Infant Frenectomy Referrals

Lip Blisters:

Lip BlistersBlanchingDifficulty FlangingPt c/o Aerophagia/Gas/RefluxNo Deficits

Tongue Deficits:

Restricted LateralizationSignificant Jaw Movement with LatchDifficulty with Tongue ExtensionNo Significant Deficits Present TodayRestricted ElevationLoose CuppingSignificant Pull to Floor of MouthNo Significant White Coating

Please select any breastfeeding issues patielt is currently experiencing (may select more than one)

Baby always seems hungryBaby crying excessivelyBaby prefers one sideBaby not interested in nursingInfant choking when nursingInfant frequently spits upThrush/Yeast to Breast/Infant Mouth Breast PainNipple PainUsing nipple shieldLatching difficultiesLipstick shaped nipple after latchingWhite/Purple nipple after latching Compressed/Flattened nipple after latchingMastitisRecurrent clogged ductsCracked/Bleeding nipplesSuspected tongue/lip tieTongue/Lip Tie was releasedInsufficient wet diapersInfant falls asleep during nursing for less than 8-10 minutesBaby nursing more than 12 times per 24 hours

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