Dear All,

I have had three cases which have been long term follow up ones with episodes of improvement and again regressing. I am looking for insights and what I might be missing.

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Case 3: Mom had a uneventful peaceful home birth. Mom contacted long distance me on phone at 3 weeks postpartum with itching and shooting pain in her breast. Guided her to follow thrush protocol. After 3 weeks of treatment, she reported 1 month of uneventful nursing.The
soreness progressed to laceration at the base of the nipples where the upper
jaw and lower jaw meet the nipple. Her gyneac recommended no direct breastfeeding for 3 weeks and the lacerations healed well. Baby was in combination of formula and expressed breastmilk until she traveled to meet me. Physical assessment showed baby with class 4 - thick labial frenulum and high palate. Deep attachement and positions shown to thge mom. We managed to get a Doc in her town to release the labial frenum. Possible slight tongue restriction (dint appear as posterior tongue tie) was untreated since mother reported episodes of intermittent uneventful nursing and I observed when eliciting sucking on finger of retracting tongue after 5 or 6 sucks with gumming. With labial frenum release, nipple distortion resolved completely. However, mom called me this morning to report pinkish nipple soreness since we met last 3 weeks ago. She has been following thrush protocol 2nd time. Clicking sounds persists during nursing especially on one breast. Baby is
 gaining well on exclusive breastfeeding. Although this time mom reports no lacerations like before frenectomy, she says soreness remains with worsening and no improvement. How long does it take for thrush to show improvement? What am I missing?

Case 2: Mom called me from the hospital after the birth of her baby premature by 8 weeks. Baby was fed with NGT and mom pumped milk for baby for several weeks until baby came home. Mom also managed to pump for other babies in the NICU. Baby went to breast but was reported to be extremely restless and painful breastfeeding and nipple distortion. Mom provided a lot of direct skin to skin contact. I saw the baby when baby was 9 weeks corrected age 1 week of age. Baby had gained with expressed breastmilk and was allowed to suckle for comfort for every feed. Assessment revealed a thick posterior tongue tie and thick labial frenum and a bubble palate. Frenectomy was stressful for baby as mom believes the doc made the experience quite stressful. This was only the 2nd frenectomy done by this doctor. Breastfeeding become almost painless except that mom felt a 10 percentage was still restricted. I insisted on after care as instructed by Dr. Kotlow. Mom says she
 followed it for 15 days. A week later she called in to say the pain has returned and she was sure the frenum has reattached. Baby is now on bottle with expressed milk. Mom is reluctant to redo the frenectomy due to stress last time. Did 15 days of after care massage not suffice? No other position helps the baby to remain stress free during the direct feeds for this baby. What are my options without a need for another frenectomy?

Case 1: I saw mom and baby at day 12 postpartum. Baby had caput succedaneum during prolonged peaceful water birth labor which ended up in an emergency cesarean. breastfeeding was extremely painful and unbearable with severe clamping and biting. Body work CST helped relax mom and baby but mom had impaired MER and could not express more than 10 to 20 ml for few weeks. Yoga, deep meditation helped with milk supply. Assessment on my finger clearly indicated posterior tongue tie with thick labial frenum and a high bubble palate and biting with every 2nd suck. The parents were turned away by city's ten top pediatricians, pediatric surgeon, and pediatric dentist stating baby had no TT and pain is normal in breastfeeding and stated mom had low threshold for pain!! After 13 weeks of disappointment and hunting Dr. Kotlow connected me with one laser dentist. He was open to trying and did the frenectomy 3 times to release lip and tongue little by little since
 this was the first time for him. Lip release turned out to be stressful for baby. Pain during breastfeeding reduced by 80 % but this mom too like case 2 mom said it was not complete. She was turned away by the doc saying he would not release more! This is same doc who worked on baby of case number 2. Mom has been very motivated, courageous and brave to try frenectomy with a doctor who was new to the procedure. Although I insisted for after care for frenectomy, mom followed doc advise of no aftercare since he claimed his laser equipment was advanced technology. The pain promptly returned after few weeks of nursing. I personally met the doc and convinced him to evaluate baby again. A 4th frenectomy was done. Mom stated the last experience had been very stressful since doc seemed rushed and unpleasant. However, pain while nursing did not reduced this time. Mom came in for a assessment. I was in for more challenge here I felt something hard in the
 center of the upper palate of baby. The hard bone like lump turned out to be palatal torus. This mom refused to express milk and she wants it direct breastfeeding but she also seemed done with any more pain. Her homeopath has given some medication for the torus. I helped mom to begin solids for baby since baby is 6 months now! Are they positions which I have not tried for such a condition for pain free nursing? What are the options with a palatal torus? what is the prognosis of this condition? Is the pain due to torus or is it still got to do with baby tongue? Mom is tired with all these challenges and wondering what more is in store.

These cases have taken intense working from me and moms and also constant counselling and support which to a point has been exhausting. But also has been immense learning experience for me about how difficult practical matters are to get a doc to really support in what you believe. I am looking forward for any insights comments and any sharing you may be able to provide for these cases.

Thank you for your valuable time, I consider this forum immensely supportive for our profession.

Take Care

Yasmin
MA,HDSE,CLEC,LLLL,IBCLC
www.nourishandnurture.in
Mumbai, India

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