Try a special needs feeder.  Look at baby's position when breastfeeding or bottle-feeding - is the chin forward, shoulders rounded, back rounded, hips flexed?  I've noticed a lot of babies who get frenotomies done late instead of right after birth, develop bad (compensatory) "habits" of position which exacerbate "biting".  Prone positioning or kneeling prone position, may help with direct feedings.  A nipple shield (small) might help with keeping the tongue in place and facilitate cupping of the tongue.  Pacifier-pull exercises with baby in sitting position with back flexed, head over the shoulders, chin forward but neck slightly flexed.  Experiment on yourself, feel where your tongue goes in different body positions.  Think about how you use a straw with a nice thick shake or a drink box.  A little logical thinking can help you design good interventions.  I wouldn't use a 24 mm shield as I've found on tongue-tie babies, it tends to encourage more biting as baby's gums touch before the tongue draw and you have the bite reflex being stimulated.  With using the bottle - make sure mom has baby on his side to feed, not reclining as the chin tends to move backward, pulling the tongue back into positions used before frenotomy done.  Also, is mom massaging under the tongue to keep the area released?  This area can re-adhere as it heals unless it's kept released. 

-----Original Message-----
From: Lactation Information and Discussion [mailto:[log in to unmask]] On Behalf Of Anne Brown
Sent: Sunday, December 13, 2009 7:16 PM
Subject: sore nipples after frenotomy

It has been a while since I have posted but I need help with a client with a 7+ wk old who had a frenotomy for a type 4 ankyloglossia at 6 wks (office procedure, no anesthesia.)  Baby still has a chomping, vertical suck, a very small angle when suckling at breast and mom still has very sore nipples.  Mom does not want to stop breastfeeding, even temporarily to heal, and is having mood issues so I'm treading lightly.  Mom's milk supply is a little low and is supplementing with a small amount of formula after most feedings to keep baby's weight up.
Baby has much more motion to the tongue since frenotomy (extends past lips, lateralizes) but I still have not witnessed the baby touching the tongue to the roof of the mouth.
I sent mom home with the following plan:
-watch to see if baby uses tongue to touch roof of mouth -mupirocin to nipples -take some feedings off to heal nipples -continue bottle feeding with expressed breast milk and/or formula if baby seems hungry afterward (slow flow nipple) -tried a 24mm nipple shield to reduce mother's pain -cranio-sacral therapy for baby -counseling for mom for mood issues Does anyone have other ideas?  
Thanks for your input.
Annie Brown, FNP, IBCLC

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