Kittie Frantz often says, and I certainly agree with this, that when the
palate is oddly shaped, look for problems with the tongue.  It is the job of
the tongue during fetal formation to shape the palate.  High palates suggest
that the tongue couldn't adequately do that.  Sometimes the very receding
chin is related also to developmental issues when the tongue doesn't grow
forward, pulling the mandible with it.  If the tongue is oddly formed,
abnormally short, low tone, then swallowing is often compromised because the
tongue can't help form a good seal at the corners of the lips (thus creating
weak suction).  Also, swallowing is affected when an abnormally functioning
or formed tongue can't create an adequate central groove.  This contributes
to poor bolus formation and milk spilling, choking, etc.  The over-active
gag reflex  lends to the sense that maybe this is a baby with multiple
problems or markers for other problems that are showing up as early feeding
problems.  These issues are so often part of syndromic clusters.

  Sometimes there isn't much you can do, but an ENT evaluation of the
tongue, or a speech pathology referral might be appropriate to see if there
is some release that would help.  While frenuloplasty is a much more
involved proceedure than a simple frenotomy, some children will certainly
require this if they are struggling with real feeding problems.  This will
be a harder sell if the baby is growing ok and not manifesting any signs of
aspiration.

I like the idea that someone else mentioned of trying a mechanical assist
like a nipple shield.  Shields can reduce the work of feeding, and sometimes
the formed shape of the shield teat assists the tongue in forming a more
well-defined central groove.  Be careful to use the smallest size you can
fit the mom's nipple into as the bigger shields may penetrate too deeply and
constantly trigger the gag and create aversion.

Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com
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