Dear Friends,
Please help.  I have practically promised the mother that I would get at least a second opinion from the best and brightest LCs around the globe, so someone please reply....

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.  Birthweight 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 ccs from her fuller side that the baby could eat for 15 minutes peacefully and then need second side.  Mom would pump off 40 ccs from that side and finish nursing.  Mom grew tired of pumping and cut back to 40 ccs and 20 ccs 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.  

We tried side lying and baby just lied there with the breast in his mouth, sucking here and there for about a minute and then again started gulping and struggling.  This time when he came off Mom's breast was dripping.  We tried with Mom on her back but the baby was miserable and wouldn't even try.  We even tried with a nipple shield, thinking that if she could slow the flow down with the sheild, she may be able to nurse the baby on the plane without too much hassle.  We soaked the sheild in ebm, dripped it on as he was latching but the baby would have nothing to do with it and screamed miserably.  He wouldn't even suck those few sucks that would get mom's milk flowing.

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 to have milk to drip on the sheild 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 suppy 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' collegues.  Perhaps he has some kind of sucking disorder.  The mom also claims that he has had a cold since he was born.

I hope that this is clear.  
Thank you so much,
Chayn in Israel IBCLC 


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