suckling assessment in the breastfed neonate kittie frantz, rn, cpnp-pc clinical instructor in...
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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
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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
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© Kittie Frantz
Suckling PhasesThe Anticipatory Response
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• 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
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© Kittie Frantz
Suckling PhasesSimultaneous Inner Lip Stimulus
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• 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
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• 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
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© 1980,1990 Kittie Frantz
Suckling PhasesThe Swallow
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• 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
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© Kay Hoover
Tongue Curling behind the alveolar ridge
23©1980 Kittie Frantz
Tongue Moving Up & Down With the Jaw
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Tongue Pushing Outward
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© 1980 Kittie Frantz
Tongue Doing Nothing
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Ankyloglossia
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© 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
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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
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Assessment of Jaw Excursions at the Breast
The Rotary Jaw
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© Kittie Frantz
Jaw Excursions:What Not to See – “Munching”
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© 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
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© 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
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© 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
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© 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
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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
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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
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BEST TEXTBOOOK FROM OT
Wolf, L. & Glass, R. (1992)FEEDING & SWALLOWING DISORDERS IN
INFANCYTherapy Skill Builders, Tucson, AZ
45
Questions?
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