Retraining a tongue-tied baby to suck after frenotomy

[Guest guest]

Hello all,

I have been seeing an epidemic (it seems) of tongue-tied babies lately. Two in the last week were 6 and 7 weeks old when they had the frenulum clipped. Both are still struggling with latch. I would appreciate any input here.

Case 1:

34-weeker. Mom pumping and working on latch. Finally called for a consultation at almost 6 weeks. Mom was producing about 4oz every three hours from weeks 1-4 then supply rapidly dropped. Mom getting ~1oz every 3 hours. Baby fussy and angry at breast. Baby has never sustained a latch for more than 30seconds at a time. Never had a full feeding at the breast. Pedi encouraging mom to give baby 3-4oz after each feeding at breast. When I saw the dyad it was immediately obvious that baby could not sustain latch due to tight frenulum (classic tongue-tie). Mom said neonatoligist mentioned it in the hospital but never told her it would affect breastfeeding. Mom saw ENT Saturday and had frenotomy. She stated baby latched well once yesterday and had a great feeding at the breast. Every feeding since then she has gone back to crying/fighting at the breast. I am going back for a follow-up this evening and would love to have any tips on helping this dyad.

Case 2:

Saw this mom at hospital breastfeeding support group. Baby born full term. Gaining weight well. Mom reports baby does not sustain latch, clicks during feeding, repeatedly looses suction and "readjusts". Mom feels milk supply is faltering. Upon oral examination, baby bunches up tongue in the back and there is no obvious frenulum. High palate and baby does not elevate tongue tip. Mom addressed the issue with her pediatrician who referred her to local ENT. The frenulum was clipped last week. Saw dyad again on Friday, tongue appears to be free bu baby still bunches the tongue in back. We were able to coax him to keep his tongue down briefly and he nursed well for about 5 minutes, then reverted to clicking and shallow latch again. I advised the mom to try "walking" her finger down his tongue (back to front) several times per day to try to help him keep his tongue down. Any other suggestions? Unfortunately, I will not see this mom again as they are moving to Montana for a month and then on to Madagascar for three years. Mom is very stresses about not getting this resolved before moving and will continue to communicate via email.

Thanks for any advice/help.

Mellanie Sheppard, IBCLC

Arlington, TX

p.s. Sorry for any typos or if anything is unclear. My primary job as MOM is demading my attention now and I don't have time to proofread. :-)

[Guest guest]

Case 1:

34-weeker. Mom pumping and working on latch. Finally called for a consultation at almost 6 weeks. Mom was producing about 4oz every three hours from weeks 1-4 then supply rapidly dropped. Mom getting ~1oz every 3 hours. Baby fussy and angry at breast. Baby has never sustained a latch for more than 30seconds at a time. Never had a full feeding at the breast. Pedi encouraging mom to give baby 3-4oz after each feeding at breast. When I saw the dyad it was immediately obvious that baby could not sustain latch due to tight frenulum (classic tongue-tie). Mom said neonatoligist mentioned it in the hospital but never told her it would affect breastfeeding. Mom saw ENT Saturday and had frenotomy. She stated baby latched well once yesterday and had a great feeding at the breast. Every feeding since then she has gone back to crying/fighting at the breast. I am going back for a follow-up this evening and would love to have any tips on helping this dyad.

Many babies will excitedly play with their newly liberated tongue, extending it and moving it with joy. However, they do not necessarily apply this new ability to the feeding process.

I have had success with the following:*** Finger feeding (= suck training, but offers the incentive and reward of milk flowing) This gives Mom a feel for when the baby is starting to groove tongue and depress the humped posterior tongue. For some babies, they will not return to breast if all is not working smoothly first. FFing gives you that information. I had one client who was soooo anxious to return baby to breast. Baby was striking: refusing to go to breast prior to the clipping. She didn't realize that she could breastfeed better yet. So, once B was extending her tongue and grooving her tongue, mother started more STS to encourage her to self-attach. It took about 24 hours after the initial attempt AFTER baby was correctly using her tongue.

*** STS, very important to have mom and baby doing this during all of this stage, helps to set them up biologically in this instinctive position.

*** Bottle first method. Use your alternative feeding method that mother had already been doing. Give the baby the easiest feeding method first, then as satiety approaches (I help the mom look for cues rather than a set amount of fluid), move the baby to the breast after possibly doing a quick suck training or not, depending on the baby's mood and patience.

** However, the single most effective follow-up to frenotomy for my clients has been Craniosacral Therapy. This gentle hands-on form of body work helps by (as pointed out by a poster to Lactnet): releasing overdeveloped muscles, waking up the underdeveloped muscles and releasing the previous pattern they had been compensating with.

