I am working with interesting baby currently. On the small size to begin
with, he presented as a very scrawny looking 5 day old 1 lb below b-wt. He
was vigorously suctioned at birth due to meconium stained waters and
suspicion of meconium aspiration.  Mom has those spirally inverting nipples
which telescope in when compressed, and which baby couldn't access.  He was
in the shut-down phase when I saw him -- just went to sleep when put to
breast, getting very dry and approaching dehydration.  He makes a funny
little cough sound (like a rasp) at the end of each cry, and he cries
constantly.  I suspect he has a sore throat or some damage to vocal cords
either due to the suctioning or the meconium.  MD says his health is ok, but
something about him doesn't quite feel right to me.

I got him to breast with a nipple shield, got mom pumping to bring out the
inverted nipples, so baby is at least doing something at breast, and getting
all human milk feeds (which has got to be helping the throat injury.)  Mom
has a copious milk supply.  She FLOODS milk even under the nipple shield.
Baby at breast has poor lip seal, spilling tons of milk. He is taking some
feeds directly at breast without the shield now that the nipples are pulling
out. She pumps and delivers plenty of milk to baby, who spills milk bottle
feeding.  In an ocean of plenty, baby has consistantly over the last month
stayed at about 1/2 oz weight gain per day with constant crying.  Pre- and
post-feed test weights have been very useful monitoring this baby.  They
document that even when offered appropriate amounts of milk to produce
excellent gain, he self-limits his intake to a bare minimum to sustain
border-line growth.  The question becomes, then, WHY?  Is the throat so
painful that swallowing hurts and he spills what he can't handle?  Is there
vocal cord paralysis which is causing baby to experience aspiration, which
is causing feeding aversion? Is there painful reflux heightened by throat
injury? Is there some sort of underlying systemic or congenital problem
which is contributing to low tonality all through his system (poor lip seal,
poor palatal seal, etc etc) contributing to a swallowing disorder
unconnected to the suctioning?

This mother is stressed to the max, but not because of test weights.  She's
stressed because her baby is thin and miserable, and she knows something is
wrong.  It has actually been validating for her (esp in the face of
criticism from all and sundry that she is starving him by bfg) that she can
have empirical feedback from the scale that while she pours it in, he
dribbles it out.  At least she is aware he has the problem and doesn't blame
herself.

This evidence also helps me describe things to the pedi. so pedi doesn't
take the easy solution (to blame breastfeeding.) Pedi, in the face of this
evidence, is now ordering tests to try to evaluate baby's gen. sit.  My
management suggestions have now been modified now that I have identified
these issues. I am asking her to pump off a bit of the copious foremilk, and
make sure baby gets hind-milk.  This will maximize calorie ct. of what he
will agree to take.  We are cont. to work on nipple eversion with pump, to
wean completly off shields, and to use postural contol to assist baby cope
with milk flow (ie hip flexion and slight head extension.) She is getting
lots of moral support to focus on baby's discomfort rather than her own.  We
can be she-bears when our baby needs us, but we often shut down when we feel
it is we who are causing the problem.

Tools are just tools.  We should all have rationales for their use.  It
would be horrible to use a scale or test-weighing as a "score card" which
makes a mother feel like she is flunking or passing bfg.  That is an
inappropriate use of a tool, and the person who uses the tool that way
should be better educated in its use. We need to remember that enthusiasm
alone is probably sufficient to encourage breastfeeding in normal
situations.  That's what we have LLL and peer counselors and friends for.
Normal is normal and we shouldn't over-involve ourselves in medicalizing it.
Not-normal requires clinical assessment and appropriate use of tools for
that purpose.
Barbara

Barbara Wilson-Clay, BS, IBCLC
Private Practice, Austin, Texas
Owner, Lactnews On-Line Conference Page
http://moontower.com/bwc/lactnews.html