Suckling Assessment in the Breastfed Neonate Kittie Frantz, RN, CPNP-PC Clinical Instructor in...

Suckling Assessment in the Breastfed Neonate

Kittie Frantz, RN, CPNP-PCClinical Instructor in Pediatrics

Keck School of Medicine atThe University of Southern California

frantz@usc.edu1

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

Anatomy of Suckling

3

© 1980,1990 Kittie Frantz

Ardran and Kemp - Bottle

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

Ardran & Kemp - Breast

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

Ardran & Kemp - Poor Suckle

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

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

Suckling PhasesThe Rooting Reflex

8© Kittie Frantz © Kittie Frantz.

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

Suckling PhasesRooting Reflex is also on Lower Lip and Chin

10© Kittie Frantz

Suckling PhasesRooting Reflex Not as Responsive on

the Upper Lip

11© Kittie Frantz

© Kittie Frantz

Suckling PhasesThe Anticipatory Phase of Suckle Elicited

by Touching the Lower

Lip and Chin

12

© Kittie Frantz

Suckling PhasesThe 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

Suckling PhasesSimultaneous Inner Lip Stimulus

14

© Kittie Frantz

Suckling PhasesSimultaneous 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

Suckling PhasesDigital Exam

Feel Tongue Peristaltic Action

16© Kittie Frantz

Suckling PhasesPeristaltic 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

Suckling PhasesThe Swallow

18

© 1980,1990 Kittie Frantz

Suckling PhasesThe Swallow

19

• The posterior tongue moves downward causing negative pressure

• Milk released is swallowed

© 1980,1990 Kittie Frantz

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

Watching the Sequence Delivery Self Attachment DVD

21© 1975 Righard, Frantz “ Delivery Self Attachment” licensed from Geddes Productions, LLC

What Not to FeelMcBride, Suckling Disorders in Neurologically Impaired Infants, CLINICS OF PERINATOLOGY 14 (1), 1987

22

© Kay Hoover

Tongue Curling behind the alveolar ridge

23©1980 Kittie Frantz

Tongue Moving Up & Down With the Jaw

24

Tongue Pushing Outward

25

© 1980 Kittie Frantz

Tongue Doing Nothing

26

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)

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

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

Assessment of Jaw Excursions at the Breast

The Rotary Jaw

30

© Kittie Frantz

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

Assessment of Tongue Action at the Breast

32

© Kittie Frantz

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

Assessment of Swallowing at The Breast:

Swallows Occasionally Until Milk Comes In

34© LAC+USC Medical Center

Assessment of Swallowing at the Breast:Swallows Every 1 – 3 Suckles after

milk comes in

35© LAC+USC Medical Center

Great Swallows

36

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

Assessment of SwallowingWhat Not to Hear:

Swallows Every 4 or More Sucks After Milk is in

37© LAC+USC Medical Center

Management of the Poor Suckle & Few Swallows at the Breast

38©Medela

© Medela

Feeding Tube at the Breast

39

© Kittie Frantz

Feeding Tube Devices

40

Medela

MedelaE

Lact-AidHygeia

Setting up the Supplemental Nursing System

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

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

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 dayNelson, TEXTBOOK OF PEDIATRICS

43

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

BEST TEXTBOOOK FROM OT

Wolf, L. & Glass, R. (1992)FEEDING & SWALLOWING DISORDERS IN

INFANCYTherapy Skill Builders, Tucson, AZ

45

Questions?

46