Question: A colleague reached out to me regarding her 3-week-old baby. She has some successful breastfeeding feedings and some that are not. Pediatrician suspects posterior tongue tie. Would that be possible if many feedings are perfectly successful?

Answer:

Feeding and swallowing are both dynamic systems, with multiple and varying influences from moment to moment and from feeding to feeding. Completing  a differential about what is causing the reported variation in feeding, and what may be the contributing the etiology(ies),  is a complex endeavor, to which many of the responses thus far have alluded. It is important to remember that multiple systems contribute to feeding/swallowing skill and the interplay, i.e., synactive relationships, amongst those systems, must be peeled apart .

None of the  systems that underlie function for nutritional intake exists in isolation. These systems include: cardio-respiratory, neurologic, neuromotor, sensory, sensory-motor/postural , airway, gastrointestinal, and oral-sensory/oral-motor, as well as the feeding “environment” (such as mother’s milk supply, milk flow rate, the caregiver’s perception of her role as a feeder and her experience, position utilized, and for bottle fed babies – nipple choice, as well as response to apparent infant stress and communication throughout the feeding). In addition, how the caregiver defines “successful” can be enlightening (e.g., volume, amount of stress observed, how soon infant disengages, feeding with or without apparent incoordination). Sometimes, infant behaviors interpreted as leading to an  “unsuccessful” feeding may be purposeful on the infant’s part to protect his airway or to signal stress (i.e., use of a compression-only sucking pattern, no longer rooting, letting go of the latch, loose latch). Sometimes what can look  like an oral-motor problem may be the infant being “smart”. It is important to ask that question. Again, think of dynamic systems theory.

You can see how if we, unfortunately, view one system as the focal point and don’t consider the bigger picture of  the context  of the other relevant systems for that particular infant, our differential about the problems observed will be sorely lacking, and our plan of care, therefore, ineffective. From this informed perspective, the SLP can present impressions and recommend further consults and diagnostic workups  thoughtfully to the physician.

An evaluation by a skilled pediatric therapist who looks at all the systems that underlie function, and their interaction, in the setting of the infant’s history, will best help to answer the “why” that can then guide the infant toward more consistency “successful ” feeding  —-  which to me, means infant-guided pleasurable safe feeding with an engaged infant and a caregiver who provides contingent responses to infant communication during feeding.

I hope this is helpful.