Laura,
You've done an excellent job of describing a thorough evaluation!
You've mentioned all of the signs of tongue tie sans nipple pain. He's
probably gaining well due to mom's abundant supply.
Is the reason you're more concerned about the upper lip tie than the
lingual frenulum because it seems tighter/less elastic than the lingual
frenulum?
CST may indeed help. I'm wondering if the release of upper lip tie will be
adequate. I'm concerned by two things: #1 the suck on your finger did not
feel normal, and #2 the baby (except when during your visit) only nurses
for 4 minutes.  In the evening when he has to 'work' for his food, he's not
transferring as well-- likely due to his inefficient suck. I vote for
revision of both lip and tongue
Melinda



On Wed, Feb 12, 2014 at 10:39 AM, Laura Spitzfaden
<[log in to unmask]>wrote:

> PTP> I am trying to tease out the reasons for this dyad's issues.
>
> Mom has NIR-PCOS and achieved pregnancy through fertility treatments with
> Clomid and progesterone. I do not know if she has hyperprolactinemia.
>
> Baby is growing fast but not super fast. He is 2lbs 10oz over birth-weight
> at 4 weeks. He nurses very frequently (up to 12 times daily) for 4-10
> minutes a feed. He is gassy and uncomfortable and has been on Zantac since
> 2 weeks. He spits up but not large amounts. He has a very shallow latch and
> very short sucking bursts. His cheeks dimple slightly when he is actively
> sucking. He mostly hangs out at the breast and swallows. He sometimes
> chokes and clicks at the breast. He has thick tight labial frenulum and a
> long (almost 2cm) non-stretchy (but not very restrictive) posterior
> frenulum that feels like piano wire. He has a bubble palate. He has good
> but asymmetrical, lift of the tongue but poor sucking on a finger. He
> lateralizes okay (better to one side than the other) but does not cup well.
> His gum-line is not parallel, he has a more than average receding lower jaw
> and he has a preference for lying on one side and prefers the breast that
> allows him to lie on his preferred side. He has several good sized yellow,
> seedy stools every day. His weight gain has been approximately 14oz a week
> for the last 2 weeks.
>
> Mom has no nipple pain and he does not pinch her nipples with his shallow
> latch. During our visit, he transferred 90ml after feeding from both sides
> for a total of 15 minutes.
>
> Baby has difficulty handling milk flow in the beginning of the day and
> then has difficulty removing milk in the evenings when supply is lower.
>
> I suggested CST ASAP. I also showed mom how to work on a deeper latch and
> suggested one (mostly) full drainage by pump before the first morning feed,
> to see if Baby can manage a deeper latch when Mom's breasts are not as
> full. I am not sure if  his latch shallow in order to slow down flow or if
> the flow is normal and he just cannot manage a deeper latch due to his many
> structural issues. I have also suggested that Mom consider reducing her
> dairy consumption, and take fish-oil and probiotics and magnesium to reduce
> her own inflammation, in case this is contributing to an over-active let
> down. I also suggested probiotics instead of Zantac for Baby.
>
> If Baby still cannot latch more deeply with a less full breast, she will
> consider frenotomy for the ULT, though I do not think the tongue is overly
> restrictive. Fortunately, we have an excellent provider whom I trust to
> evaluate both tonge and lip if this is needed.
>
> Does anyone have any input for this case? I do not want to jump to the
> conclusion that it is an oversupply problem since Baby has structural
> issues and I want to be careful to protect her supply while she figures out
> what he needs to be comfortable. I also do not want to jump to the
> conclusion that this is a tt or lt problem since there are other factors.
>
> Laura Spitzfaden, LLLL, IBCLC, APL
>
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