Spent most of the day with a one-day old infant.  Had been breastfed
soon after birth. Bottle fed next feeding because mom didn't feel up to
breastfeeding after C-section, and then had had a number of poor
breastfeeds.  When I helped the mother put the baby onto the breast,
infant would appear to have latched appropriately, but when she began to
suck, her cheeks would pull (dimple) in.  She would suck a few times and
then come off the breast when I finally let her stay on to see what she
would do.  Thought she had learned an inappropriate suck and developed a
flow preference from bottle feeding.  Tried a supplementer.  She liked
it.  Sucked mom's nipple and got milk.  Still dimpled--repeatedly.
Thought she had figured out how to make the supplementer work with a
straw.  Tried a nipple shield.  She got lots of milk, but still
dimpled.  The milk also seeped out around her lips.

Now I'm getting suspicious that there is more to this than I thought.
Checked her mouth.  Frenulum seems OK, but noted bubble palate.  Talked
to mom.  Not particularly enthusiastic about the concept of finger
feeding, but willing to try it and willing to pump. Wants to breastfeed,
but likes the idea of bottlefeeding better than finger feeding.

Call the pediatrician.  Had to talk with the on-call physician. Recite a
shortened version of the above.  Suggest the attending might want to
consult a speech pathologist.  (When I had mentioned this possibility to
mom, stated that she had needed some speech thereapy as a child.)
Doctor says, "Have you tried a bottle?"  I told her mom was open to this
and we would try it.  She said she would pass on my report to the
attending.

Went to mom's room.  Grandma is babysitting while mom is outside
smoking.  Baby is fussy.  I want to see how this baby sucks when she has
milk flow, so I finger feed the baby.  Baby initially has sort of a
fluttery tongue movement and minimal "in and out" movement, definitely
not enough to pull mom's nipple into her mouth and keep it there.
Initially she had a poor seal on the finger, but after practice had a
reasonably good suck and maintained a seal except for slight transitory
breaks in the seal toward to end of the feeding.

At the next feeding, mom put baby to breast.  Latch looked good.
Dimpling seemed a little less, but we didn't worry about it.  Mom felt
some pull and both mother and baby enjoyed the feeding.  Mom felt that
she had sucked for about 15 minute out of the 1 1/4 hour she was at
breast.  Infant didn't seem satisfied, so I taught mom to feed her with
a Haberman feeder (suggestion from a local LC whose brain I picked this
afternoon).  Baby did well.  Never saw any dimpling.  Maintained seal.
Took 22 cc in 15 minutes and was satisfied.

I taught mom to hand express and to pump.  She plans to offer breast,
supplement with Haberman, then maybe pump or hand express.

Night nurse says she heard at a conference done by a geneticist that
misshapen palates result from abnormal tongue movements and have
neurologic implications.  I personally prefer the thumbsucking theory.
It has much less scary implications.  What do you all think?

Please forgive the rambling.  Guess I would like some company when I get
this cases where I feel like I'm out of my depths and don't seem to be
able to effectively communicate my concerns (it's not just a
breastfeeding issue!) to the physician.

Thanks for listening.
Bonnie Jones, RN, ICCE, IBCLC
from the sunny S.W. USA