I have been working with a mom and baby for the past two weeks with a very frustrating scenario. I actually helped this mom w/ her 4 yr old, but I met her when he was over a week old. Her milk supply was very low and the baby was both nipple confused and clamping on her breast. He had been deep suctioned. It took about a month w/ suck training and an SNS and pumping to get him fully bf. She nursed for 15 mos.    With this baby, she called me ahead of time, hoping to avoid all of her problems. She chose to have a scheduled cesarean b/c of a breech baby. I saw her within 18 hours of the birth. I found a baby who just did not open her mouth very wide at all. Her tongue did not protrude past her lower gum and it usually rested on the roof of her mouth. She has a pronounced ridge behind her top gum and her palate is quite flat. Her tongue cups toward the back, but flattens at the front. Mom has very large breasts and very soft tissue. The baby did not latch on at my first visit, but I returned later that evening and she nursed for a few minutes while I applied gentle pressure to her chin. This was after I helped mom hand express about a tbsp of colostrum and fed it to the baby by syringe. The mom was very anxious b/c her first baby had been jaundiced and had also lost a lot of weight. I showed the parents how to show the baby to open wide w/ mimicry and how to do suck training to keep her tongue down. Mom also began reg
ular pumping.   On my next visit to the hospital, things were pretty much the same--baby did not open wide enough and seemed unable to draw the nipple in. I hoped that she might do better when mom had a more adundant flow. A home visit proved no more successful and even though mom's milk was in, the supply was low. The baby would latch for short periods, but could not sustain a latch--adding some milk at the breast did not solve the problem. On Christmas eve, the parents took the baby to a ped for an assessment of the baby's tongue--he said there is no tongue-tie. The grandmother was tongue-tied and the dad has a very high palate and had serious speech problems as a child. He said his mother said he "could not bf". On Christmas day, I met w/ the parents and another LC at the hospital where the other LC worked so that I could get another opinion. She found all of the same things I did and reinforced my recommendation for chiropractic. We were able to get the baby to latch sitting up, coming straight toward the breast. With
just the right support and pressure below her shoulders, she could open, flex and latch from below. We used the SNS and and she fed pretty well. The next day, mom took the baby to a chiropractor. The chiro said the hyoid was too tight and keeping the tongue from working properly. She also said that there were problems w/ the jaw. After she saw the baby, I did another home visit and the baby was noticeably different. She was more alert, her state changes were more organized and she was very calm. Her mouth opened better and she latched very well w/ the SNS and took about 2 oz.
    Unfortunately, there has been little improvement since. She had one more chiro adjustment, but mom does not see the differences I have seen as being significant enough. If anything, I think the baby is opening less well, b/c mom has been letting the baby suck the SNS like a straw on her nipple. We tried a nipple shield, but the baby did not want it in her mouth. She doesn't seem to like anything very far in her mouth at all.
    So, we have a combination of things--the ridge behind her gum, the palate shape, the mother's very large breasts and soft breast tissue. There is the structural problem which I think needs more treatment. There is the fact that even when the baby latches on, she will drop the breast at the slightest movement. And that she needs to be so precisely positioned to get her to latch, which is really hard for the mom, b/c she can't see well past her large breasts. When she does get on pretty well, she very quicky moves to the nipple. I suggested the parents skip the chiro and try an integrated form of PT. Mom is running out of patience and this is very hard on her. BTW, based on her reaction to the nipple shield and anything else in her mouth, I do not think she would do well w/ a bottle, either.
    Any assistance at all would be greatly appreciated.
Jenifer Tow, IBCLC, CT, USA

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