February 8, 2005 Features

The Speech-Language Pathologist and the Lactation Consultant: The Baby's Feeding Dream Team

The incidence of preterm birth and "just a little early" births in the United States is rising. These infants, be they significantly preterm or born 3-4 weeks before their due date, often face problems with feeding, both at the breast and with the bottle. Working together, the hospital-based speech-language pathologist and the international board-certified lactation con sultant, known by her credential, IBCLC, can help the infant and mother overcome the obstacles that prevent them from undertaking this most basic of life's functions.

Women helping women with feeding their infants has existed for centuries. Until the early 1900s, mothers could look to family members for help. But as American societal, cultural, and economic expectations changed, fewer women breastfed, and bottlefeeding become the norm. In the mid-1970s, as more American women returned to breastfeeding, a new profession of "consultants" emerged: lactation specialists to replace the lost generations of breastfeeding experience. Lactation consulting as a profession celebrates its 20th anniversary in 2005. This is an excellent time for infant feeding experts in the speech-language pathology and lactation fields to begin to forge new and stronger relationships.

The field of lactation consulting is an interdisciplinary one, with IBCLCs coming to lactation via nursing, medicine, many allied health care professions, mother support group leadership, and personal experience. Exam eligibility is based on the accumulation of thousands of supervised practice hours and lactation-specific education. Recertification by continuing education and examination are required to ensure continuing competence.

Recognizing their scope of practice, IBCLCs occasionally find themselves in a position of needing to refer clients to a professional trained extensively in infant sucking and swallowing. Hence, we look to SLPs. Of all the medical and allied health care professionals, SLPs are best trained to understand the intricacies of infant oral anatomy and swallowing function.

The interdisciplinary team caring for the extremely low birthweight infant, led by the neonatologist and other medical subspecialists, is supported by SLPs, respiratory therapists, registered dieticians, and the nursing staff. During this time, the SLP and IBCLC work with the breastfeeding mother, helping her initiate and maintain her milk supply, the species-specific and gestational age-specific food for her child. As the infant matures and moves closer to the 40-week gestational age marker, however, focus turns from keeping the infant alive to identifying and initiating normal feeding skills. It is at this juncture that the alliance between the SLP and IBCLC becomes critically important to the breastfeeding mother and her child. The transition from intubation and tube feeding to the breast for feeding requires the support and knowledge of a specialist, just as the infant required, and continues to need, specialized medical, nutritional, and other support.

It is not unusual for these infants also to face great difficulties in coordinating their suck-swallow-breathe cycles and swallowing, as well as gastrointestinal disorders including reflux, and other issues that are beyond the scope of the IBCLC, but well within the expertise of the SLP. Working together, using the knowledge of each, successful breastfeeding, or the bottlefeeding of human milk, is more likely to be achieved than when either professional is working alone.

SLPs and IBCLCs also should work together when, under various circumstances, infants have difficulty with both feeding methods. Transitioning from feeding tubes to either oral feeding method is challenging for some infants; others acclimate to bottles and later refuse the breast. Such anatomical variations as ankyloglossia, or cleft lip and/or palate, and the anatomical variations that accompany the related syndromes including Pierre-Robin Sequence present a multitude of feeding challenges. Research has indicated that the successful initiation and extended duration of breastfeeding results in better oral and dental development, which can only improve outcomes later in life for children facing these challenges.

The SLP is often the first clinician to see an infant that is not feeding well in the neonatal intensive care unit (NICU). It is important for the SLP to discuss the infant's history and, with the nurse, to review what feeding methods have been attempted. The SLP should have a basic understanding of the mechanics and physiology of breastfeeding. Many babies are receiving pumped breastmilk from a bottle in conjunction with attempts at breastfeeding. Given the fragility and medical needs of infants in the NICU, supplemental bottlefeedings of calorically enhanced breastmilk are often necessary to meet the infant's caloric needs. Pumped breastmilk also is given via bottle or other methods as the mother may not always be present at the infant's bedside for each feeding. It is essential that the SLP in the NICU be knowledgeable about breastfeeding and work in conjunction with the IBCLC to support breastfeeding or bottle feeding, according to the mother's wishes.

