>
>I, too, have been monitoring a baby (now 5 =BD months old), who is
>exclusively breastfed, gaining weight well, never has latched well,
>tends to chew at breast (although Mom is no longer sore), comes off the
>breast frequently, is gassy, has a BM once a week at most and won=92t =
>suck
>on my finger. This baby has a sideways S shaped palate and gags a lot if
>you put something near his palate.


so similar!  i would love updates on your grandson if there is anything of
interest to report (breastfeeding wise of course - there are *always* other
interestign thigns to report about one's grandchildren!)

and to catherine:
thank you so much for your response - i have several questions and
responses to your post below:

>Lyla,
>This baby's tongue is definitely restricted from what you describe.  The
>clicking, asymmetrical tongue elevation, and difficulty holding a milk
>bolus for a controlled swallow are tip offs.

what clues you in to the difficulty holding a milk bolus?  the clicking?
the lack of rythmic suck swallows?  the whole picture?

>   Babies with poor tongue mobility usually use one or both of two
> compensations in their sucking:
>   excessive jaw compression (biting the milk out) and excessive lip
>movement (using the lips to move milk from the breast).  It sounds like
>the baby you saw is combining these two strategies.  If the baby's lips
>are habitually curled in, it is possible that the labial frenula are
>tight as well,

i thought the upper labial frenulum seemed a little tight, but i don't know
what the range of normal is . ..it is hard to gage without the landmarks of
gum ridge, extension, and lift, as with the lingual frenulum . ..

>but the baby might also be doing this "fixing"
>deliberately to get more "oomph" in his lip movements.


yes, this makes sense, too.

>The high anterior palate and the hyperactive gag reflex are typical of a
>baby with restricted tongue elevation.  The tongue can't get up there to
>spread the palate, and the palate is naive to stimulation and
>hypersensitive.


ohhhh. i knew this about hte palate not spreading appropriately because of
the absence of tongue pressure, but i didn't think of the hyperactive gag
reflex being a result of palatal naivete.

>The other possibility is that there is a mild neurological problem, with
>low tone and asymmetrical tongue movements.  Hypotonic infants often use
>fixing and compensatory sucking strategies.  Sometimes both conditions
>exist in the same infant, and the relative contribution of each thing
>can be difficult to unravel.


and an OT would be the appropriate referral for such a problem?  or a
neurologist?  what type of treatment is appropriate for such problems,
if  neurological in origin?  i do sort of wonder if it isn't both hypotonia
and restricted tongue .. .

>I would certainly refer this baby to an ENT.  Sometimes, if there is no
>lingual frenulum but the tongue attachment is restrictive, a procedure
>called frenuloplasty can be performed.  Unfortunately, it requires
>general anesthesia and stitches, but several babies in my practice have
>had this procedure with great results.  It can be difficult to find an
>ENT who will do this surgery.  It can be helpful if you fax the doctor a
>report outlining your observations of the baby's feeding and tongue
>funtion before the baby's appointment.


thank you - i wasn't aware of that procedure.

>An asymmetrical latch will also help the baby in several ways.


we have tried to go extreme on the assymetric latch, as that is a tool i
use often anyhow.  it hasn't seemed to help this mom, but i haven't had a
chance to really work with her on it intensively, so it may be her lack of
persistence and technique.  nursing at the park and with our two 3 year
olds throwing sand at each other while we talk doesn't exactly make for a
focussed consultation!

In this particular case, I would also advise mom to bf on one breast at
>a feeding,


she is doing this already, and perhaps i should suggest 2 in a row - the
only caveat is that mom feels that baby gets fussy at breast and even worse
at nursing once the flow has slowed - i assumed it was because baby really
couldn't get much without a fast flow, due to poor latch and suck . ..

>or even one breast two feedings in a row, to increase baby's
>fat intake and reduce the gassiness of lactose overload.  If feeding is
>stressful and scary for baby due to inability to control milk flow, he
>is likely to refuse to breastfeed at all once sucking becomes more
>voluntary at around 3 mos of age.


oh gosh - i hadn't thought of that!  and it hardly seems he is sucking at
all, anyhow, at least not by yesterday's observation. he does not have a
strong suck reflex, and i fear that refusal might be all to likely ..
thanks for mentioning that.

thanks so much for your insightful post - i learned a lot today, and i look
forward to following this mom and baby, and observing the outcome. i will
call her soon with some of these thoughts and some referrals.

Lyla Wolfenstein
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