Prior to learning about and finding CST, clients struggled for weeks and months post frenotomy with issues of;

** persistent variation in infant palate (high, domed, arched, bubble, fast sloping, etc.)

** persistent compensatory movements of tongue, lips and jaw;

** persistent humping of posterior tongue

** persistent lack of grooving and extension of tongue during feeding.

as evidenced by continuing difficulties with latch and suck and nipple pain. Not at the same level as pre-clipping, but discouraging and frustrating.

CST resolves all of these issues.

Just had a client return a pump yesterday. Her daughter had been born at 36 wks GA, baby was in the NICU for obstructive apnea, they rented a pump from me. I didn't hear from them for some time, assuming that this was just a near termer and time would be the tincture needed. She called me for a consult at 4 weeks + 1 day b/c of difficulties latching, wanting to get off a nipple shield, still pumping b/c of baby's poor feeds. I assessed a Type 3 posterior TT. In addition, baby had some postural issues, mild torticollis. She was not opening her mouth wide enough, not flanging her upper lip. She was a messy feeder at breast and on bottle.

Frenotomy was performed 8 days later. Parents were doing sucking exercises immediately post-frenotomy with some limited improvement noted. CST was begun several days post-frenotomy, with significant improvement in latch, suck and flanging of lips noticed with each CST treatment. Baby's posture improved, she had complete range of motion of her neck. She was flanging her lips, feeding effectively and comfortably and easily. Mother is so pleased with the results of the frenotomy AND the CST.

An additional factor that was pointed out to me by Genna is that babies post frenotomy will make an easier and better transition if mother has more than ample milk production. If milk production is lagging behind baby's needs, it will make the transition to the breast more difficult. I have found this to be true. If M production is marginal or almost what baby needs, they sometimes never make the transition. Of course, a huge factor is how soon after birth baby's TT is assessed and clipped.

I, too, have had so many babies in the last 6 months. 13 posterior TTs in a 6 week period in Oct-Nov, and 10 in a two month period April to May.Ann See what's free at AOL.com.

[Guest guest]

Thanks so much Ann & Christie for your valuable input.

I saw the mom with the 34-weeker (now 40 weeks) last night. There are still many issues at play here. First, I am really not sure the frenulum was clipped properly. It appeared that the frenumlum was cut almost vertically and was not cut all the way through, leaving an open flap and not quite freeing the tongue. The mom is very upset that it may have to be done again. I advised her to either follow up with her pediatrician or seek a second opinion from another ENT. She is worried that her pediatrician will be upset that she had the tongue clipped. Hopefully she will follow up with a more knowledgeable ENT. gave her a reference for a good one, but they went with someone her husband knew. I wish I had a picture of what the tongue looks like now. I have never seen anything like it.

We did introduce finger feeding using a 5-fr feeding tube and mom was thrilled with this option. She feels that the bottle is just reinforcing her daughters frustration at the breast. We gave baby one ounce via finger feeding and attempted a feeding at the breast with the nipple shield and tube. Baby refused to latch. She was grunting, squirming, pushing and crying. I believe reflux may have been contributing to her discomfort at the breast, based on her posturing. Baby is on reflux meds but mom feels they need to be adjusted, as she has not seen much improvement. Baby never did latch, even when we filled the tip of the nipple shield with milk. Mom was a little discouraged but is still wanting to work on it. Our current plan is to continue to work on moms supply (she has increased pumping with Symphony, has started fenugreek & blessed thistle and is getting better MER since switching to hands free pumping and doing STS prior), continue with finger-feeding with tube, follow up with pedi or ENT, lots of STS. I advised her to offer the breast but not "fight" baby over it. We also practiced with positioning in a more upright football hold to help with possible reflux issues. I discussed CST or chiro with her and she said she will "keep it in the back of her mind."

I will pass on the info that you gave Ann and maybe that will encourage her to consider it a little more seriously.

Oh, and to top it off, baby appears to have developed an umbilical hernia since I last saw her, giving mom yet another thing to worry about.

Thanks again for your advise.

Mellanie Sheppard

p.s. Just an interesting side note: As I was discussing fenugreek, etc with the mom last nigt we made an interesting discovery. She had been taking Nature's Herbs brand fenugreek and saw a significant increase (was up to pumping 4oz at a time). She ran out and sent her husband for more. He bought the Vitamin World brand and a few days after mom started on it is when her supply abruptly dropped. She ordered more of the Nature's Way brand and will begin taking it today or tomorrow. It will be interesting to see what happens with her supply.

Retraining a tongue-tied baby to suck after frenotomy

Hello all,

I have been seeing an epidemic (it seems) of tongue-tied babies lately. Two in the last week were 6 and 7 weeks old when they had the frenulum clipped. Both are still struggling with latch. I would appreciate any input here.

