Dear Friends,
On April 10th I wrote asking for help with a baby I had just seen.  Here is
an shorter version of what I wrote:



The mother called complaining that she has too much milk and her baby is
unable to cope with the flow, making nursing miserable.  As she needs to fly
with him to England on Tuesday (5 hour flight) she needs help fast.

Baby is a bit less than 6 weeks old.  Birth weight was 3.130, discharge
weight, 2 days old 3.060.  Today he weighs 4.420 (5 weeks, 5 days)

Mother reports that the baby nursed decently in the hospital except that he
didn't open his mouth wide enough.  She was in a bit of pain but nothing
terrible.  Baby got one bottle at night per mom's request.  Day 3, they went
home and the mom's milk came in and she had to pump to relieve herself of
engorgement.  Baby became fussy on the breast, choking sputtering and
pulling off.  The mother discovered that if she pumped 80 cc from her fuller
side that the baby could eat for 15 minutes peacefully and then need second
side.  Mom would pump off 40 cc from that side and finish nursing.  Mom grew
tired of pumping and cut back to 40 cc and 20 cc from fuller and less full
breast before each feed.  Baby nurses 5 minutes, gulping, comes off, gets
burped, goes back on, back and forth for a while until he is finally
satisfied.

Today I went to see her.  She tried to put the baby on without pumping
first.  Positioning was beautiful! Baby went on well but closed up quickly.
Within moments he was gulping and making high pitched noises and clearly
struggling.  Mom took him off and there were no spray, not even drips.  Her
nipple is a bit pinched but doesn't hurt at all.


Baby has normal bowel movements and does not spit up. Mother tried feeding
him with ebm from both a terrible fast flow nipple that she brought home
from the mother - baby rest home and a MAM nipple for newborns.  She said
that he choked on both.

The mother pumped  with an Avent hand pump  and she did not pump especially
quickly.  Before that she tried to squeeze some milk out with her hand but
got almost nothing, maybe a drip.  She is not uncomfortably full.

Watching baby cry I noticed that his tongue stays perfectly flat in his
mouth.  Upon oral exam, his palate felt higher than normal, like a dome.
While he was resting, he put his tongue up against his palate, in the dome.
He did not lateralize when I ran my fingers across his bottom biting
surface. No visible frenulum.  Unfortunately I had run out of tubes and
could not check his suck with a flow.

So I'm thinking that the baby has a submucosal tongue tie and lousy bolus
formation coupled with Mom's ample supply and he can't handle it. I
explained to the mother what I thought but she is reluctant to take him to
be clipped so I told her that I would check it out with a 'few' colleagues.
Perhaps he has some kind of sucking disorder.  The mom also claims that he
has had a cold since he was born.
Several of you responded that it does sound like a sub mucosal tt and should
be clipped.  I told the mother and she went to the doctor I suggested, had
it clipped and ran off to England without getting back to me.  In fact she
only called me again tonight.

Baby is now 4 months old and has had his frenulum clipped 4 times!  The
mother said that she noticed a marked improvement for about a week after the
3rd time and then he began the same behaviour so she took him back again 3
weeks ago and he is still miserable at the breast. He really only nurses at
night when he is asleep.  During the day he sucks a few times and comes off
screaming.  When the mother is not trying to feed him he is calm and happy
and sucking on his fingers (which he began after the 2nd or 3rd cut).  He
eats well about 4 times during the nights.  He has gained weight steadily
but nothing indicative of too much milk.   Mother says that he has lots of
wind even after a few sucks.  He is no better on the bottle.  Mother has
tried with several nipples and AIM with the same results as while
breastfeeding.  She would probably have quit all together if the baby would
take the bottle.
I would really appreciate your thoughts on what is happening with this dyad
and what steps to take next.
All the best,
Chayn Fogelman IBCLC Israel where it is already past everyone's bedtimes.

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