1. Suckling Assessment in the Breastfed Neonate Kittie Frantz, RN, CPNP-PC Clinical Instructor in Pediatrics Keck School of Medicine at The University of Southern California frantz@usc.edu 1

2. Suckling Reflex Suckling is described in infants under 4 months of age Characterized by the tongue reaching over the lower alveolar ridge, cupping at the edge with a peristaltic wave back & up toward the pharynx 2

3. Anatomy of Suckling 3 © 1980,1990 Kittie Frantz

4. Ardran and Kemp - Bottle 4 Ardran, Kemp (1958) A Cineradiographic Study of Breastfeeding. BMJ,31(363).

5. Ardran & Kemp - Breast 5 Ardran, Kemp (1958) A Cineradiographic Study of Breastfeeding. BMJ,31(363).

6. Ardran & Kemp - Poor Suckle 6 Ardran, Kemp (1958) A Cineradiographic Study of Breastfeeding. BMJ,31(363).

7. Sucking Seen in infants 4-6 months of age Tongue motion changes to up and down in preparation for chewing We won’t look at that today 7

8. Suckling Phases The Rooting Reflex 8 © Kittie Frantz © Kittie Frantz.

9. The Purpose of Rooting 9 © 2007,2010 Smillie, Frantz, Makelin “Baby-led Breastfeeding: The Mother-baby Dance” licensed to Kittie Frantz by Geddes productions, LLC

10. Suckling Phases Rooting Reflex is also on Lower Lip and Chin 10 © Kittie Frantz

11. Suckling Phases Rooting Reflex Not as Responsive on the Upper Lip 11 © Kittie Frantz

12. Suckling Phases The Anticipatory Phase of Suckle Elicited by Touching the Lower Lip and Chin 12 © Kittie Frantz

13. Suckling Phases The Anticipatory Response 13 Jaw drops down Tongue releases from roof of the mouth Tongue tip curls at the edge Head tilts back slightly © Kittie Frantz

14. Suckling Phases Simultaneous Inner Lip Stimulus 14 © Kittie Frantz

15. Suckling Phases Simultaneous Inner Lip Stimulus 15 Touching the inner lips simultaneously with the breast or the pad of examiner’s thumbThis causes the tongue to reach out over the lower alveolar ridge and pull the pad of your glove inward In breastfeeding, this would pull in the breast tissue © Kittie Frantz

16. Suckling Phases Digital Exam Feel Tongue Peristaltic Action 16 © Kittie Frantz

17. Suckling Phases Peristaltic Action 17 Examiner can feel the wave of the tongue move up and backward Tongue tip remains over the alveolar ridge © Kittie Frantz Geddes, D. et.al.; Tongue movement and intra-oral vacuum in breastfeeding infants EARLYHUMAN DEVELOPMENT, 84: 411-77,2008. Woolridge, M (2013) Ultrasound video analysis for understanding infant breastfeeding. 18 th Intl. conf. of Image Processing, Belgium

18. Suckling Phases The Swallow 18 © 1980,1990 Kittie Frantz

19. Suckling Phases The Swallow 19 The posterior tongue moves downward causing negative pressure Milk released is swallowed © 1980,1990 Kittie Frantz

20. Suckling reflex and the swallow Tongue and jaw move forward again (rotary jaw action) The suckle reflex & swallow reflex is a “chained” reflex. They act together. 20 © 1980,1990 Kittie Frantz

21. Watching the Sequence Delivery Self Attachment DVD 21 © 1975 Righard, Frantz “ Delivery Self Attachment” licensed from Geddes Productions, LLC

22. What Not to Feel McBride, Suckling Disorders in Neurologically Impaired Infants, CLINICS OF PERINATOLOGY 14 (1), 1987 22 © Kay Hoover

23. Tongue Curling behind the alveolar ridge 23 ©1980 Kittie Frantz

24. Tongue Moving Up & Down With the Jaw 24

25. Tongue Pushing Outward 25 © 1980 Kittie Frantz

26. Tongue Doing Nothing 26

27. Ankyloglossia 27 © Kay Hoover Srinivasan, A., et al (2006) Ankyloglossia in Breastfeeding Infants: The Effect of Frenotomy on Maternal Nipple Pain & Latch. BREASTFEEDING MEDICINE, 1(4)

28. Finger Sweep Detection Sweep finger under the tongue Frenulum felt midway causing motion obstruction needs evaluation Frenulum insertion should be no more than 30% of ventral tongue surface 28 LAC+USC Medical Center

29. Gryboski Published NORMAL FOR TERM NEWBORNS TO ORGANIZE THIS SUCKLING BY 5 DAYS POSTPARTUM NORMAL FOR PRE-TERM NEWBORNS TO ORGANIZE THIS SUCKLING BY 7 DAYS POSTPARTUM POORLY ORGANIZED NEWBORNS NEED FOLLOW-UP FOR WEIGHT Gryboski, Suck & Swallow: MAJOR PROBLEMS IN CLINICAL PEDIATRICS, vol 13, 1975 29

30. Assessment of Jaw Excursions at the Breast The Rotary Jaw 30 © Kittie Frantz

31. Jaw Excursions: What Not to See – “Munching” 31 © 2007,2010 Smillie, Frantz, Makelin “Baby-led Breastfeeding: The Mother-baby Dance” licensed to Kittie Frantz by Geddes Productions, LLC

32. Assessment of Tongue Action at the Breast 32 © Kittie Frantz

33. Assessing the swallows You can hear the swallow as an “eh, eh, eh” Use the bell of the neonatal stethoscope to clearly differentiate the breathing and the swallows 33 © LAC+USC Medical Center

34. Assessment of Swallowing at The Breast: Swallows Occasionally Until Milk Comes In 34 © LAC+USC Medical Center

35. Assessment of Swallowing at the Breast: Swallows Every 1 – 3 Suckles after milk comes in 35 © LAC+USC Medical Center

36. Great Swallows 36 © 2007,2010 Smillie, Frantz, Makelin “Baby-led Breastfeeding: The Mother-baby Dance” licensed to Kittie Frantz by Geddes Productions, LLC

37. Assessment of Swallowing What Not to Hear: Swallows Every 4 or More Sucks After Milk is in 37 © LAC+USC Medical Center

38. Management of the Poor Suckle & Few Swallows at the Breast 38 ©Medela

39. Feeding Tube at the Breast 39 © Kittie Frantz

40. Feeding Tube Devices 40 Medela MedelaE Lact-AidHygeia

41. Setting up the Supplemental Nursing System 41 © 1996 Kittie Frantz “Supplemental Nursing System” licensed to Kittie Frantz by Geddes Productions, LLC

42. NIPPLE SHEILD FOR HYPOSENSITIVE MOUTH Baby doesn’t feel the breast in the mouth & doesn’t respond to your thumb unless you move it around. Nurses have to move the bottle to elicit a suckle. 42 © Kay Hoover

43. Don’t Forget Weight Parameters Babies can tolerate a 12% weight loss No more than 12% in the first week Should be back to birth weight by 2 weeks Should gain 15-30 grams a day from 2 weeks to three months Weight gain after 3 months is 15 grams a day Nelson, TEXTBOOK OF PEDIATRICS 43

44. Breastfed babies gain weight differently than formula fed babies Formula fed babies are overfed We use the new WHO growth charts to reflect the growth of the breastfed infant The old growth charts reflected overweight formula only fed Midwestern USA infants 44

45. BEST TEXTBOOOK FROM OT Wolf, L. & Glass, R. (1992) FEEDING & SWALLOWING DISORDERS IN INFANCY Therapy Skill Builders, Tucson, AZ 45

46. Questions? 46