I have a few thoughts on this situation...

unfortunately my practice is evolving into being comprised mostly of these 
difficult cases, so I empathize with your frustration.

My first question would be, did the HCP completely free the tongue?  In my 
experience, with non-elastic frenulae that attatch near the tip of the 
tongue it is very difficult to free the tongue completely with one snip.  As 
I do more and more (~ 5 per month) I have gotten more "daring" and the other 
day I snipped three times before applying the guaze.  The challenge is that 
most HCPs will only clip as far as the eye can see (as they should!) but if 
the frenulum is at all tight, you cannot see all the way to the base of the 
tongue because you cannot elevate it completely.  SO each snip allows you to 
see farther back. Often one snip will get you back to where the salivary 
ducts come across the floor of the mouth, and sometimes that is far enough 
to relieve the issues mom and baby have been having...but sometimes not.  I 
have gone back to snip more later in the same visit, or at a future visit. 
SO if there is still any frenulum left, it would be worth clipping.

Having said that, there are a few babies who continue to cause trouble after 
clipping.  Usually (but not always) you can see evidence of continued tongue 
restriction, such as a heart-shape or limited elevation/extension. 
Unfortunately there isn't much you can do about this other than try a nipple 
shield. (24 mm)

Even if you feel tongue motion is now normal and there is no frenulum left, 
it would be worth trying a nipple shield.  If this baby has issues with 
keeping the nipple elongated into the back of the mouth the shield can be 
very helpful.  However, the baby must get past the "nipple" portion of the 
shield and onto the breast.

Does the baby tend to prefer to nurse with jaw relatively closed?  If so, 
working on getting a firm bottle nipple all the way in the mouth can be 
helpful in training baby to open wide whenever eating.  I have two babies 
right now who are 7-8 weeks old and still hurting their mothers despite all 
of my best efforts.  They are getting closer, and obviously their mothers 
are very determined.  I think one baby is very "tense" in general and may 
have benefitted from craniosacral, but I don't have anyone to refer to here. 
And I think the other has had a mother who is too "permissive" in letting 
the baby slurp on and stay shallow.  She would rather endure the pain than 
insist on the baby changing her ways.

Anyway, you are not alone, for what that is worth.  Hopefully something 
above will be useful.

Kathy Leeper, MD, IBCLC
MilkWorks- Lincoln, NE

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