Case 1:

34-weeker. Mom pumping and working on latch. Finally called for a consultation at almost 6 weeks. Mom was producing about 4oz every three hours from weeks 1-4 then supply rapidly dropped. Mom getting ~1oz every 3 hours. Baby fussy and angry at breast. Baby has never sustained a latch for more than 30seconds at a time. Never had a full feeding at the breast. Pedi encouraging mom to give baby 3-4oz after each feeding at breast. When I saw the dyad it was immediately obvious that baby could not sustain latch due to tight frenulum (classic tongue-tie). Mom said neonatoligist mentioned it in the hospital but never told her it would affect breastfeeding. Mom saw ENT Saturday and had frenotomy. She stated baby latched well once yesterday and had a great feeding at the breast. Every feeding since then she has gone back to crying/fighting at the breast. I am going back for a follow-up this evening and would love to have any tips on helping this dyad.

Case 2:

Saw this mom at hospital breastfeeding support group. Baby born full term. Gaining weight well. Mom reports baby does not sustain latch, clicks during feeding, repeatedly looses suction and "readjusts". Mom feels milk supply is faltering. Upon oral examination, baby bunches up tongue in the back and there is no obvious frenulum. High palate and baby does not elevate tongue tip. Mom addressed the issue with her pediatrician who referred her to local ENT. The frenulum was clipped last week. Saw dyad again on Friday, tongue appears to be free bu baby still bunches the tongue in back. We were able to coax him to keep his tongue down briefly and he nursed well for about 5 minutes, then reverted to clicking and shallow latch again. I advised the mom to try "walking" her finger down his tongue (back to front) several times per day to try to help him keep his tongue down. Any other suggestions? Unfortunately, I will not see this mom again as they are moving to Montana for a month and then on to Madagascar for three years. Mom is very stresses about not getting this resolved before moving and will continue to communicate via email.

Thanks for any advice/help.

Mellanie Sheppard, IBCLC

Arlington, TX

p.s. Sorry for any typos or if anything is unclear. My primary job as MOM is demading my attention now and I don't have time to proofread. :-)

[Guest guest]

Case 2:

Saw this mom at hospital breastfeeding support group. Baby born full term. Gaining weight well. Mom reports baby does not sustain latch, clicks during feeding, repeatedly looses suction and "readjusts". Mom feels milk supply is faltering. Upon oral examination, baby bunches up tongue in the back and there is no obvious frenulum. High palate and baby does not elevate tongue tip. Mom addressed the issue with her pediatrician who referred her to local ENT. The frenulum was clipped last week. Saw dyad again on Friday, tongue appears to be free bu baby still bunches the tongue in back. We were able to coax him to keep his tongue down briefly and he nursed well for about 5 minutes, then reverted to clicking and shallow latch again. I advised the mom to try "walking" her finger down his tongue (back to front) several times per day to try to help him keep his tongue down. Any other suggestions? Unfortunately, I will not see this mom again as they are moving to Montana for a month and then on to Madagascar for three years. Mom is very stresses about not getting this resolved before moving and will continue to communicate via email.

What is mom's milk production like? Is it still faltering?

If so, that may be why you see the baby reverting to previous sucking behaviors. He is struggling to make it work and when he is frustrated or fatigued he reverts to the old habits during the feed.

This baby might benefit from the mother doing some serious pumping to increase her milk production and/or follow Tina Smillie's information (dubbed "bottle first") which is in the files section of this yahoo group. By feeding the baby via bottle (using paced methods) or other alternative feeding methods, you meet the baby's need for immediate fast flow, satisfying hunger and thirst more easily. As satiety approaches and baby is more relaxed, he may be able to use the more correct sucking methods at breast, and reach satiety at the breast..happily. Then as baby does this more consistently, you decrease the amount of milk fed to the baby via the alternative and move to the breast earlier and earlier in the feed until baby is not needing the alternative feeding method.

It doesn't always work, but it is an effective tool for many women and babies.

Again, I have found that the fastest resolution to post-clipping issues that persist, is Craniosacral Therapy. Or try Infant Chiropractic if they are more inclined toward that.

I would also sg to this mom that she go to the Upledger website to see if anyone in Montana is certified as a Craniosacral Therapy practitioner. Oops, I went to the Upledger website and it didn't have any "Find a practitioner" option, so I called them.

To find a CST practitioner, the mom should go to www.iahp.com. Click on "Search for a practitioner".

When she has names of people certified in CST who live in Montana, they should have had several of the courses, have had lots of experience with infants and be willing to give names of clients who can share their experiences. Ask if they do work in the baby's mouth. I have eliminated several CST practitioners b/c they did not do that kind of work. If they don't work in the mouth they will not help resolve palatal issues.

Hope this helps,

Ann See what's free at AOL.com.