Have a curly one today!
Permission from mum to post.
Have a baby Day 7 today at a home visit, with feeding problems.
Birth weight 3.5 kgs, still 330 gm under birth weight.
Gravida 1, forceps delivery, cephalhematoma right side, persistent bruising R side (temporal region).... (and BTW Hb mum 7.5 and she has forgotten her iron, another story!)
Obvious asymmetric facial tone since Day 1. Not noticeable at sleep. When awake, R side of face only slight tone (as in has very slight dimple when bottling otherwise that 'plastic' look), creases under the eye minimal compared to left. Contorted lips when crying with pulling to left side. Does *not * root on R side when face stroked (not even a flicker!), L side roots immediately. Tongue however *is* symmetrical, that is equally curved sides. Not what I expected.
Suck assessment showed weak suck with 'up and down' tongue movements. not front to back. Does *not* extend tongue past lower gum and jaw has a tonic chomping action. (I am trying to describe this as best I can!) Tongue has a *slightly* tight lingual frenulum, one I would consider as a very slight tongue tie. Not right to tip of tongue, further back than that. Palate slightly high. Maybe the lingual frenulum is a red herring!! My question is, is the tongue not forward because of the palsy or the lingual frenulum????
To me (and others) all of the above points to a facial palsy, except the symmetric tongue doesn't fit.
This baby has been seen by 2 'paeds', the second one feels it an "absence of depressor angularis". I had never heard of this so I looked it up with google and "low and behold" it does exist ;-) LOL
see http://pediatricneuro.com/alfonso/pg184.htm
Has anyone seen or had experience with this?
If it was 'absence of depressor angularis' wouldn't the sensation be *intact*?
If it is a palsy why the symmetric tongue?
.......meanwhile this baby is having hour long breastfeeds, then bottling either expressed milk or formula (more of the latter!). Mum claims he didn't feed well with a shield and only feeds better lying down (I asked for the shield but she couldn't find it, so I couldn't see for myself). Today he would not attach while I was there (had that "I do not perform on command" look!), flatly refused to open his mouth. Mum did try a bottle so at least I got to see that ( I guess you can force that in better, eh?). She is using an Avent teat. Takes 10 mins to have 60 mls from bottle. Did better than I thought he would, although tongue still not 'down' over gum ridge. Got mum to support chin with first finger to stabilize jaw and did quite well.
She is going to the 'Breastfeeding Centre' tomorrow then I will see her next day. I have asked for a consultant paediatrician to review baby tomorrow while she is there.
I told her today to concentrate on expressing 8 x day for 20 mins (has a hospital grade pump) as she has only been expressing 3-4 times a day. This is to increase/protect her supply and reduce/eventually eliminate the need for formula. Baby spits up with the formula comps.
Concentrate on getting calories in to baby for now, so he has energy to feed.
Reduce time at breast (temporarily) as I feel it may be ineffective at the moment. Limit to 30 mins then offer EBM/Formula then express. Currently the feeds are taking about 90 mins (with 1 hour breast, comping then 20 mins expressing) I am trying to aim for an hour all up. Showed her how to do 'dancer-hand' and breast compressions. Feeding for comfort is fine.
Considered Habermann feeder? Supply line probably not first choice because of poor tone. Am I right? Finger feeding may be worth a try?
Where to now?
I feel this baby needs a proper evaluation by a Neurologist (?) or a speech therapist with experience with newborns. Medical staff did not offer any follow up, just OK'ed the discharge home! I admitted baby to 'hospital in the home' today as I feel it needs sorting out and daily visits at least till it starts gaining well and progressing and so there is lots of support for mum!
Lactnetters familiar with Melbourne, got any suggestion who to send this lady and baby to?
How long till things improve (probably no answer to that!)
Also BTW baby has funny ears-the pinna of both ears are 90 degrees to the rest of the ear. The right is worse that the left. Mum denies oligohydramnios. (mu first thought). Is it possible this a syndrome of some sort that we have missed????
Any thoughts welcome.
Cheers
Karen Clements
RM IBCLC MELB AUST
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