Hi everyone
I have a client in my private practice who is happy for me to post here for any ideas or direction anyone can give. She has a 7 week old daughter who is having attachment & sucking issues.  PTP  (a long post)Relevant history

 Maternal   

 Placenta praevia

Threatened pre-term labour at 28 and 32 weeks 

Emergency caesarean section

Birth at 36+2 weeks

Post partum haemorrhage 2,000 mls

Several family members on both sides were tongue tied

Nipple tenderness

 Infant

 Resuscitation at birth for 7 minutes (Apgars 2, 2 and
& 7)

Jaundice requiring 24 hours bililight therapy 

Weight loss initially 500 grams

Slow regaining of birth weight by 4th week

 Breastfeeding observations

 No obvious anterior tongue tie seen

Tongue appears to be held back and bunched, not
reaching alveolar ridge

Tongue never seen to extend forward to cup the breast
on attachment

Tongue does not appear to lateralise when stimulating
lower alveolar ridge from side to side 

High arched and narrow palate (looks to me to be bubble shaped although it's the first one I've seen apart from pictures)

Recessed mandible

Sucking pattern throughout the feed irregular and
arrhythmic (does not progress to rhythmic suck/swallow/breathe pattern after
letdown). 

Attaches to the breast but soon loses attachment,
becoming frustrated and tense in posture and pulling off. 

During bottle feeding of expressed breastmilk, she is
also tense and feeds noisily (milk sloshing, clicking, gulping, fists tightly
clenched), struggling to tolerate flow

Some dribbling of milk at mouth during feeding

Mother reports that baby has a weak suck. 

Mother then gives expressed breastmilk to top-up each
feed. She has needed to express following every feed since Day 4, that is, 3/24
during the day and 5/24 at night to satisfy Izabelle and to maintain her milk supply.


 My impressions

 Suspected posterior tongue tie that is restricting the
normal range of motion of the tongue significant enough to be interfering with
normal breastfeeding.

 Breastfeeding difficulties compounded by prematurity, a
recessed mandible and a steeply arched palate, causing an inability to deeply
attach to the breast and an inability to maintain a sufficient seal and sucking
pressures required for breastfeeding.

 Mother is finding the continual expressing to
supplement feeds impractical, tiring and not able to be easily maintained long
term, especially due to fatigue following her eventful pregnancy, surgical
delivery & complicated post-natal course. She also has another four
children at home. This is Mum's fifth breastfed child and, as an experienced
breastfeeding mother, she is certain that this breastfeeding experience is
different. She strongly desires to continue breastfeeding and knows that
“something is not right”.

 
I am continuing to follow-up this mum & baby. Mum is now struggling to maintain a milk supply as baby is now starting to refuse the breast. She is also arching now this week & mum thinks she is in pain (although when I saw her last week, I didn't think it was reflux). Most feeds are predominantly by bottle about 120 mls per feed. Breasts were OK, just tender, now becoming very sore. She is only using a smaller personal use hand pump that can be converted to electric, but she feels it is not doing the job well & is causing nipple discomfort. I suggested she get a referral from the GP to assess for posterior tongue tie. The Paediatrician felt that as the weight gains were OK, there was no real cause for concern. He did a check of weight & other measurements & a quick check of the mouth, concluding that the tongue could be poked out somewhat & the palate was OK. He felt there could be some reflux and suggested positional modifications during & after feeds. He felt mum should continue what she is doing and the the recessed jaw will grow & other maturity will follow, and that feeding will eventually improve. He requested to see them again in 6-8 weeks. Mum is not happy & quite discouraged with this outcome, as she feels things have not improved at all and she doesn't know where to go from here.  She is really wanting to breastfeed this baby. 
I have suggested another referral this time to an ENT specialist (who I know treats anterior tongue ties if needed; don't know about posterior ones or other restrictions), a chiropractor who sees infants (for any structural issues) & a hospital grade breast pump (to build & maintain supply). All the breastfeeding position modifications I have suggested have already been tried without improvement.  She has also been referred by an earlier doctor to see a Speech Therapist but is still waiting to get an appointment.  Mum has 4 other children (2 pre-school age) and lives out-of-town, so difficult to get to see doctors and other specialists, but is willing to do whatever is necessary to get baby breastfeeding.
I did not do an oral assessment as I did not have gloves and have not been specifically trained, but working off the Hazelbaker assessment tool, I still feel there is possibly a posterior tie or some tissue restrictions affecting normThis is the first time I have suggested a doctor referral  
Debbie Dixon IBCLC CIMI PMCAustralia

 



 		 	   		  
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