In response to Sheila Waterstrat's post for babe not able to latch x 2 days, history of nursing well and often, no previous nursing problems, birth weight 6 lbs, weight at 6 weeks is 11 lbs.  Baby "does not appear in distress but does grunt and squirm often."  

Certainly agree with referral to peds.  Regarding the baby's frequent grunting and squirming, the baby may have reflux/GERD, which is fairly common in young infants.  

When grunting and squirming are observed during a lactation consult, positioning the baby so that the baby's head is higher than the baby's stomach will often improve the baby's comfort to the extent that the grunting and squirming stop, as the feeding continues then without further difficulty.  Holding baby upright after feeding for at least 20 minutes and ideally 30 minutes utilizes gravity to keep the milk in baby's stomach, which is a standard recommendation for GERD in infancy.  I recommend holding baby upright against mom's chest after feeding in these instances, versus holding baby in a sitting position on mom's lap, which often puts enough pressure on baby's stomach to bring up the milk.    In more pronounced cases of infant GERD, meds can be prescribed by peds, in addition to the above-mentioned positioning changes during feeding and immediately after feeding.  Nighttime nursing in a side-lying position is typically difficult for the babe with GERD, since the baby's head is either not elevated or minimally elevated during the feed, and the milk comes back up the esophagus more readily.  

Preemies are often prescribed meds for GERD (which lessens the risk of aspiration), and the fact that so many preemies are rx'd GERD meds in appropriately tiny preemie doses is often helpful to point out to some new parents who state that they don't want their baby to take any prescription medications at such a young age, explaining that they prefer to take an all-natural approach in caring for their baby.  When babies are uncomfortable during feeds and even vomiting after feeds, a prescription medication can be a wonder of modern medicine and not at all a bad thing.
When GERD is mild, positioning changes during and after feeding is all that is necessary to improve the baby's feeding experience.  

The grunting behavior heard during infant GERD episodes is likely the infant's effort at trying to keep the milk down, and my perception of the baby's squirming during difficult feeds as discomfort from GERD.  When GERD continues long enough without any treatment, including no position changes during and after feeds, the protective lining of the esophagus can become eroded by the stomach acids during chronic GERD, and infants then are more likely to cry during and after feeds with the increased discomfort and pain of untreated GERD.   

In taking the infant's history when GERD is suspected, it is also helpful to ask about any family history of GERD.  It's not unusual to hear that a sibling and/or parent has also been treated for GERD, or is current being treated for GERD.  

IBCLCs in outpatient practice will see infant GERD behavior far more often than inpatient IBCLCs.    

With best regards,

Debra Swank, RN BSN IBCLC
Ocala, Florida USA
http://www.MoreThanReflexes.org
http://www.MoreThanReflexes.org/on-learning/


Ms. Waterstrat's post:
Had a mama come in with her 6 week old worried that baby was not "able to latch" for the last 2 days. Up until 2 days ago, baby was nursing well every 2-3 hours on both sides (about 10-15 min each side), no BF problems. Mom denies any change in routine, diet, or medication. Mom has been hand expressing and letting baby "lick and drink" since baby is "not feeding well", has lots of milk, and does admit that baby will latch occasionally at night "for a few sucks" and then come off.

On observation, baby is a chubby healthy BG- 6 lb at birth and 11 lb at 6 weeks!!!  Alert, active, curious. Does not appear in distress but does grunt and squirm often. Mom reports no change in stools or voids- stooling every few hours- mustard color, normal consistency (I did observe a diaper change). Some increase in spitting up. Abdomen not distended. Baby just does not seem hungry. We got baby to breast (mom states baby BF "only latched and sucked 5 times" 3 hours before) and baby can latch, suck a couple times, then comes off and just does not seem interested.  She does not choke or sputter. It does not seem to be teething related.
  
I came to the conclusion that this is not an issue with cannot latch when hungry, but that baby has no interest in eating. So, either baby is just not hungry or something is bothering her. I referred her to her pediatrician and am monitoring her- what am I missing? Seems to me that mom has oversupply as baby has gained so much weight with such little effort- is it possible baby is getting enough with the occasional snacking? She has just lost her appetite for a couple days? Mom states she did try to give baby a bottle of pumped breast milk but baby would not suck on nipple.
Any experiences or information would be helpful!

Sheila Waterstrat, RN, IBCLC
Olympia, WA

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