Thanks, Pam Morrison, for presenting a wonderful protocol for dealing with the poorly-growing infant. I use this protocol myself. It works well, problems resolve quickly unless infant is ill, and successful outcomes give confidence to mothers and doctors that this is not an insurmontable situation requiring weaning. I repeat what Pam put so well: the poorly feeding infant is generally a hungry infant. The use of supplementation (ideally with own-mother's expressed hind-milk) is a quick, effective way to give the infant more energy to apply to feeding. I often supplement at the beginning of the feed to achieve a more alert, calmer, teachable infant at breast. Certainly, an individual assessment needs to be made to determine which is the best way to "jump start" these babies with some caloric energy. I rarely use the SNS, because it is complicated to use and won't help with the baby who won't/can't latch, and is useless with the baby who is deliberately self-limiting intake (the hardest kind of situation I work with.) I think that everyone working has developed some sense of what equipment they are most comfortable with, and which things mothers will/can tolerate. I don't think the specific method is as important as getting the baby quickly stabilized and maintaining feeding at the breast during the whole time -- even if intake is poor. The nursing and skin-to-skin must not be interrupted or baby will forget. I see lots of babies being supplemented all sorts of ways, and they usually do fine with a gradual weaning away of all supplementation as things improve so long as nusing has never been discontinued. With poorly feeding babies, the milk supply is in danger. If breast drainage is not augmented by effective post-feed hand-expression or pumping with an effective pump, quite often the supply will be permanently compromised. Positioning and latch should ALWAYS be adjusted. I continue to be desperately saddened by the generally voiced opinion that latch-on is entry level knowledge, that everyone already knows it (and hence general disinterest on workshops on technique.) After 20 years I am just now beginning to feel confidant that I understand how the baby's oral-motor function at breast works and how body-position impacts it. So often, problems can be fixed JUST by fixing the positioning and latch. That's the first line of defense, of course. Barbara PS Also thanks to Dr. Dettwyler for her insightful remarks about constant-contact mothering in Mali. I read the business about defecation and urination signals in The Continuum Concept years ago, started looking for the signs, and can usually tell when an infant is about to go. This has saved me a lot of laundry woes in the course of my work. Barbara Wilson-Clay, BS, IBCLC Private Practice, Austin, Texas Owner, Lactnews On-Line Conference Page http://moontower.com/bwc/lactnews.html