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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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