Thank you so much for your prompt replies with all the great suggestions / information.

At yesterday's visit, the mother was able to achieve a comfortable latch by trying the lying down position again and for the first time, her nipple was beautifully rounded at the end of the feed instead of the usual pinched / ridged shape. Observationally, she has a much more capable approach to her baby and is less timid in her handling of him.

We have been using the asymetrical latch technique (as shown in the video "Follow Me Mum" and demonstrated by Kitty Franz. This baby is not great at maintaining a wide open mouth and the mother, with her large pendulous breasts is not easily able to catch the exact moment of opportunity to latch - very much a "hit-and-miss" affair. Lying down obviates the need of supporting the baby's head and adds support to her breast but when we tried this a few weeks back, the mother could not manage it without ending up in tears.

I agree that it is this baby's tongue that seems to be the root of the problem. I think the frenotomy was deep enough in that there is definitely much more freedom of movement but it is what happens during a feed that indicates all is not well. On digital assessment, this baby initially pulls his tongue back (bunching), then cups well and sucks well for a while before drawing it back again. (Lateralization is scored at 2 on the Hazelbaker ATLFF).  Visually at the breast, this is exactly what he does. Difficult latch, then does well with superb milk transfer (I can hear the milk pouring into the baby for a sustained 3 - 4 minutes without a break) and then he wriggles and starts munching (the mother's description).with only an occasional swallow. Palate is of normal range - not high or bubble shaped.

This is a very stressed mother and I have tried to keep interventions down to a bare minimum. She had tried nipple shields before my initial consult with her, and had not found them to be of use or comfortable, although she probably had not used them correctly. This baby can latch and do well, and I thought it would be better to work with that than re-introduce something she already had an aversion to. Test weighing would have been more than she could suffer through and I have judged that the baby's output has been sufficient not to warrent doing it. I will have to consider supplementation at the breast if the weigh on Friday does not elicit at least a 150 - 180g gain. This mother's breasts leak milk all over the place and her supply appears adequate at present.

I have been concerned about a yeast infection all along and together with the infection spreading from the nipple, considered that the APNO (still being applied) would be the easiest treatment. Perhaps I should add Gentian Violet? This mother automatically does breast compression.

CST therapy is not big here in SA but I will certainly research any update in this field.

The rolled up small towell under the breast did not seem to make a difference. 

I will keep in touch

Gratefully

Rose Gauld


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