The SLP in the NICU should exhibit competencies in assessing the feeding and swallowing behaviors of preterm infants. The SLP also is trained to assess difficulties with feeding that may indicate an underlying physiological problem with swallowing such as coughing and choking with feeding, apnea and bradycardia during feedings, and respiratory compromise. These infants may require further objective assessment of the swallowing mechanism that would be carried out by the SLP.

Assessment by both the SLP and IBCLC can provide the mother with strategies to promote efficient feeding. The SLP may try various types of nipples that are most consistent with the infant's sucking pattern. The skills of the IBCLC are essential to optimize breastfeeding and help with appropriate positioning of the infant during breastfeeding. The end goal for all infants is optimal nutrition for development, which may involve both pumped breastmilk and feeding at the breast.

After discharge from the hospital, follow up with both the SLP and IBCLC should be arranged to continue to support the mother and infant. Acclimating to life at home with a medically involved infant leads to further challenges. The family is accustomed to a supportive environment in the NICU and is now faced with the challenge of feeding their infant a minimum of 10-12 times per day. Home visits by the IBCLC and SLP, in conjunction with consultation with the pediatrician, help to monitor the infant to ensure weight gain is adequate and help resolve any feeding problems. Continuation of early intervention services is essential through the early months and beyond. The SLP also will play a key role in determining readiness for spoonfeeding, which typically occurs around six months.

The SLP and IBCLC bring both overlapping and unique skills to the table when assessing and treating infant feeding difficulties. An awareness and respect for each other's roles as well as forming a partnership will only improve the quality of care provided. Promoting and supporting consumption of breastmilk via the most efficient method whether it is the breast or bottle will provide the infant with the optimal nutrition to promote brain growth and development.

Kara Fletcher, is a senior speech-language pathologist at Children's Hospital Boston. She specializes in the assessment of infant and pediatric feeding and swallowing disorders. She consults to Level 3 NICUs in the Boston area as well as lectures on pediatric dysphagia in the New England area. Contact her by e-mail at kara.fletcher@childrens.harvard.edu.

Barbara Ash, is an International Board Certified Lactation Consultant and is the assistant executive director of the International Board of Lactation Consultant Examiners. She has a particular interest in working with infants with neurological and other developmental challenges. Contact her by e-mail at barbaraash@iblce.org.

cite as: Fletcher, K.  & Ash, B. (2005, February 08). The Speech-Language Pathologist and the Lactation Consultant: The Baby's Feeding Dream Team. The ASHA Leader.

10 Facts About Breastfeeding

  1. If it hurts, it's not right.
    Pain indicates a problem, usually improper positioning or attachment. Mother and infant require a consultation with a knowledgeable breastfeeding counselor.

  2. Demand makes supply.
    The more often an infant feeds correctly, the more milk the mother will make. Very few women are physically incapable of making enough milk.
  3. Insufficient milk supply is generally caused by infrequent or ineffective breast stimulation.
    The infant who is feeding well is the most effective way of stimulating and maintaining a milk supply. A quality breastpump should be used when the infant is unable to breastfeed. Colostrum, the "first milk," is critical to the health of any infant, and especially for preterm infants. The anti-infective properties of colostrum offer protection against necrotising enterocolitis and other infections.   

  4. Maternal use of nearly all prescription and over-the-counter medications is compatible with breastfeeding.
    Generally speaking, if the prescription medication is safe for the infant, it is safe for the breastfeeding mother. Very few medications are contraindicated. Lactation consultants provide information and research on specific medications and their compatibility with breastfeeding.

  5. Early, unrestricted, and unscheduled breastfeeding is the best insurance for healthy, full-term neonates and their mothers to prevent many common difficulties, including engorgement in the mother and attachment problems for the infant.
    Twenty-four-hour rooming-in makes unrestricted breastfeeding easier.

  6. Even if the mother and infant must be separated, she can still breastfeed, or feed breastmilk.
    If health problems or hospital policy prevent mother and infant from close and continuous contact, the breastfeeding mother should be taught manual expression first to offer her infant colostrum, and then offered and encouraged to use a breastpump to supply her infant with breastmilk.

