Tongue tie can cause inefficient feeding without causing pain.  Tongue
elevation is most restricted with a tongue tie (even a posterior one).
Peter Hartmann said (in light of Donna Ramsay's newest ultrasound during
sucking reserach in his lab) that the downward movement of the posterior
tongue is most important for removing milk from the breast.  If it did
not go up, it can't go down as much, therefore there is less milk per
suck, more sucks needed per feed to fill the belly, and more chance that
mom is going to not take the time to make sure baby is totally full.  I
have seen this cause reduced milk supply, gradually over time.

Some infants with tongue tie have difficulty handling a bolus of milk
for a controlled swallow, due to reduced grooving of the posterior
tongue.  Infants with this difficulty frequently resist any attempt to
increase the speed of flow, thus may refuse to feed with an sns.

I've also seen relatively mild cases of laryngomalacia contribute to
slow weight gain in infants.  If mom does not know to do shorter, more
frequent feeds to avoid overstressing the baby's respiratory capacity
(feeding is aerobic exercise, and the baby can only feed as long as they
can breathe well enough to sustain the energy and oxygenation level
necessary to support this work.).  Again, this is a subtle problem.
Yes, laryngomalacia and related conditions are self limiting, but some
babies get tired and give up feeding instead of getting totally satiated
and dropping off.  If they even take 5 calories less than they "should"
have per feeding, this gradually translates to a slowing of growth
velocity and milk supply.  Again, infants with more work of respiration
start to have sloppier coordination between swallowing and breathing as
the feeding progresses, which increases the risk of aspiration.  Even
microaspiration is darned uncomfortable.  Babies with a history of
aspiration are also going to resist increases in milk flow.  And they
are more likely to end a feeding prematurely, perhaps when they've taken
the edge off their hunger but before they're full enough to sustain
genetically programmed growth.

I was not trying to intimate that you "missed something", just laying
out two situations that I have seen be responsible for gradual
deteriorations in milk supply over time that many people would not
necessarily think of.  When someone as experienced as you posts to
Lactnet, I imagine you've looked at all the obvious stuff, and I'm
pulling out the not so usual for you to assess and see if they are
possibilities.

Hope this is coherent, I am exhausted.

--
Catherine Watson Genna, IBCLC  New York City  mailto:[log in to unmask]

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(R)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html