Yesterday I saw a mom and baby in the office that were referred to me for
breastfeeding difficulty.  They live in a neighboring county and are
eligible for WIC, but that county's WIC office has no lactation support.
The mom then called our county's WIC office to speak with the IBCLC there
about her problem.  Our IBCLC cannot see her since she does not live in the
right county, so had provided some phone support.  Mom described to her that
baby will not latch, or stay latched when he does go to breast.
Breastfeeding is painful, and the baby also seems very unhappy.  Baby seems
to slide off on to the nipple frequently, struggles to maintain latch, and
cries a lot at the breast.  He also does poorly with a bottle, seems to gag
a lot, and is just generally unhappy when feeding all the time.  He does not
spit up at all, and breathing sounds normal to mom.  Weight gain has been
good (8lbs 2 oz at birth, 11 lbs in my office at 5 weeks.)  Mom has been
pumping, but not enough to maintain her supply (she has a Lactina rental.)
She told the IBCLC on the phone that baby doesn't seem to be able to get his
tongue over his lower gum, so the IBCLC suggested to see me for an opinion
over whether he had a tight frenulum.  Her own pediatrician has told her
(without looking in his mouth) that since he is gaining weight acceptably
with primarily bottle (and now primarily formula) feeds that there is no
problem.  If baby can't breastfeed, then just bottle feed, and he should
grow out of the crying!

Anyway, they came to office with her two older girls (4 and 8) who were in
terrible moods and fighting, so it was a difficult visit and I could not put
the baby to breast.  Unfortunately, he was scheduled right into my regular
office practice, so I didn't have the time needed to do a thorough
assessment.  Anyway, I did look in his mouth and he did not have a tight
frenulum.  In fact, he seemed to have none at all, the tongue was simply
attached at the base.  He did have a recessed chin, high palate, and short
tongue.  When sucking on my finger, he did not protrude the tongue over the
gum at all.  If my finger touched the back of his hard palate, he gagged and
looked miserable.  By extending his head some, I could get his mouth open
more and the tongue a little more forward, but still not right.
Any suggestions for this kind of anatomy?  I did suggest usual measures to
protect her supply, and suggested she try offering breast when baby is
sleepy (he's started to cry even when offered the breast.)  I tried to
describe to her an assymetric latch and positining with the head extended
since that seemed to bring his tongue more forward.  I gave her the phone
number to our LLL for some mother to mother support.  I will call her to
follow up, and offer any other suggestions if you have them.

I was very frustrated by the limits of a busy family practice setting, and
also that her older kids had already been on several errands (including one
of them having a tooth pulled) and were in no mood to cooperate, so we were
repeatedly interupted so mom could break up a fight!  I was so hoping I'd
find a tight frenulum so I could FIX this baby, but no such luck.  Also, I
was very frustrated that this mom spent 5 weeks telling her ped about this
problem and being told there was no problem.  I used what someone else wrote
here not long ago about breastfeeding being a normal human behavior, and
that something is wrong if the baby is unable to breastfeed.  If nothing
else, I think this mom felt that her concern was valid after our visit and
she could let go of the feeling that SHE was just "failing" to breastfeed.
I'd appreciate any other ideas you can offer.

Jennifer Tieman
Family Physician
Mom to 4, including nursling Caroline Rose born 5/31/03

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