Friday, March 20, 2009

Tongue tie

Tongue tie is when the skin fold underneath the tongue (frenulum linguae) being too short/tight.

Tongue tie prevelance is suggested to be at aout 1 in 1000 newborn.

On observation, the tongue can be a 'heart shaped' - when the sides of the tongue roll up, but the front/middle doesn't, but not always. When the tongue is lifted up, if normal it should be on the roof of the mouth, if not, then the tight frenulum can been seen. Also the tongue will not be able to project beyond the lower gum line.

Symptoms of tongue tie are:
  • weak and intermitten suck:
  • innability to latch well onto breast
  • slow feeding
  • needing to feed often
  • eventually if undiagnosed, can be a cause of poor weight gain
Treatment for tongue tie:
  • At home: Babies with tongue can't do the intial suck process of bringing the tongue out to bring the nipple into the mouth. Therefore, 1)try bringing your nipple to the baby's mouth. To make the child open the mouth, put their chin to the areolar area and the nose to the nipple. 2) thry shaping the breast to make a mouthful shape and bring towards baby.
  • Medical intervention: Not all paediatricians agree, but by snipping the frenulum linguae, babies have been reported to suck harder, feeding becomes easier and quicker, and weight gain begins faster again. This is a simple in-office treatment.

Thursday, March 19, 2009

Turning a breech baby

What if the baby is in a breech position? This is the baby in the postion where the bum in heading down towards the pelvis and the head is up.

Obviously this is not going to be a good position for baby or Mum. Trying to push the largest part of the body out first is not the way to go... So what can we do to turn the child?

There is a technique used by the gynaecologists/obstetricians that is pretty hectic for the child, called external cephalic version. This is when the doctor forces the baby around by pushing on the mother's belly. This technique is usually reserved until 34 weeks of the pregnancy onwards. This is performed in the hospital with a team on standby.

Another technique is the 'Webster technique' peformed by chiropractors. The idea is to help the pelvis open up (by working on the back of the pelvis) and avoid any torsion/ unequal movement from side to side, that may cause the baby to avoid lying in the head-down position.

But what can we do at home?
The idea here is to get the heaviest part of the baby - i.e. bum, to be nearer the upper part of the mother's body. Apparently, drinking a glass of juice before doing the exercises (but not so much to cause a full stomach) can increase the baby's movements. The baby likes the sugar high!

Exercises include:
  • lying on back with pillows under bum, therefore allowing the baby's bum to go towards to the diaphragm. Lie here for a long as you can at a time. If you get light-headed or get palpatations, stop.
  • on all fours doing 'cat stretch' - meaning arching back up, and then lowering buttocks towards heels and arms reaching out forwards. Again, the mother's chest will be lower than the pelvis.
  • kneel at the top of steps/stairs, slowly walk your top body down 2-3 steps and hold for 10 mins. In this position your upper body is lower than your pelvis
  • Swimming on front- frontcrawl and breastroke. Avoiding doing frog's legs for the days that the baby is still in breech position. Only do frog's legs once baby is in the right position and you want the child to head further into the pelvis.

Avoiding posteriorly positioned babies

So, after talking about baby being in a posterior position (head facing outwards/back to back) in utero, what can we do to help baby turn the right way around?

The main understanding is that the child's back is the heaviest part of the body, so it will naturally try to fall into the position with the least resistance. Therefore, using common sense, the baby's back will fall to the back of the mother's body if you are: lying back in arm chairs (lazy boys - v. bad!), sitting in car seats and leaning back (no boy racer style driving!), and anything with your knees higher than your pelvis. Of course - all these positions are bad for the mother's back anyway. All these positions place the lumbar spine into flexion and create greater pressure on the pelvis and lumbosacral junction - not good.

Positions to avoid:
  • lying on back,
  • deep squatting (to avoid baby engaging into the pelvis when in the posterior position)
  • putting the feet up (with legs above hips)
  • swimming with 'frogs legs' (especially when baby in posterior position - again, to avoid engaging in the wrong position)
  • Crossing the legs. This reduces the amount of space in the front of the pelvis, and opens it up at the back. For a baby to go into anterior position there needs to be space at the front

If the baby is lying in the posterior position, the main aim at the beginning is to avoid the baby heading down further into the pelvis. If baby is too far down, it makes it harder for it to turn around. After the child has turned, then you can focus on getting the child further into the pelvis by doing the exercises like breastroke with frogs legs and deep squatting.

Positions to AID anterior positioning:
  • Kneeling, leaning forward
  • Moving around on all fours (longer than 5 mins)
  • Sit on a chair facing the back of it and leaning over
  • Sit on a wedge cushion in the car, desk chair
  • Swimming with your belly down - i.e. front crawl or breastroke. N.B. If you are trying to turn the baby, don't do frog's legs with breastroke, only do straight kicking of the legs. Only do the frog's legs when baby is in the anterior position and you want the child to settle deeper in the pelvis.
  • On all fours: rocking pelvis from side to side, around in circles, and the 'cat stretch' - arching back upwards.
  • Sleeping on your tummy (obviously support by lots of pillows).

Wednesday, March 11, 2009

Blood sugar level in neonate

I've had quite a few mums come to me explaining all about the ordeals they get after having their child in hospital - or one even fighting with the staff even before the babies were born!

It seems like at the moment the buzz word in the neonatal unit is 'glucose'. All the nursing staff seem to have it drummed into them that the new born must be monitored closely for their blood glucose level - to avoid hypoglycaemia.

So I set about trying to find what all the fuss is about.

Hypoglycaemia in the neonate seems to be linked to two important things (well as far as I have found out so far anyway). 1) the development of neurodevelopmental impairment and 2) jaundice/ kernicterus/ hyperbilirubinaemia - if the child has something called Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency.

Hypoglycaemia can be symptomatic and assymptomatic. Thats why the testing in the early hours after birth has to be so consistent. Symptomatic hypoglycaemia can be mild or severe - and as it usually goes in neonates: mild can turn into severe rapidly.

Symptoms of hypoglycaemia can be:
depression of cerebral function: lethargic, hypotonic (limp), poor feeder,weak cry, apnoeic, cyanotic or absent moro reflex
overstimulation of cerebral function: jittery infant with high pitched cry, fixed stare and fisting, abnormal eye movements or convulsions
and excessive sweating: speaks for itself, but may not be present in pre-term infants.

Babies most at risk are:
low birth weight for gestational age
wasted infants,
infants born of a diabetic mother.

Medical limits for glucose in neonate:
>2.0mmol/l (up to 7.0mmol/l): normal
1.5mmol/l -2.0 mmol/l: mild hypoglycaemia
>1.5mmol/l: severe hypoglycaemia VERY DANGEROUS!

SO what is the way of helping the baba naturally?!
1)Easy: go with the feeding of the infant as soon as possible - WITH MILK - meaning colostrum. Which leads me onto the next blog...
2) Keep the child warm. If the child is cold, they burn more energy to keep warm - meaning all the energy that they should have stored up whilst inutero - should be used. If this is all used up, then they can easily go into hypoglycaemia

Don't you think it makes sense in South Africa why the c-section babies (60% of births in SA!!!) are always watched closely - if they were pulled out 'early' - without storing all the fat energy to burn in the first few days - they are going to be low on energy and can easily go into mild hypoglycaemia early on before they can feed enough to get the energy up and live off mum's milk.