I just saw a wonderful presentation at our WIC by Barbara Wilson Clay on 
latching on. If the nipple is coming out pinched, then the latch on is 
not right. It might look ok from the outside but Barbara said the nipple 
is not far enough back in the mouth. I would suggest the asymetrical 
latch where the nipple is put on baby's nose or under the nose and let 
him open wide and come up for the nipple. So more of the jaw is smooshed 
into the breast. You could also have a jaw clencher but these babies 
usually have the tight lips and the fish lip or pucker up kiss type of 
lips. Not a wide open U at the corner of the lips.

Baby might have a tongue tie in the posterior end that is easily missed 
except for mom's pain. If he does not have enough tissue into his mouth, 
he will get reduced milk flow because the jaws pinch in the wrong spot. 
The jaw needs to be smooshed into the breast because it does the work 
and if it is hanging out away from the breast, the baby is going to 
clamp down or use its gums to milk the breast and hang on.

If the weight gain was better I would suggest maybe a too fast MER 
because of the pinching and the unhappiness at the breast (with the good 
weight gain). These babies are often unhappy at the breast and stay on 
forever because they are looking for comfort sucking and are fussy after 
nursing. I have seen many like this slide down to the tip of the nipple 
and "bite" to stop the too fast flow.

LLLI says normal weight gain is 170 grams or 6 ounces per week and if 
this baby gained only 220 in the last two weeks that sounds low to me.

If mom is in severe pain and you are using the asymetrical latch with 
the chin smooshed into the breast, she may need to pump every other 
feeding and use a wide based bottle, slow flow nipple for those 
feedings. Make sure she has large enough flanges or this could be 
pinching her nipple and contributing to the problem. If baby can not 
open wide enough on something like an Avent, or wants to tip suck with a 
tight mouth on the Avent (lips below the wide base or just up to the 
wide base), this leads to a jaw clencher where CST helps. Some babies 
clench so tight there is a white ring around the outside of their lips 
on the breast and bottle. You can see the tension in the muscles of the 
face.

When I am not sure what is going on, and test weights show poor intake 
but mom can pump more than baby's intake at breast, I watch the baby 
bottle feed (if already getting bottles) because I can see how the lips 
grip the bottle nipple and it tells me a lot (either too tight with too 
much tension, or too loose where one lip is not gripping at all).

Can mom pump more than test weights show for intake? If yes, the leads 
to an oral motor problem or tongue tie.

She's a trooper for continuing so long! Hope this helps, Kathy Eng, BSW, 
IBCLC, Houston, TX

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