Rachel Myr writes about a complicated case (baby with broken clavicles) who
is only happy when not eating.  I worked with a baby who was full term, good
sized, and healthy in every way except she hated to eat.  For months the
mother struggled to get the baby to eat (breastfeeding with improved
technique, milk in a bottle, formula in a bottle, feeding tube device worn
at breast, on finger, cup feeding, etc)  Nothing we did made this baby want
to eat.  I urged the pedi and mom to seek a swallowing study after about 4
weeks of this, but they both wanted to wait and see.  At 4 months postpartum
the baby was finally diagnosed with failure to thrive.  Having begun life in
the 85th percentile, she was below the 2nd percentile at 4 months.  After
blood work and urinalysis ruled out infection, a swallowing study finally
was done.  I was present for the study, and the results were that baby had
severe gastric reflux disease.  The baby very early on figured out that
eating and the aftermath of eating caused pain.  Consequently, she
self-limited intake,  protecting hydration status, but never consuming
enough of anything for normal growth.  This baby was not a big "spitter."
Her reflux was silent, and the tip offs (the ones I was concerned about
early on) were her behavior towards eating (not normal -- babies normally
LIKE to eat) and nasal congestion in the absence of respiratory illness.

Some of the things I've learned to do with these refluxy babies to help
avoid episodes is to roll them on their sides to diaper them (rather than
lifting their legs), and to feed them in side-lying and other open positions
that avoid jack-knifing them over their diaper waistbands.   Anything that
increases abdominal pressure pushes stomach materials back up into the
esophagus, so car seats and burping in seated positions are also bad for
these babies.  Open, extended positions, upright over the shoulder burping,
and allowing babies to take many small, frequent meals instead of huge bolus
feeds really can assist.

A swallowing study is not a particularly invasive proceedure.  The baby has
to drink barium stained material, but after that, baby lies on a table and
the fluoscopy machine is simply positioned over the baby and the radiologist
looks to a video screen to observe the path of the swallows.  Parents can
stand there with their hands on the baby for reassurance.

This baby I am describing (one of many with reflux) was so aversively
conditioned by pain associated with feeding that she needed OT therapy to
enable her to begin and to manage solids.  I think it is better to discover
severe reflux early rather than later.  I've also seen severe ulceration of
the throat in another reflux case.

Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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