiny milk boluses or 
saliva, and they show that the baby is not coordinating their swallow 
correctly. This can either start with a tongue/sucking problem that 
discombobulates ("scientific" term, that) the rest of the "cascade" of 
movements that makes up the swallow, or a specific problem with the 
pharyngeal part of the swallow. Usually when the baby makes loud gulping 
sounds with a very tiny milk flow, the problem starts in the oral phase, 
in my humble experience (In other words, no I don't have a reference for 
this). Kids with pharyngeal phase problems usually have nasal 
regurgitation, feeding induced apnea, or milk retained in the 
hypopharynx.(look at articles by Lisa Newman).  Those are the kids who 
have wet breathing or nasal congestion after feeding.

You can get some idea of where the swallowing is messed up by listening 
with a stethescope on the baby's neck, near the cricoid cartilage, or 
under the chin if you can't get near the neck. Young babies will keep 
right on eating and just ignore the stethescope. You'll hear either 
bubbling of milk retained from an incomplete clearance of the 
hypopharynx, stridor of laryngeal penetration (when the vocal folds 
attempt to close rapidly while the baby is still trying to inspire), or 
sloppy or slow or too fast movement of the muscles of the tongue and 
pharynx when you really get a feel for it. You can learn more about this 
by attending one of Robin Glass and Lynn Wolf's conferences on Feeding 
and Swallowing Disorders in Infancy, or reading their book of the same 
title.

Now, fixing the problem is a whole 'nother issue. Upright positioning or 
more head extension or some preparatory tongue exercises might help.
Catherine Watson Genna, IBCLC  NYC

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