Thanks for an interesting case presentation, Lynn.  The baby's tongue is
probably sore from two clippings, and a restricted, short tongue is weak.
The clenching of the nipple is a compensation for lack of ability to pattern
and use the tongue correctly.  When the milk flow rate is augmented (with
SNS) the baby probably doesn't have to rely so much on the compensations and
can just swallow away.  For the poorly feeding, weak sucking baby, the
feeding tube is not a device that actually promotes much milk transfer
directly from the breast.  It is a way to supplement, keeping the
orientation at the breast and away from bottles, but mom should still be
doing pumping.  Check the size (base diameter of nipples).  If they are
fleshy, hard to compress and thick, the baby's ability to compress them will
be compromised by the weak tongue and high palate. Make sure she has the
right size pump flange to protect the milk supply.  Personally I wouldn't
bother clipping the superior labial frenum.  The lip retraction is probably
another compensation to try to hold the breast in the mouth with
insufficient help from the tongue.  You can clip it (will prob. help prevent
a gap toothed smile:) but it probably won't improve lip flanging much.
Remember, tongue-tie and tight labial frena are mid-line defects, and they
could be indications of issues elsewhere in the baby because they are
connected with other genetic issues.  The mother doesn't necessarily have to
get this info from you (that's the peds job) but your awareness that this
infant may have systemic weaknesses can help your perspective.  There may be
many improvements from CST or other gentle forms of manipulation, but some
babies are not immediately "fixable" in terms of their feeding capabilities.
Maturation will help.  In the meantime, keep emphasizing how valuable the
milk is, keep the milk supply well protected, get the nipples healed up
(does she need topical antibiotics to clear up a persistent, superficial
skin infection?)
Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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