I apologize for the very long post. I have PTP.

I saw a 10 month old yesterday and I am looking for input. This baby is exclusively breastfed with complimentary solids and has been gaining well, increasing percentiles from birth 15.9%tile at birth to 46%tile currently.

Baby was birthed vaginally without pain medication. Labor was 27h total. Progression was normal until labor stalled at 9.5cm. Mom was given Pitocin for 2h. Pushing stage was 4 hours and Baby was born with both hands beside Baby’s head. Baby had immediate skin-to-skin. There were some breathing problems and jaundice. Baby was sleepy for first few days and lost 11% of birth-weight. Mom expressed and bottle-fed a few time in the first few days and then breastfeeding went well. After initial weight loss, Baby gained an average of 11oz/week for the next 4 weeks.

At 3w, Mom reports breastfeeding difficulties, Baby either only nursing for 60 seconds when awake or long feedings of 1-3hrs while sleeping.

Baby saw LC@ 3w and was assessed to have a restrictive lingual frenulum. Baby had laser release of lingual frenulum and 2 visits to a CranioSacral Therapist @ 4w. Symptoms did not improve. Baby also had mucousy and bloody stools. Mom suspected lactose overload. Mom suspected reattachment of lingual frenulum in spite of active wound management. Baby returned to provider for second release of reattached frenum @ 3months. Symptoms did not improve. Returned to provider @ 5.5 months and was reassured that frenulum had healed normally.

Mom reports that Baby usually seems discontented. Baby must be held frequently and does not like to interact with strangers. Baby will not comfort nurse and must be very calm to nurse. Baby prefers to breastfeed while sleepy and during the night. 
Baby had some flattening of occiput and was not rolling over by 6 months and was referred to OT. Oral exercises prescribed by OT resulted in significantly improved breastfeeding. OT continued for 3 months and Baby was rolling @9 months. Occiput is no longer flattened. Baby has had 1 visit to a chiropractor.

Baby’s stools remained mucousy with occasional blood until solids begun. After solids, Baby became constipated. Mom began elimination diet of top allergens (soy, dairy, eggs, shellfish, tree nuts, peanuts) and gluten and has been on this diet for 5w without improvement of Baby’s stools or fussiness. Baby eats small amounts of fruits, veggies, meats, potatoes, and drinks water with meals. Baby is given prunes, pears, and peaches for constipation.

Mom has been doing weighted feeds with a rented Medela Baby Weigh scale and Baby usually transfers an average of 2.5oz/feed with a range of 1-5 ounces. Baby nurses an average of 4-5x during waking hours (the only feeds that are weighted) and 5-8x during the night. Baby transfers a total of 11-18oz during the day and gets the remainder of nutrition at night. Mom reports that breastfeeding does not seem comfortable for Baby. There is much grunting, pulling, and writhing. Mom reports that Baby does not squeak, click, or cough while breastfeeding.

I consulted with this dyad for the first time @10 months. Baby was difficult to assess. Baby would not breastfeed until I removed myself from view; I had to watch from a distance. As Baby became sleepy, I was able to move closer and see that Baby’s top lip was flanged comfortably and the bottom lip was everted. Baby had a somewhat shallow latch. I could see the tongue cupping the breast and the tongue was stable. Baby had normal length sucking bursts but only swallowed well for the first few minutes. Baby was pretty upset by my presence at this point of the consult and fell asleep while nursing in a side-lying position (preferred position). Baby only transferred 30ml. 

An oral exam was difficult as the baby cried for the entire exam. I was not able to assess lateralization or sucking. I was able to note that the baby’s tongue tip does not rise at all (never has, even after frenectomy) and only the edges rise. The frenulum feels flexible and the release provider has assessed it as properly healed. Maxillary labial frenulum is thick but the upper lip is very mobile and frenulum was assessed as non-restrictive. Provider is a member of IATP and is well versed in proper release. A very interesting finding is that Baby’s lower jaw is prominent, resting completely outside of the upper jaw. Additionally, though I was not recognize this in person, I noted in photographs that Baby’s lower jaw tends to deviate toward Baby’s left side. 

Physical findings are left eye is more open than right eye, Baby has an open-mouth posture (also noted by OT) and Baby has significant hypermobility of hips and spine/neck. When held in a baby carrier, Baby arches backward until back of head touches spine. When sitting in Mom’s lap facing Mom, Baby was completely folded forward in a pike position. Mom reports that Baby is not crawling. Baby can propel along the floor and engages right side more than left when doing so.

I suggested getting rid of the scale. Mom is upsetting herself with the variation of transfer during day feeds and Baby is growing well so the information she is getting from the scale is not helping. I have suggested considering more CST, myotherapy, and/or OMM. I have given her sucking exercises to try and positioning suggestions.

I am wondering if anyone can recognize anything in this combination of feeding issues, prognathic mandible, deviation of mandible to left side, low tone, hypermobility, digestive problems, and nervousness around strangers. This mom is not enjoying breastfeeding, is getting little time out of the house, and very little sleep. She is hoping for some input on what type of therapy to pursue.

Laura Spitzfaden, LLLL, IBCLC

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