It sounds like the reasoning behind the bottles and rice cereal is to 
thicken the feeds to make swallowing easier. Thicker liquids are 
supposed to be easier to swallow. I would suggest this is a baby who 
will need a very slow flow bottle, like Dr. Browns or a Haberman. He may 
choke on a bottle if the flow is too much.

I would like to see test weights before and after nursing on a scale 
rated to 2 grams to see how much this baby is actually taking in. It 
could be that he is receiving 3-4 ounces in 5 minutes or less. Which I 
have seen. I usually start with a test weight and then as soon as baby 
comes off the breast, or chokes, I reweigh. I have been amazed at how 
much and how fast the intake can be. Conversely, if the baby is choking 
and gulping and gasping and the intake is very small, like 1/2 ounce, 
this tells me an oral motor issue not milk supply issue.

Another clue is that baby squirms his body at the breast, or flails his 
arms and legs while nursing. Normal is for baby to relax not get 
agitated. Some babies slide down to the tip of the nipple and clamp down 
to slow the flow.

The gas can be from the too fast flow and taking in too much air, as 
well as taking in less fat at the end of the feeding so that digestion 
is sped up. Green or mucousy stools are also a clue.

What I would have mom do is consider pumping off 1/2 to 1 ounce at each 
breast before nursing if her supply has not down regulated at this point 
(with a manual pump or hand expression). Electric pumps tend to keep 
stimulating more milk supply with these moms. I would also suggest the 
things you have already told her, one breast per feeding, sitting 
upright, sling, etc. And I would have mom put baby back on the same 
breast 2-3 times during the one feeding so that baby gets plenty of fat 
and fills up with the slower flowing milk.

Lots of these babies are fussy because they want a little more but not 
the fast flow. They tend to cut themselves off before they are really 
full or comforted. If mom keeps putting baby back onto the same breast 
for the same feeding session, he will eventually get to the slower flow 
and can comfort suck. Sometimes babies are mad that the flow has slowed 
down but mom just needs to keep to the plan.

I find it takes at least a week to down regulate the milk supply like 
this. And whenever baby hits a growth spurt, her milk supply will jump 
back up and afterwards she will most likely have over supply problems 
again.

Moms often describe this problem as "not enough milk" because baby is 
fussy at the breast and wants to nurse "all the time."

A baby with laryngomalacia may need to have a video flourescent suck 
swallow study (may have misspelled this). This is where baby is given 
barium in a bottle and then fed with a video camera taping it through an 
X-Ray. To see what the problem is in his mouth and throat structures. A 
good SLP or OT needs to be seeing this baby to devise a plan to improve 
whatever weakness he may have.

My last thought is that I have seen babies who seem to have stridor from 
the too fast milk flow. When we get things down regulated to "normal" 
the problem often goes away. Sometimes we can get the problem to subside 
for most feedings but not at the morning one because she is overly full 
first thing in the morning. Perhaps there is a weakness in the 
mouth/throat to begin with that is made worse by mom's milk supply.

I would encourage mom to give this problem two weeks on the breast with 
better management and see how things improve. If she chooses to pump and 
bottle feed, she will need a rental pump and pump 8 times in 24 hours if 
she wants to keep up her supply for a long time. I think things are 
going to be better in two weeks, as this is my experience with over 
abundant milk supply.

What I like about test weights is I can show mom how in five minutes her 
baby "inhaled" 4 ounces and that is why he is fussy. I tell moms that if 
I made her eat a full Thanksgiving dinner in five minutes, she would be 
unsatisfied and not enjoy this meal much!

Kathy Eng, BSW, IBCLC

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