A speech pathologist's 15-week-old secondborn has a conditioned dialling up with breastfeeds. This is how she resolves it.

“She's 15 weeks old, our second,” Adrienne says, looking at little Darcy who is asleep in the pram. The baby has short fine blonde hair, like her mother's, and is slender though not too thin, I notice, on a first glance.

“I breastfed our eldest, Henry, until he was two and we never had any problems really. I hadn't imagined for a moment that I'd have problems this time round with Darcy.”

But evidently, right from the beginning, Darcy has been prone to fussing at the breast.

“Some feeds went beautifully, but at other times, perhaps a couple of times a day in the beginning, Darcy wouldn't want to come on. Or she'd come on and then pull off after a short period of time, upset. Or she might breastfeed for just a few minutes then begin back arching and pulling back, coming in to suckle desperately, until she finally pulled off altogether.

“It's been getting worse over the past six weeks. Now every breastfeed is like this, right throughout the feed.”

Adrienne is a speech pathologist who works in a large children's hospital with families who have infant feeding problems. She's tried many of the usual speech therapist strategies, including 'pacing' the baby by taking her off after a few minutes of feeding, to give her a break and to burp her.

“She swallows a lot of air,” Adrienne explains.

And Darcy won't take a bottle. They've really tried. She has been dropping percentile lines and is now 1.5 lines below her birth weight. The local child health nurse is keeping an eye on this.

I take a detailed history.

"How often do you offer her the breast in a 24 hour period, would you say?” I ask.

“Well I'm demand feeding,” Adrienne explains. “It used to be every couple of hours during the day and a few times in the night. But now I'd say every three hours.” I nod.

“Does she take both breasts when she feeds? Or roughly how often would she take each breast in a 24 hour period, do you think?”

Adrienne gives this some thought. “It varies, so it's hard to say …. But maybe half the time, she'll take both breasts.”

In the medical records, I type: about six feeds each breast in a 24 hour period. This is a recipe for low supply – and of course, results from the baby dialing up at the breast like this, so that breastfeeding is an unhappy experience for both of them.

Adrienne adds: “But now that things are this bad Darcy goes for four or five hours during the day without breastfeeding, and it makes me really worried. She must be so hungry! So sometimes it's less.”

I nod.

“Once, after Darcy went about six hours without a breastfeed during the day, I dropped Henry off at a friend's and went into the Emergency Department, I was so worried. But they sent me home, suggesting that if she wouldn't breastfeed in the next few hours, I should offer her a bottle. Since then, I've been trying to pump as well, to keep my supply up. I use a hakkaa during the feeds, to collect milk.”

I continue typing notes into the electronic medical records, standing at my electronic height-adjustable desk, pausing regularly to listen and make eye contact.

“Ah,” I say. “And what happens through the night?”

“Still waking every couple of hours. Sometimes she'll take the breast, other times she refuses and we just rock her back to sleep. We can be awake for an hour or more two or three times in the night.”

On the whole, breastfeeds seem to go better at night.

“To tell the truth,” Adrienne continues, “the only way I've been able to get Darcy to feed for any length of time is when she is waking up from a sleep, whether that's during the day or at night. I often try to go into a quiet dark room during the day, but that's hard with Henry. I have to leave him by himself in front of TV.”

“The paediatrician is also worried about Darcy's weight,” Adrienne says. “She put me on to a cow's milk and soy free diet last week, and we started reflux medications, too, because of the back arching and puking during feeds. It does seem to have helped, although it's hard to say whether it's the elimination diet or the losec.”

I am not surprised that Darcy is taking medications. Allergy, reflux, and tongue-tie are the most common diagnoses inappropriately applied to babies who are struggling with positional instability or a conditioned dialing up during breastfeeds.

Adrienne has been staying at home and trying to get into feed play sleep cycles the last week or two, as the child health nurse advised.

“It's hard though because her brother's needs aren't being met, and now Henry is throwing temper tantrums and being difficult to manage.” Worse, Darcy is now not only fussing with feeds, but irritable all day long.

“She's overtired a lot of the time, probably because she is so hungry.”

