I am way behind in reading Lactnet but would love any input on a case. I saw
a mom and baby today for a follow-up. Baby is now four months old, I
originally saw dyad at one month. Many issues going on, I'll try to
summarize (hard to do, sorry, this will be long!), and would appreciate any
insights you might have.

Uncomplicated vaginal delivery at 39 weeks gestation. Mother's nipples flat,
used shield for latching. Baby always held head to one side, pediatrician
gave mother exercises to do with baby, improved and mother stopped doing
them. Latch always better on L and worse on R. Initial oversupply, then
mastitis in R breast, supply reduced after. Some remaining nipple damage at
my first visit. Helped with latch (with shield), mom comfortable, baby
sucking well. Did not notice (nor did mom report) head-tilt at this visit.
Mom never able to latch baby effectively without shield (has tried many
times). Baby always a frequent feeder, then started sleeping long stretches
at night around 2 months, frequent feeds during day. At three months, baby
had two vaccinations, very fussy that day, two days later mother noticed
some pink urine, also even more frequent feeding (every hour during day),
lots of testing but no diagnosis for cause of pink urine and it resolved.
The following week baby had a 24-hour nursing strike, two days later mom had
a period (light). Baby also started waking 1-2 times at night to feed,
coinciding with developmental milestones and signs of early teething (mother
giving Tylenol 1-2x/day for teething pain). Baby back to feeding every 2
hours or so during day, but also fussier at breast, less willing to latch to
R breast except when mother offers it after L. Mother feels supply is down,
having trouble pumping, breasts don't feel as full. Baby described by mom as
more of a high-need baby, fairly fussy.

At today's visit, baby latched well on both breasts with nipple shield,
transferred 85 ml. Despite what looked like good latch with shield, mom's
nipples very slightly compressed after feed, and not everted much further
than at start. Naked weight 13 lbs. 11 oz. (at 4 months), which is only 7
oz. more than weight at pediatrician one month ago (3 months); however, baby
gained 6 pounds in those first 3 months. Baby alert, active, reaching
developmental milestones typical of 5 month old. Baby's stool at visit was
green, very liquid, possibly mucousy. Mom reports sometimes green, sometimes
more yellow, sometimes more formed. Noticed head turning to one side,
possibly one ear slightly lower, one eye slightly larger. Suck assessment
seemed normal at first, then later baby pulling tongue in behind gums. Good
extension, some twisting of tongue with lateralization, moderate elevation.
No visible frenulum but can feel some cord under tongue.

Mother (and father) both very educated. Mother committed to breastfeeding,
many attachment-parenting choices. Mother has MANY allergies (bad nut
allergy, many fruits, some beans, other foods, some pollens; many
antibiotics; new allergies postpartum to chicken, soy, sesame; used to be
allergic to dairy and egg but outgrew those). Mother also has other health
issues (asthma, esophagitis, PCOS); is on aciphex, claritin, flovent,
rhinocort long term.

Dad had bad experience with chiropractor when younger, categorically refuses
to consider chiropractic treatment of baby; other treatments (such as
craniosacral therapy) also excluded.

So . . . I think one of the main issues is probably torticollis that has not
fully resolved, and I will provide further information on that for the mom,
and encourage her to seek further treatment. It may be possible that baby
has some tongue-tie, mom already has an appointment with our local ped who
treats for posterior TT next week. My concerns: is the lack of sufficient
weight gain in the last month (my scale vs. ped) a big worry? Baby had been
gaining so fast, so might it be normal to slow down? Or does it suggest (as
mom and I are both guessing) that baby was living off the oversupply and is
now having more difficulty getting enough? Also, with mom's history of
allergies and baby's green stool, is there a likelihood of baby exhibiting
an allergy to one of the already limited foods mom is eating? Finally, is
there any reason to be concerned about baby getting tylenol once or twice
almost every day for teething? Any other thoughts you wise women have would
be welcome.

Thanks for reading through this -- it helped me to write it all down.

Lisa Mandell, MBA, IBCLC
Havertown, PA
www.best4both.com

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