Something about the baby's early oral exper. may have made him/her aversive.
Or he/she is injured (sore throat).  Or is somewhat early and unready to
feed and can't make the breast work.  Babies have to be able to create
adequate levels of positive and negative pressure to breastfeed.  They have
to be able to seal off the oral chamber with a tight lip seal around the
breast.  They have to be able to pull the nipple to twice its resting length
to the junction of the hard and soft palate.  They have to be able to lift
their lower jaw and compress the nipple in half between the tongue and the
hard/soft palate. Some newborns who are early or who are injured can do
this.  Some cannot.

 For the baby who WON'T breastfeed, you must mentally substitute the word
'CAN'T'.  The baby is hard-wired to breastfeed or in nature would be
vulnerable unto death.  So the baby who doesn't feed normally is in trouble.
Our response to this should be ALERT, ALERT, ALERT.  What is going on with
the baby?  What do the muscles of the face and mouth reveal?  Are they
slack, or too tight?  Is the face assymetric?  Any droops?  Aversions going
on? At what part of the feed does baby balk?  Beginning, middle, end?  How
does baby handle fluids delivered via another route?  Can baby seal lips
around finger, bottle teat.  Does baby choke and spill milk?  Lots to
observe for.

The rules are:  Feed the baby.
 Protect the milk supply.
 Protect the option to breastfeed by trying to keep something pleasant
happening at breast.

 A nipple shield works very well (if you chose a short, thin silicone one).
They are used by Paula Meier, (and lots of other people) to keep baby at
breast through the intervention period while we try to work out what is
wrong and while infant recovers.  Meier and Hurst have demonstrated that
preemies can actually take in 3 x more milk from breast with than without
the shield.  The mechanism for that is prob. several fold.  The nipple tends
to be held in an everted position by the neg. pressure inside the shield.
(Notice the next time how the nipple stays sucked out after baby comes off a
shield).  Because the nipple is held in this elongated position, baby
doesn't have to work quite so hard to generate neg. pressure during the feed
to hold the nipple in this position.  Also, milk tends to pool in the tip of
the shield, providing a reservoir that gives baby a quick milk reward when
their energy begins to wane and they pause in the feed.  As soon as they
begin to suck again, there is a big swallow for them ready to go with little
effort.  Additionally, if the baby is low tone, or depressed, the teat is
perhaps more stimulating back at the palatal junction -- keeping the
'switch' in the on position.

We don't use shields or alternative feeding for functional feeders.  Why
would we?  A normal baby can breastfeed without interventions.  For the
dysfunctional feeder (and this is generally a temporary designation) we want
to quickly intervene with rules #1,2,and 3.  Remember what Neifert,
Lawrence, and Seacat say  in their J Peds article about nipple confusion:
you can't call it confusion if the baby can't breastfeed in the first place.

 Barbara Wilson-Clay BSEd, IBCLC
Austin Lactation Associates
http://www.lactnews.com

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