I look at her and shake my head slightly, in sympathy. “This is so difficult!” I murmur, typing.

“Darcy has terrible gut pain,” Adrienne continues. “I've tried everything, and I think the child health nurse is right, this is the problem. She gets very upset at the breast, and then she passes wind. I've been burping her regularly throughout the feeds. The child health nurse advised this too. Darcy seems to take more from the breast when she is burped.”

To try to help with Darcy's gut problems, Adrienne holds her upright after feeds on her shoulder for twenty to thirty minutes. It takes them an hour or more each time they wake at night to feed, hold upright, and settle the baby in the cot again.

Adrienne has also been trying to hold Darcy skin-to-skin in the bath. It didn't help.

The lactation consultant she saw recently said the fussiness at the breast was due to a posterior tongue-tie, and if Adrienne didn't have it released, Darcy was at risk of speech problems, sleep problems, and orthodontic problems down the track. The lactation consultant said Darcy had bags under her eyes, a tight mouth, and narrow cheeks consistent with restricted oral connective tissues.

“That really upset me,” Adrienne says. “Before that, I just looked at her and thought she was so beautiful! Now I look at her and worry that she's got these connective tissue problems and what the effects might be long-term.”

She sighs. “And I might as well tell you, I have a couple of close girlfriends who are speechies too. And they've been watching us feed and saying that she has obvious suck-swallow-breath co-ordination problems. One of them even thought she might be aspirating. Sometimes she does cough, especially with my letdown.”

“I really can't keep on going like this,” Adrienne repeats finally, with quiet but intense emotion. “I'm thinking I need to wean her. But I really want to breastfeed. And anyway, I can't wean her because she won't take the bottle. That's why I'm here.”

I take a deep breath and meet Adrienne's steady gaze, reflecting upon her courage. “You've done everything,” I say quietly. “Truly, it's amazing what women do for the sake of their children's well-being.” She is grateful, I think, for that moment of recognition.

My first step is to perform an oromotor assessment.

Darcy has no visible membrane under the tongue and a frenulum that sits out only a small way along the undersurface of the tongue. The little tongue follows my finger as I run it along the lower gum, from one side to the other, and it pokes out to the lower lip when I place my finger there.

“The IBCLC said she could feel the restriction when she ran her finger along the undersurface of the tongue,” Adrienne comments, doubtfully. She has her hands on either side of her little daughter's head, holding her reasonably still as I examine her mouth.

“It's true that we might feel the presence of some frenula that way,” I say. “But that doesn't mean anything. Oral connective tissues are as diverse as humans are. Darcy has a very normal frenulum,” I observe. “With normal tongue movement. Both frenula and tongues come in a whole range of shapes.”

Darcy is happy kicking and gazing at us from the nappy-change mattress that I have placed my examination couch, and I perch on the couch beside her. Adrienne stands in front of her, holding her little foot and sending her smiles of encouragement every now and then, as we talk. Darcy watches us both and kicks her legs happily.

“So you don't think she needs laser treatment?” Adrienne asks, confused.

“No, I don't. She doesn't need any kind of frenotomy. You see, her tongue isn't tied. And I'd be worried that if you went ahead with laser treatment, she could develop even worse feeding problems, because we know that is one of the side-effects of frenotomy sometimes, most especially with laser because it goes deeper.”

“So what do you think is going on?”

“I think Darcy has developed a conditioned dialing up at the breast. Another way of thinking about this is that she has become very sensitive at the breast. I often explain it to parents in this way: she has a very powerful biological drive to breastfeed, but things haven't always gone easily for her with the breastfeeding, and as a result she has developed a habit of her sympathetic nervous system going into over-drive whenever she is at the breast, a conditioned association. Each time she is at the breast she gets very tense … I want the breast, I want the breast ….. “ – I hold my hands up as if I am the baby and am very frightened – “but is it going to work? I'm worried it isn't going to work!!!! She gets tense and starts to dial up as soon as she knows it is going to happen, or soon after she is on, and can't relax anymore at the breast. She has become very sensitive …..”

I can see Adrienne's eyes filling with tears. “That's exactly it,” she says. “It's conditioned now.”

