I have permission to post. I have been working with a mom for a week
now. Baby is now 5.5 weeks, was 4.5 weeks at the time. When I met
her, she had tiny blisters, scaling and bright pink nipples. She had
tiny cuts on her areolas, just where the baby's lower lip curled in.
Mom had already been given nystatin and a single dose of diflucan
before I met her. Ped has also prescribed nystatin for baby. When I
first saw her, the baby's bottom was bright red and broken down,
bowel movements were frequent and very liquid. Nystatin, as usual,
just made thing worse for mom and baby. Mom stopped it for both.
I suggested mom use GSE herself and discuss APNO with OB (mom was
only able to get APNO with miconazole cream, not powder. This was
very frustrating for me and the mom--OB was willing to order whatever
mom wanted, but getting ingredients was difficult. I also told mom to
eliminate her high sugar intake (she was very willing) and to use
vinegar in her laundry rinse. I was also concerned that mom might
have some additional bacterial infection, but was hoping the APNO
would be helpful. I suggested she use GSE and then calendula on baby
and he cleared in about 48 hours.
What I saw at breast was the baby with a very shallow latch, using
his lips to feed. There was no visible jaw excursion. Baby had a very
receded chin, very high, narrow palate. Tongue was absolutely flat,
very limited range of motion both towards the palate and laterally
and could not extend. There was little lingual frenulum visible,
however. Labial frenulum appeared normal. I referred mom for eval to
a ped, who was trained by Dr. Coryllos to clip posterior tt. I also
referred baby to CST, as he had a cesarean birth, very obvious facial
asymmetry, receding chin, was sleepy and had poor oral-motor
function. Mom stopped feeding at breast and pumped to heal nipples
(and baby was not going latch properly until clipping anyway, so more
damage was likely to occur until then). She has been using paced
feeding, but is using an Avent (this was the bottle she already had
on hand).
At ped appt on Tuesday, baby's weight gain was 1 oz per day. By mid-
week, nipples were beginning to heal, but mom had a rash now that had
spread up and around her breasts and down her trunk towards her
stomach. It was very itchy--did not look at all like yeast or like
her nipples had. I suggested she call her OB and see about an appt
with a dermatologist. Mom could not make any connection to the
topical applications of GSE or APNO as they were not being used in
such a broad area.
Frenulum was clipped 4 days ago (Wednesday), baby had been to CST
twice by then. Baby latched pretty well in ped's office and has only
done so once more since. Mom saw dermatologist Friday who said rash
was an allergic reaction. She stopped GSE and APNO--I told her to
also stop vinegar. (Mom is also taking fenugreek, but started this
after the rash had spread). We have been trying to balance her pain
with the need for baby to be at breast. I suggested she feed first
with bottle, finish at breast as often as possible. I also watched
her pump and suggested she get a larger size flange.
As of today, mom is feeling some burning again (this had stopped), so
she is back to APNO with no worsening of the rash. I suggested co-
bating and providing baby many opportunities to latch, not just when
he is hungry. I suggested she try a different bottle and even
possibly finger-feeding just a bit. I do have her doing some suck
training and she has been given exercises by the CST to help relax
his jaw. Baby's tongue has much greater range of motion and he
appears to not know what to do with it. When I saw him, on Thursday,
his lower lip was not flapping in and out like it had been, but he
was still very shallow. On the bottle, he seemed more disorganized
than before, but when I applied a tiny bit of pressure to his tongue
with the bottle nipple, he did much better. I was actually very happy
to see him have a harder time with the bottle, since it suggested
that there had been a functional shift.
Mom is also planning to take gentian violet tomorrow.
These are my questions.
What else can we do to get this baby to learn what to do with his
tongue? I have suggested a nipple shield, but told her we could only
do this if he can latch deeply enough with it on (as this has not
happened so far, it may not, but if there is some pain relief, she
may be more relaxed and it may work). Please consider that mom cannot
tolerate a lot of discomfort, although things are much better, she
has a lot of fear of it getting worse again. I again suggested
changing the bottle or finger-feeding (for a short time). I also
suggested we try him in the bath, lying down and self-attaching.
I have had lots of tongue-tie babies and most have not had such a
difficult time. What has worked for other mommies and babies?
Jennifer Tow, IBCLC, CT, USA
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