This is moms first baby. Infant is a 7.5 week old at time of visit.
Concerns: Infant slow gaining.
Birth weight: 8.6
Current weight at time of visit was: 9.7 >> (Infant is 1 lb below normal birth weight.)
Intake: Mom had sore nipples, baby appeared always hungry. Was having 1 dirty diaper a day and 7 wets. Breastfeeding was taking 40 minutes. Baby getting 2 bottles a day with 3-4 oz of breastmilk.
Suck assessment: Infant had a weak suction. Tongue snaps back past the gum line during sucking, can not create a seal at breast, The tongue could not elevate. Had a slight heart shaped tongue. Medium barrier noted under tongue per Murphy Maneuver. Had an high arch palate.
Breastfeeding assessment: Infant had slurping and clicking noises at breast. Creates very little seal at breast. Had intermittent swallos. Infant was chomping and had disorganized feeding behavior. Infant appears stressed during swallowing. Dimpled cheeks noted. Little jaw glide. Infant popls off and on.
Thoughts: Infant has a posterior tongue tie and not using the lip or the tongue to help create seal at breast, therefore little milk transfer is taking place.
Plan of Care: Mom is to offer breast to infant, pump for 10 minutes afterwards and then bottle feed 3-4 oz – 8 times a day.
Referred mom how to pediatric dentist who would revise the lip. Referred mom to preferred ENT to revise the tongue. (It was important for this mom to use health care providers on her insurance plan, as she was on Medicaid.)
I also discussed how to do suck training and the importance of retraining infant.
Follow up visit 2 weeks later:
Mom took infant into pediatric dentist and he revised the upper labia frenulum. Mom took infant into the ENT the following day. His assessment thought the tongue looked fine and that the upper lip just needed revised. Mom insisted he do the frenectomy because of my assessment.
Current weight: 10.10 >> up 1 pound and 3 oz!!!!!!
Assessment: Mom reports that nipple pain is gone.
We did a pre and post weight and infant transferred 2 oz on left side. Less clicking heard, seal at the breast has improved, infant not so wiggly or struggles at breast.
Current plan: Pump 4 times a day. Offer 1 oz after each feed.
5 days later…weight check: 10.12. pounds
Mom is still pumping 3 times a day and infant only gets 6 oz daily of supplementation.
8 days later…weight check: 11.09 pounds
Pumping and Supplementation stopped.
7 days later…weight check: 12.2 pounds
3.5 weeks later…almost 5 months old…weight check: 14 pounds!!
Another success story!