Catherine, I really liked your description of the good uses of
finger-feeding and your description of how to teach the baby's tongue what
to do.  I read this very carefully tonight, searching for something I
obviously missed today. However, there is a word that both you and Barbara
have used in recent posts - "proprioceptive".  Can you explain further what
this is, please?

Today I really needed some ideas.  I saw a 9 day old baby who has been
breastfeeding well, according to the mother, but had received a bottle of
formula, on the advice of a friend, one hour (!!) before coming to my
office.  Mom had sore nipples, and wished to "rest" them.  I provided a
pump, we discussed how much baby would need etc. then I persuaded her to
show me what the baby was doing, in order to try and find the cause of the
sore nipples.

Mother's nipples were an "easy" shape (very graspable, superficial abrasions
on the face of the nipple), but this baby was impossible to latch.  She has
a very large tongue, so that when she shuts her mouth the tongue protrudes
in the middle, almost like a third lip and on latching can be seen quite
easily over the bottom lip.  Baby would take a mouthful, compress the breast
tissue and then appear to slip off. We tried everything I could think of,
different positions, compressing the breast into a "sandwich", taking a
pinch of the areola and placing the nipple right up into the palate -
nothing worked and the nipple would appear to fold up on to the areola with
the tongue pushing it *out* of the mouth at each attempt.  Mom was not keen
to try a shield (which I thought would keep the tongue down and provide a
firmer nipple which could stimulate the palate).  Baby was becoming
increasingly frustrated, rooting everywhere, little arms flailing, so we put
the EBM in the bottle and offered it.  I was fascinated to see the bottle
teat being pushed *out* of the mouth in exactly the same way as the breast
nipple had been.  I have worked with babies with large tongues before where
this has not been a problem so this is something new to me.  Perhaps this is
just a case of a retracting tongue, but the tongue just happens to be
larger-than-"normal"??

I have suggested for the time being that mother attempt breastfeeding first
at every feed (on the least sore nipple, cup breast in a little wedge,
tickle lower lip to encourage wide gape with tongue down, draw baby in with
chin *very* close to breast) but that if the baby becomes frustrated she
should offer EBM in a bottle with a long rounded teat with a wide base (like
the A***t, if she can find one) in order to try and "teach" the baby to open
the mouth wide, and to teach the tongue to stay down.  Perhaps
finger-feeding would be more effective? Anything else? Does anyone have any
words of wisdom to offer?

Pamela Morrison IBCLC, Zimbabwe