“Although I can never promise,” I say carefully, “in my experience this can usually be repaired. It will just mean experimenting with some approaches that sound very different to what you've been told elsewhere.”

“The first step is to make sure our little one never feels under pressure when she is at the breast. This is extremely hard to do when you are naturally so worried about her weight and even how hydrated she is! We are hardwired from an evolutionary point of view to feel very very worried when feeds are not going well. Something primal in our brain believes it is our responsibility to get milk in, and if we don't do this job, our baby will die! It's that ancient, that hardwired!”

Adrienne is wiping away tears, and nodding.

“So then it is normal to start accidentally applying a little pressure: 'come on sweetheart, take some more, let's just get a bit more in!'. But unfortunately, that pressure around feeds, which is absolutely normal for a mother because she so much wants to do the right thing by her baby, can back-fire and cause a conditioned dialing up.”

“It's so true,” Adrienne says. “I was almost force-feeding her a lot of the time, I was so worried that she was losing weight!”

My heart goes out to these devoted, hard-working women, who are trying so incredibly hard to do what's right for their baby in the midst of a world that gives such unhelpful information.

“That's such a normal response!” I exclaim. “Of course! You are trying to protect her!”

“So the very first thing we need to do is to take all pressure off any feed.” I describe to Adrienne what frequent flexible feeding is, how it is offering at least 12 times each breast in a 24 hour period (but not counting!), how the feeds may not go for long, how you can't overfeed the baby, and how there is no pressure to get milk in on any particular occasion.

“That's so different to what you hear!” Adrienne said. “I was always watching the clock trying to get 15 minutes each breast or whatever. I'd freak out if she was only on for five minutes …”

“I know,” I say. “But actually, babies feed for both sensory nourishment and for milk, and we can't really distinguish between the two. We just use the breast as one of our two tools to make the days as easy as possible.

“The second tool, rich and changing sensory nourishment, is particularly important from now on for a baby with a conditioned dialing up. Rich and changing sensory nourishment tends to keep the baby dialed down, which helps feeds go better. Sometimes women have even noticed that feeds go better when they are out.

But mostly, when you have feeding problems, you don't want to leave the house! That's so normal, too! You feel exposed if she starts crying and fussing when you try to breastfeed when you're out. You don't have the breast working as an easy tool to keep her dialed down.

And often when we are inside the low sensory interior of our homes, we are thinking the baby is dialing up because he or she isn't satisfied at the breast, and needs more milk. But it may actually be that our little one actually needs a change of sensory nourishment.”

“So often babies have had enough, but the mother is thinking oh no, that's not a long enough feed, or there wasn't much milk transfer, and keeps on trying.

“Then at 15 weeks, Darcy – “ and as if to prove my point, she is gazing up at us and burbling happily – “will be increasingly distractible at the breast. This is normal. Once we have the fit and hold working well for us, you'd be surprised at how much milk a baby of her age can take from the breast in a short period of time! If you are happy to go with this, and offer very frequently and flexibily, she will take all she needs over a 24 hour period. You can see that going into a quiet dark room could actually make the conditioned dialing up worse, because she is wanting richer environmental experience ….”

Adrienne is nodding.

“This is so different to what you hear!” she observes again. “The child health nurse was insisting that she was overtired and overstimulated and that was why she wouldn't feed, and wouldn't go to sleep.”

Often after an examination I'd suggest that the woman offers a breastfeed, so that I can see what has been going on. Sometimes in a situation like this, when it is very likely that there has been positional instability and breast tissue drag from birth, the baby is so dialed up at the breast that any attempt to bring her on needs to be as prepared for positional stability as we can make it, so that we are not simply reinforcing the baby's distress with breast tissue drag. We'll work through the gestalt approach before we actually try it. So I simply ask the woman to show me using a doll, fully clothed, the style she has typically tried when bringing her baby to the breast.

But today I ask Adrienne to show me what she has been trying to do with Darcy.

I hold Darcy and have a little conversation with her while Adrienne sits on the couch and nervously prepares, rolling down her black singlet bra, taking the breast pad and tucking it away.

“I know this is going to sound weird,” I say, “but our babies really don't swallow much air with breastfeeding. I know this from the research. We actually don't need to burp our babies.”

