Hope you are not all getting sick of my comments on this thread, which I find fascinating. I promise I will shut up about it after this post. The reading I have done suggests that the gag reflex protects the airways from large objects. In very young, normal infants it is an exaggerated reflex which can be triggered by contact about midway back on tongue. As baby matures a bit, it retreats and takes up "residence" (in normal kids) at the rear of the tongue. It is not really much involved in protecting the airways from fluids. That is the role of the cough reflex. (There are refs for this in the OT, PT, Speech Path lit.) When I saw Wolf and Glass present, I also watched numerous videofluoscopic films of infants aspirating. There are many ways of aspirating fluids, and many times it is silent. Aspiration can take place during the swallow cycle. If baby can't form milk into an organized bolus, it can leak and spill over the sides of the tongue into airways before baby can lift posterior tongue and soft palate to seal off for a swallow. If baby has difficulty with regularizing or timing respirations, fluid can be sniffed up into nasal pharynx where it will result in a sound of "wet" breathing. Some babies aspirate reflux. Apirating babies often become quite aversive to feeding due to the distress this causes. I saw a baby like this last week. Born 6.5, down to 5.7 by the time I saw him at 1.5 wk pp. Mother had flaccid breasts, and we couldn't figure out where the milk was. It never really seemed to have come in . We didn't have much breast milk to work with, so began immed. steps to bolster production with pump, frequent nursing with excellent positioning, and fenugreek. This might have looked like a milk supply cause for SWG if it weren't for how aversive baby was to supplemental feeding. You'd expect a starving baby to be glad to get some food. Test weighing revealed baby who essentially hung out at the breast doing non-nutritive sucking. We heard swallows, but turned out it must have been baby swallowing own saliva (or reflux) because it produced no discernable intake. Baby looked very stressed when I tried to cup feed pumped milk to see what he could handle in way of alternative feeding. He also looked very distressed when I tried to feed him milk from a bottle or off my finger. In fact the only thing that didn't stress him was hanging out and doing NNS. Due to lack of available milk, MD recommended formula to try to get some weight on baby. Baby immed. began episodes of projectile vomiting and didn't stool for 5 days. My report to the MD had emphasized how many motoric stress cues baby evidenced when feeding. MD made referal for barium swallow study and discovered baby has a partially blocked valve at entrance to duodenum. No wonder baby won't eat! Everything he eats backs up, causing painful reflux. He has very wet breathing from all this backed up fluid, a worried look, and cries a lot. The issue of the WAY food was delivered is not this baby's main problem, but it illustrates my point that ill infants don't feed normally. The risk to them of proceeding without more information can be significant. These infants need evaluation in person, not over the ph. management, and they probably need more testing than an LC would be able to obtain. Clearly the LC role here is interpreting the infant's feeding distress to the pedi in order to get the pedi's attention on behalf of further investigation. Current status of the infant described above: mom's supply is slowly increasing allowing more of his diet to be human milk. Formula has been switched to "hypoallergenic" until we can get him exclusively on human milk. Surgeon is looking at test results. Baby is being nursed at breast with supplemental bottles and is essentially in holding pattern while decision is made about whether surgery is nec. Mom understands that her milk will be best if baby does have surgery, and is relieved to have some answers -- not just the fear it is her incompetancy causing the distress. Human milk IS more physiologic if it comes in contact with mucus membranes. The cleft palate lit. supports this. However, infants with clefts who are fed human milk still are often chronically ill with respiratory infections and otitis media. We MUST ask the question: can it be good for fluids -- even human milk -- to be in the lungs or nasal passages? I have had exclusively bfed infants in my practice who have had many upper and lower respiratory infections -- not a normal presentation for the breastfed. Some have later been discovered to have swallowing probs. In fact, my middle daughter was my only infant to have chronic, repeated ear infections during the time she was breastfed exclusively. (She bfed partially to age 4.5) Today as a 16 yr. old she has exercised induced asthma. She has been extensively tested for allergies and has never reacted positively to any allergen. Yet, her respiratory function is not normal. Is there a connection between early silent aspiration, ear infections and the current lung issues? Who knows? The point: Babies who WON'T eat normally are generally babies who CAN'T eat normally. Care must be taken to separate out the infants who can be safely fed just about any old way from infants who may not be safe unless great care is taken. And if we are to be taken seriously as breastfeeding experts, we need to obtain continuing education in anatomy and physiol. of oral-motor function. An LC is more than a cheer-leader. S/he must constantly use very critical thinking to refine an ever deepening understanding of how the process works. We can't extrapolate that what works for the normal can work the same way for the abnormal situation. In fact, there are probably some babies we may see who cannot be safely fed, and need gavaging. Individual case planning is the key. Barbara Barbara Wilson-Clay, BS, IBCLC Private Practice, Austin, Texas Owner, Lactnews On-Line Conference Page http://moontower.com/bwc/lactnews.html