Ahhh....the chompers...as an "outpatient only" clinic we see a lot of
these.  They can be very frustrating.

In my experience the babies who are "clamping" or "chomping" are almost
always doing so in a effort to "hold on" to the breast when their tongue
is not able to do the job.  If you did not "actively" look for a lingual
frenulum, I would start there...especially since you describe the tongue
as staying behind the gum-line.  Sometimes the frenulum is not visible
unless you take a finger and "lift" the tongue to look underneath...all
the way to the base.  Some of them do not come very far forward (toward
the tip) of the tongue, but hold the base of it down in the floor of the
mouth...and you feel the resulting "hump" posterior to this on suck exam
as the tongue tries to lift in vain.   Unfortunatley, some of these kids
do not have any frenulum but seem to have a "short tongue" that is
unable to extend forward far enough.  If a shield does not help (and it
often doesn't) all you can do is wait while they grow.

CST is worth a try...I have found it most helpful if the baby has
obvious restriction of jaw movement all of the time...i.e. when
crying/yawning etc the jaw never opens wide.  Or obvious cranial
assymmetry.

Another possibility would be a submucus cleft in the palate...there can
be a "U"-shaped defect or a "slit" down the middle posteriorly. (You
cannot see these but feel with the finger, although  occassionally the
uvula is "bifid" or split.)

I am not familiar with the "old-fashioned" shield.  As I am sure you
know, at some point the mom may need "permission" to pump and
finger-feed or bottle-feed for a while.  I usually try nipples with her
to see what type allows the baby to relax while suckling, and have the
mouth open as wide as possible.  These babies often have some trouble
with bottle nipples...occassionaly needing a Haberman.  Whatever it
takes to feed the baby and preserve the milk supply while the babyh
grows.  Sometimes these moms can take nursing once or twice a
day...sometimes not.

Anyway, hope things improve for this couple soon.  It is so
disappointing when moms have tried so hard not to repeat a previous
negative bf experience.

Kathy Leeper, MD, IBCLC

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