In a message dated 03/27/2004 9:05:31 PM Pacific Standard Time,
[log in to unmask] writes:

> How do you tell when sneezing, hiccoughing, gagging and vomiting are stress
> signs vs just a bodily function?

Christine,
I was not at the Rush conference, but I'd like to offer my thoughts....In
fact, today I helped a mom breastfeed her preterm baby who was discharged from
the hospital yesterday.  The baby had been to the breast twice and taken 14 and
15 cc's.  At today's consult, baby transferred 28 cc's at the breast, and I'd
base the most logical reasoning for this baby's improved intake at the breast
as determined by appropriately reading her stress signals and interpreting her
behaviors for the mom so as to educate her as to signs of readiness to feed
versus signs of stress/distress.

As this preterm infant latched onto the breast, she initiated the feeding by
exhibiting a rapid suckling pattern for approx. 2 minutes until mom's
let-down, and then she proceeded to long jaw excursions related to the expression
phase.  As she willingly nursed, I talked to mom to explain how her baby's
appearance was related to her ability to coordinate suck/swallow adequately at the
breast.  I was aware that this mom was told in the hospital setting that
breastfeeding was not tried due to the baby's apneic spells on bottlefeedings.
Despite educating mom on the research findings demonstrating less distress at the
breast, mom still felt concerned about stressing her baby out at the breast.
Teaching her to read her baby's cues is more effective than portraying myself
as knowledgeable and contradictory to earlier statements given by the hospital
staff.

So, as baby fed at the breast, I spoke to mom about baby's relaxed appearance
- her relaxed forehead, her eyes shut but not tightly, her fists closed but
not tight, nor exhibiting splayed fingers, and long jaw excursions with
periodic pauses for breathing, and her apnea monitor never alarmed (I never figured
it would!).  Baby persisted with her feed at the breast until she spontaneously
detached during an obvious let-down as mom's milk spray released, and baby
appeared satiated.

Well, when the mom proceeded to attempt to put the baby back onto the breast,
the baby then responded with splayed hands, a bit of choking; enough that mom
said it sounded like there was some fluid at the baby's throat, a very small
spit-up, and a facial grimace.  I counseled the mom on the interpretations of
these signals as stress signals and the reasoning behind respecting these
signals to meet the baby's needs.  After allowing the baby time to regroup for a
few minutes, the baby exhibited early hunger cues by smacking of lips, opening
and closing her mouth, and getting her fists to her mouth, so I then suggested
the mom try to re-latch her baby onto the breast.  Because we read the stress
signals, and paused until baby showed readiness again, the baby latched onto
the breast, and proceeded to breastfeed effectively again.

In response to the question as to when are hiccoughs and gagging/choking just
merely what they are versus stress signals has to do with the big picture.
One must assess the baby for other physiological signs of stress versus
non-stress.  We understand that a preterm baby is different than a fullterm baby.  A
preterm baby could merely hiccough and that can be denoted as a stress signal.
 But, merely hiccoughing in a fullterm baby may simply be that; if the baby
has a relaxed forehead, relaxed fists, etc., etc. versus the fullterm baby who
extends his/her head, twists his/her torso, defecates, squirms, grimaces,
etc., etc., and therefore may indeed be demonstrating signs of stress.

I believe many times babies are stressed out by forced feedings at the breast
in the early days.  It behooves us to educate moms not to force babies to
breastfeed, but to learn to read early hunger cues versus stress signals.  Being
permissible to follow babies' cues gets them to latch onto the breast more
readily, with less oral aversion as an outcome.  When feedings are forced in the
early days by ignoring the gaggings, hiccoughings, and other stress signals,
these babies often exhibit refusal of the breast and/or dysfunctional sucks
once home with the mom.

Carol Chamblin, RN, MS, IBCLC
Breast 'N Baby Lactation Services, Inc.
St. Charles, IL

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