Adrienne glances at me incredulously as she unbuttons her shirt. “Are you serious?”

I nod wryly. “I know everyone tells you the baby is fussing because she has swallowed too much air, and that you've got to burp her and hold her upright, but it is a misconception. Babies will relieve themselves of any gas they have swallowed no matter what position they are in. But they are not swallowing much air at all.”

Adrienne says: “So the whole concept of pacing the breastfeeding, pausing to burp, isn't right?”

I pull a face. “It really doesn't help – or have a scientific basis. And worse, regularly disrupting her like that when she is breastfeeding can actually worsen a conditioned dialing up. She just wants to keep on feeding.” Adrienne has paused from her preparations while we talk.

“And my speech pathologist friends are sure she has suck-swallow-breath dyscoordination …?” She trails off.

I know that there's a lot of confusion about the idea of suck-swallow-breath dyscoordination. Some health professionals believe that there are predictable ratios of numbers of sucks before a swallow. They talk about nutritive and non-nutritive sucking. But the research demonstrates that suck-swallow ratios are quite irregular in successfully breastfeeding babies. And the number of sucks which will result in enough transfer of milk to require a swallow depends mostly upon letdowns, and on how much milk is in transit in the milk ducts even when there isn't a letdown - which is highly variable between women. I don't try to say all this.

“Unless the baby has a true neurological condition or is still premature, the concept of suck-swallow-breath dyscoordination is also unhelpful. Darcy won't have a problem coordinating her breathing and swallowing, but she might be working very hard to manage breast tissue drag. We'll take a look and see.”

Adrienne sighs. She takes her little daughter, chatting to her brightly. “What do you think Darcy-girl?” she asks. “D'you want boobie?” Darcy smiles back at this mother whom she adores with every cell in her little body. Adrienne begins to bring her on, using a method which puts the baby in the crook of the arm low under the breast, then rolls the baby's face up and on. As soon as she lies Darcy down in the crook of her arm, Darcy's smile is gone and she begins to cry and pull back in anticipation, pushing against Adrienne with her small hands.

“She's so smart, she knows what you're about to do!” I murmur.

Adrienne is sitting upright, or if anything leaning forward to help the breast fall forward when the baby comes on. I recognize this method, which is very popular in the city I live in.

One positive aspect of this method is that it is aiming for a symmetrical face-breast bury. However, unless a woman has a breast of a certain suitable size and shape, this approach may result in breast tissue drag problems, and landing pad encroachment. As one Brisbane midwife commented to me: “It works if you have an average breast! But most of us don't.”

The gestalt method aims to work for all women, regardless of breast shape and anatomic fit with the baby.

Darcy's forehead is against Adrienne's upper arm. Adrienne is holding Darcy with her right hand tight on her upper back, the right forearm tucked under her head and drawing her in. She is using her left hand to lift the breast a little, to pull out Darcy's lips into a K shape, to hold Darcy's hands out of the way, and then rests her left hand very gingerly on Darcy's bottom, not wanting to upset the baby further.

Darcy's back sways out and her legs flail in the air as she dials up. I can see that Adrienne is pulling her face in and up in a way that drags the breast up significantly higher than it wants to fall. Adrienne doesn't have much control over the face-breast bury because of the way she is holding Darcy, in the crook of her arm with Darcy's forehead up against Adriene's upper right arm. Little Darcy has been trying to deal with landing pad encroachment and breast tissue drag from the beginning.

Darcy is struggling and crying and we quickly stop.

Adrienne looks at me, distressed.

“Well, that isn't suck-swallow-breath co-ordination problems. It isn't aspiration. It isn't reflux or allergy or connective tissue tightness. But there is underlying breast tissue drag, that's probably become an issue as she has grown longer and bigger. She is positionally unstable, and has developed a conditioned dialing up because the feeds have been so difficult for you both.”

And three weeks later, after we apply a gestalt intervention, which requires some finessing in a second consultation, and all the strategies for a conditioned dialing up, Adrienne and Darcy are back to an enjoyable breastfeeding relationship. The baby's weight has gone up a percentile line, too.