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From:
Pamela Morrison <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Sun, 8 Jan 2012 12:33:08 +0000
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Katrina

Another thing I've found with babies who appear to have short/bunched 
tongues is that this can happen when the baby is hungry.  In fact the 
consistently hungry (slightly underweight) baby often appears to be 
disorganized during breastfeeding, fussy, pulling on and off, and 
extremely tense all over - high body tone in all the muscles. And the 
hungrier the baby, the harder he sucks, which could be a reason for 
the mom's pain and nipple damage. I've found that when the baby's 
intake is improved, then the tongue relaxes and the baby begins to 
breastfeed more gently, as well as more effectively.

As you saw that the milk supply seemed to be adequate, with dripping 
milk, but that the baby has been largely formula-fed, it's likely 
that this baby hasn't been _breastfeeding_ effectively, and remains 
hungry during or after breastfeeds.  Have you checked that he has had 
adequate weight gain since birth?   I would perhaps focus on getting 
enough EBM and ABM into him to ensure a good weight gain for age 
(30g/day), work on increasing the mother's supply to replace the ABM 
supplements, continue offering the breast plus supplements until he 
is exclusively breastmilk-fed and is a good weight and then expect 
that he will eventually take over complete feeding from the breast 
when he is stronger/more organized.

I think you did right to refer the mother on to someone else if you 
were not able to offer your services as an IBCLC during an LLL 
meeting.  I think you've put your finger on one of the perennial 
problems we have when we wear two hats.  I myself found it too 
frustrating, and elected to retire from active LLL work, preferring 
to receive referrals from other LLLLs or act as a resource for them 
so that _they_ could work with the mothers, rather than seeing things 
in meetings that I wanted to help with but couldn't.   This worked 
well for me, since I would refer the mothers that I saw as an IBCLC 
back to their LLL meetings once the breastfeeding problem was over - 
this meant that the mother had specialist help for special problems 
and the on-going mother-to-mother support and modelling/motivation to 
carry on breastfeeding for an ideal time that I couldn't provide as 
an individual IBCLC.

As to lacking confidence, you may need to tell yourself that as a 
newly certified IBCLC you certainly know enough to have passed a 
difficult and taxing test of your knowledge and skills :-)  And that 
with all your existing experience you'll know enough to be able to 
distinguish the very unusual breastfeeding difficulties from the more 
usual ones.  Better get that insurance!  Then you'll be able to give 
an appropriate oral exam of a struggling baby, a breast exam to 
assess more accurately whether the mother's supply is good or 
inadequate, and spend more quiet, one-to-one time observing how mom 
and baby behave during breastfeeding;  a busy, distracting LLL 
meeting, though lovely, may not be the best place to make such a very 
detailed assessment.  I have to say that I learned more in the year I 
spent intensively studying before sitting the IBLCE exam and in the 
first year or two after newly certifying than I ever would have 
believed.  And though we may become more experienced over time and 
receive fewer surprises, I think we can all truly acknowledge that we 
never stop learning, because every single mother and baby are 
different. That's one of the challenges and one of the buzzes of 
being in this fascinating and nail-biting profession.  You may need 
to take a nice deep breath, get the insurance (!!) and just jump 
in.  You have your hard-won certificate, and the support of 5000 of 
us on LACTNET - and the water's fine :-)

Pamela Morrison IBCLC
(your neighbour in Rustington, England)

I am also a LLLL and a mum came today to our meeting with very painful
 > nipples and a baby predominantly on formula. I have mum's permission to
 > share her story. I had spoken to her before on the phone and we discussed tt
 > due to the persistent pain and damage she was getting, blanching and chafing
 > and the fact lots of people have seen her and said the latch looks fine. I
 > explained that pain meant something was wrong so she came along to see us.
 > The first thing I noticed that although baby's tongue was very mobile and
 > moved upwards quite well there was no visible frenulum (more like a
 > web/membrane) and that the tongue seemed very short. During the feed(which
 > was painful even though baby's position was good and his mouth looked well
 > attached) I felt that he hardly transferred any milk(very little swallowing,
 > lots of NNS and fretful wriggling-even though mum had milk dripping).
 >
 >
 >
 > I was at a loss really because I couldn't do any sort of manual exam (I was
 > there as LLLL not IBCLC and haven't bought my insurance yet so haven't
 > practiced in that capacity yet) but to be honest I really lack confidence in
 > the area of identifying unusual tongues through examination (I wondered if
 > this might be a sneaky posterior tongue tie due to short tongue and baby's
 > inability to maintain good suction without damaging mum). I really couldn't
 > see the baby bringing his tongue down over the gum line at all-but it's so
 > difficult to see!! I hated to refer her to a busy clinic but felt I
 > couldn't do much more for her other than help her feel ok about feeding the
 > baby and maintaining supply. How do people gain this kind of experience? I
 > think I'm more scared of missing a tongue tie than I am of wrongly
 > diagnosing one that's not there, so I didn't rule it out and suggested she
 > went to get a second opinion. Any other ideas? Was I completely off the mark
 > to be suspicious about posterior tt? I really want to learn from these
 > difficult helping situations, so am grateful for any information or
 > suggestions you may have.
 >
 >
 >
 > Katrina Soper LLL Leader and IBCLC in Wales UK.

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