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.