  7. Pacifiers can be a useful tool for calming preterm infants and encouraging sucking, but also can be detrimental to healthy infants in that they may be used to defer essential feedings.
    Research conducted worldwide has found a correlation between pacifier use and shorter breastfeeding duration in healthy, full-term infants (see Aarts et al., 1999, in resource section in The ASHA Leader Online). However, in preterm infants, pacifiers have been demonstrated to assist the infant in development of feeding skills (Measel & Anderson, 1979). Each infant's case should be evaluated individually.

  8. Preterm infants can, in many cases, transition from nasogastric feeds directly to breastfeeding without interim bottlefeeding.
    Such tools as nipple shields, tube feeding devices, or other aids may assist in the transition. Lactation consultants are trained in the evaluation of the infants and in the use of feeding devices and aids.

  9. No special dietary rules need be observed by breastfeeding mothers.
    Women with food sensitivities or allergies, or a family history of food sensitivities or allergies may wish to avoid specific foods. However, "all things in moderation" is a fine rule of thumb regarding food and beverages.

  10. Maternal smoking and consumption of alcohol negatively affects all infants and should be avoided, or at least timed to have the least impact, whenever possible.
    Maternal smoking has been identified as a cause of decreased milk supply. Alcohol (beer) consumption does not increase milk supply. Exposure to second-hand smoke has also been identified as a risk factor for SIDS, upper respiratory illnesses, and other health concerns in infants.

-Barbara Ash 



The SLP and IBCLC Working Together

A Case Study

Infant X was referred to the outpatient feeding team at two weeks of age. Referring concerns included poor feeding and poor weight gain. Mother reported she was both breast and bottlefeeding the infant and that the infant had a "poor latch" at the breast and fell asleep during bottlefeedings. Mother reported to the feeding team, which consisted of an SLP, developmental pediatrician, and nutritionist, that she successfully breastfed her other child and wanted to continue a combination of both breast and bottlefeeding with her newborn daughter.

Infant X was born full term weighing 6 pounds 2 ounces with no significant peri- or post-natal difficulties. The infant was assessed during the feeding team visit for both breast and bottlefeeding. At the breast, the infant presented with a poor latch and mother reported nipple pain. The infant exhibited reduced endurance during feeding and had frequent pausing. There was judged to be discoordination of the suck-swallow-breathe sequence. After 10 minutes the infant was presented with a bottle with a rubber Nuk nipple brought from home. The infant exhibited a reduced seal with liquid loss and an immature suck for her current age of two weeks. Her sucking was judged to be weak and fluid extraction was reduced. There was no sputtering, coughing, or choking during or after feeding. The infant's breath sounds remained clear during and after feeding. Subjective assessment of the pharyngeal swallow was judged to be intact with no clinical signs of aspiration.

The feeding team recommended an appointment with an IBCLC within three days. The nutritionist provided suggestions to increase the calories of the pumped breastmilk that was being given via bottle to help increase total caloric intake. Recommendations from the SLP included switching from a rubber to a silicone wide-base Nuk nipple to provide a firmer nipple and to reduce liquid loss. Trials with the silicone nipple during the appointment resulted in improved extraction and greater total volume taken.

When the family returned to the feeding team two weeks later, both mother and child were doing very well. Mother's visit with the IBCLC and the resulting recommendations were discussed with the SLP on the team after the visit. Recommendations were made for positioning changes, which greatly improved mother's comfort during breastfeeding. The IBCLC agreed the infant's suck was immature and weak and that supplemental bottlefeedings of increased calorie breastmilk should continue to help promote weight gain. Further recommendations were made to allow the infant to alternate both breast and bottlefeedings. Mother was also counseled on the use of a hospital-grade breast pump to keep up her milk supply. Mother reported consistent improvement in the volume taken during bottlefeedings with the switch from the rubber to the silicone Nuk nipple. The infant exhibited steady weight gain averaging one ounce per day. The developmental pediatrician on the team continued to have concerns regarding the infant's overall tone, which was judged to be hypotonic. A referral was made to a pediatric neurologist. The IBCLC was to see the family back in one week.

This study highlights the importance of the team assessment in treating feeding problems in the newborn. Open and direct communication between the IBCLC and SLP is essential although it is not always possible to be in the same facility. As an SLP I could not do my job to the fullest without the support of the IBCLCs in my hospital and community.

-Kara Fletcher 



  

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