Hi Julie
At risk of teaching Grandma to suck eggs ... I'd be looking for either, a
really receded chin, some assymetrical muscular tightness/weakness as a
result of birth or in utero positioning (positional turn) or a posterior
tongue tie al a CW-G.
When you lay the baby on its back, it is bent, shaped like a banana?  When
s/he is placed on her tummy, does she bring both hands up underneath her
chest, draw her knees up and push her chest up off the bed/ table?  Does she
follow the sound of her mother's voice all the way from one side of the room
to the other?  When you lay her naked on her back and hold one hand across
her body will she pull herself onto her side?  In both directions?  If any
of these shows an asymmetrical muscle tone, this may explain the poor
attachment - although, typically, the nipple damage would be worse on one
side than the other.  Carrying the baby in an upright sling or plenty of
tummy time (they hate it at first!) helps with these kids.
In the meantime I often find that increasing the assymetry of latch when
there is no obvious cause for poor attachment can help.  Start with the
nipple in line with the very end of the nose (this often means shifting the
bub quite a bit) and shape the breast into a vertical breast-sandwich  (but
watch that she is not lifting the breast into the baby's mouth).  Then when
bub gapes, plant the bottom lip on the breast and kinda 'fold' the nipple
and a goodly amount of breast under the top gum...  Then I check that baby's
feet are tightly wrapped around the mum, that her wrist is as straight as it
can be, her elbow is close to her body and encourage her to press the baby
towards her firmly between the shoulder blades with the heel of her hand
(this tips the baby's head back a fraction, pushing the chin into the breast
and freeing the nose).  This is also really good for those babes with really
receded chins.  I'd also check that mum is well supported in her chair,
sitting really upright so she brings babe to breast and not breast to babe.
All that said, I'd also give baby-led attachment a try.  I think there are
some good videos on the web.
If neither of those help I'd be looking for posterior tongue tie a la Cathy
Watson-Genna - I think you can find her slides on the web - she shows pics
of tongues that are really bunched up at the back and/or held assymetrically
in the mouth.

Any other ideas?

Nina Berry BA/Bed(Hons) Dip Arts(Phil)
Breastfeeding Counsellor
PhD Candidate - "Ethical Issues in the marketing of 'Toddler Milks'"

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