Hi Pat,
I second Diane's motion...
When a baby cannot take the breast, there is some reason.  If not a
tight frenulum, then often a short or recessed mandible (lower jaw) is
responsible when a baby has difficulty breastfeeding in the early days.
When the mandlible is short and/or set back, it changes the relationship
between the jaw and the tongue attachment, making them closer together
than they would otherwise be.  Even if the tongue tip is free, there is
usually less space between the insertion of the lingual frenulum on the
tongue and the tongue tip, making the anterior tongue effectively
shorter.  Since it is the anterior half of the tongue that elevates to
press the milk from the breast, shortening this reduces the amount of
milk the baby can get from each peristaltic wave proportionally.  If the
free portion of the tongue is very short, the baby might not even be
able to hang onto the breast, and may fall off constantly like a very
tongue tied baby can.
My approach is to maximize tongue contact with the breast, using an
asymmetric latch.  We start by placing baby's body so that the nipple is
presented at the baby's philtrum (the little ridge between the nose and
upper lip) so baby extends his head and opens his mouth maximally to
reach the nipple, then mom pulls him toward her from between his
shoulder blades, which increases his head extension.  This should land
his lower lip at least a half inch away from the nipple. It really helps
to bring his belly against mom's torso first, this seems to line
everything else up properly.  In a newborn, the baby's navel sits on
mom's ribcage, right under her contralateral nipple. This works in
either the cradle hold or the transitional hold, whichever lines the
baby up better.

After the latch is as good as we can get it, if the baby is still unable
to meet all his nutritional needs at the breast, I would strongly
consider either fingerfeeding after breastfeeding to help strengthen
that little tongue, or a tube at breast to increase the bolus size and
keep him in a good suck:swallow rhythm.  I would use the tube if tongue
motions were correct and the baby just fatigued quickly or needs to suck
multiple times per swallow; and the fingerfeeding if baby is using a
munching motion at the breast indicating poor tongue peristalsis.

It is also necessary to be watchful for other sucking compensations:
excessive compression (biting) if baby is too shallow or having a hard
time maintaining the latch.
excessive upper lip movements if the tongue is unstable or the latch too
shallow.
excessive mandibular excursions (too wide opening of the mouth) if baby
is low tone or the tongue is relatively immobile.
If any of these are happening, the root cause needs to be dealt with.

Whew, so much for a short reply!
Good luck with this baby.
--
Catherine Watson Genna, IBCLC  New York City  mailto:[log in to unmask]

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