Catherine,

Thankyou.  I had forgotten about the wonderful resource that is your book and after posting remembered that you would have covered this and so I did my homework and looked it up!  After seeing the mom today, I am fairly certain I can rule out submucosal cleft.

I did another oral exam and realized this time that there is maybe a mild PTT, though she still has pretty good mobility, so I think it is very mild and is not a big factor.  There is a tiny bit of slight rigidity midline underneath the tongue, but there is good extension and lateralization.  I was not able to evaluate elevation because she did not cry, so I have told mom what to look for and showed her some pictures of normal and abnormal from your book.  I have asked her to make a point of looking next time she cries.  Also palate is quite wide, not narrow or highly arched at all.  In fact, I think this is one of the widest palates  I have felt.  Is there such a thing as too wide?  Could the wideness be indicative of a problem?  There is an arch to it, it is not flat, just really wide and perhaps smoother that most palates I have felt. I feel fairly confident in my ability to detect TT, but I think I missed this subtle one because she was so lethargic when I first checked, and it is REALLY subtle.

The good news is that she is doing much better.  Much better able to sustain suckling (8 min as opposed to 2-3, not enough, but closer to it).  She is now 100% breastmilk fed, no more formula, and she is getting most of it directly from the breast.  50 - 200 mls fed away from the breast per day, as opposed to more than 400-500 mls per day.  Diapers are good and there is a avg gain of 41g per day over the past week.  So we are moving in the right direction.  I think she was just really sensitive to having had the milk pushed for her and took a wile to develop her own suckling skills.

A question that crossed my mind:  Could the fact that the calma teat is so long, and therefore, the milk exits quite far back into the mouth have anything to do with her ability to deal with it?  I know when at the breast, the nipple is elongated quite far back as well, but I'm not sure if it is as far back as the calma, or is it?  My thinking is that if the milk is exiting the teat farther back than it would normally from mom's nipple, maybe this is making it more difficult for her to coordinate milk flow with swallowing, thus making her choke on it sometimes.  Incidentally, the choking has been improved by simply keeping her more upright when being fed the bottle.  I know this would not have much effect on the flow of this teat, since it is a valve, but it would affect where the milk goes once in baby's mouth, with upright positioning giving her a bit more control.

Mom is also finally going to see an Osteopath and Cranial Sacral Therapist this week.  When I first saw her at 1 week, I noticed some very subtle signs of musculoskeletal issues.  I had recommended body work right away, but mom has not gone.  Now at nearly 1 month, the issues are much more prominent, to the point that mom can see them, perhaps even a full torticollis.  That, combined with the continued difficulties, has motivated mom to finally go.  The CST is also an IBCLC, much more experienced than I, so we will ask for a 2nd opinion on the tongue and oral cavity.  The muscle tension is also likely a big factor here.

Thanks for your info and helping me think this through!

Jennifer Welch, IBCLC, LLL
Montreal

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