Hello, Cindi.
    Babies with cardiac problems frequently have  trouble gaining weight
well, because it takes so much more effort for their  bodies to circulate blood
and oxygen, so they burn calories more, yet don't have  good oxygenation for
their muscles, so tire very easily.  It really is a  "catch-22" for those babies
who can't have surgery to correct their heart  problems until they reach a
certain weight, yet those very heart problems make  it so much more difficult for
the baby to actually reach that weight!
    Bottle-feeding may indeed be the way to go for this  baby at this time.
You've shown the parents how to sit baby up during  bottle-feeding, which may
help offer some protection of the airway.  (You  are right, this baby should
have a swallowing study done.)  I have found  that for babies who tire easily,
a medium-flow nipple can be just the thing they  need.  Some brands make that
flow-rate for "infants 3 months and  older".  I never recommend switching to
this faster-than-slow flow for  healthy infants because, after all, mom's
nipples don't change at 3  months!  But for a baby with cardiac and/or neurological
problems, the  slow-flow can be just too taxing and baby wears out before he
gets enough to  eat.  Sitting baby up with a medium-flow nipple can often
allow these  babies to get enough to eat before wearing out, but yet not drown
them as a  fast-flow can do.  I describe to parents that bottles are easier than
breastfeeding, even with my method of bottle-feeding, because once the
storage  areas of the breast have been emptied with the initial let-down, then the
milk  comes much slower from the breast and baby must do 3-4 sucks to get
enough milk  (bolus) to trigger a swallow.  However, the bottle is suck-swallow all
the  way through.  That is how a bottle can be an energetic bonus to a
compromised baby--he never has to do 3-4 sucks to get a swallow, so he doesn't  use
as much energy to get enough food.
    You mentioned that mom barely has enough  milk.  She found the PNS and
the Lactina painful but the Symphony doesn't  hurt.  I have to wonder if she has
the correct size breast shield/flange  for her pump.  I have frequently found
that when the PNS or Lactina hurt,  the breast flange size is wrong.  And
this mom may be taking advantage of  the Symphony's lower suck levels to be able
to use the wrong-sized shields  without pain.  If this is going on, then the
too-low suction combined with  the poorly-fitting shield not hitting the areola
in the correct place will  definitely contribute to lower milk production.
You can contact me  privately if you don't know how to help a mom determine if
she needs a different  size pump shield/flange.
    If the shield is the correct size, the mother could  just be having
supply trouble due to the extra stress she is experiencing.   Have you talked to
her about galactogogues such as almonds, oatmeal, papaya,  herbs (teas or
tinctures), etc.?
    Sometimes babies with cardiac problems just don't  feed well until they
have the surgery to correct the heart condition.  But  I have worked with
several mothers whose babies with Down Syndrome did not have  heart conditions.
These moms used my method of bottle-feeding to feed or  supplement their babies
as needed.  The babies were able to be completely  breastfed with no need for
supplementation by various ages from several weeks to  5 months.  The moms
were always very happy when their babies were finally  exclusively breastfed.
(Meaning, at breast, not breastmilk in a bottle or  other supplemental device.)
    You ask if you should be "pushing the  breastfeeding".  I would suggest
that you don't really want to "push" mom  to do anything, but offer her
information about her choices.  However, I  think it is perfectly acceptable to be
sure to point out that some means of  feeding the baby (like my bottle-feeding
method vs. traditional bottle-feeding)  have a better chance of reinforcing the
correct sucking style for baby so that  he is more likely to be able to
exclusively breastfeed once he has more  energy.
    Dee

Dee Kassing,  BS, MLS, IBCLC, RLC
Collinsville, Illinois, in central  USA


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