Okay, I need help.  Permission to post:  I got involved with a case at about age 2 weeks for failure to gain weight.  There was suppressed milk supply at that time which has rapidly resolved with best pratices.  However, even at the initial consult, it was apparent that the baby was not effectively transferring milk.  Baby has full tongue mobility and no visible/palpable tongue or lip restrictions and can achieve deep latch in all positions (upright or laid-back).  Vacuum levels seem as expected - he does not lose latch easily while nursing and can easily transfer milk through a SNS.  There is no visible body assymmetrical  or unilateral positional preferencing.  (Non-traumatic, natural term birth.)  Palate visibly and palpably intact.  Mom reports his latch varies from "good" to "bad" repeatedly thoguhout every feeding, creating pain only during the "bad" moments.  Nothing done externally seems to resolve/change this cycle during his feedings.  There are significant nipple distortions after every latch which result in persistent vasospams.  These vasospasm only come on after latch and rapidly improve with usual measures.  Upon manual exam, he does varies how/where he holds his tongue while sucking - preferring to flatten and thrust.  He can extend, cup, elevate and lateralize and does move posterior tongue when sucking "right".  

Mom has chosen to primarily bottle supplement pc feedings for convenience and has resumed full-time work at PP Week 4 (Grrrrr).  It matters not if she has 1.5 oz or 5 oz in the breast, baby can only transfer 20-40ml of it in a 20-40 minute period.  Although he is happy to nurse and enjoys it, she is confident he is not emptying any breast at any feeding.  She has declined bodywork (at father's insistence).  I have observed that she is reporting large (4-5oz bottle-feeds or 2.5-4 oz post-feeding supplements - Yipes!), infrequent  meals (q3-4h) and is resistent to change due to unwillingness to "hear him cry" and stated desire to "get some sleep".

Here is the confusing part:  Now that he has gained back 1.6 pounds in two weeks and strengthened, I note that about half-way into each breastfeeding, he begins making soft, late expiratory stridor which persists into his sleep at the end of the feeding.  Mom reports that this sound is "his usual" and that it usually resolves before next meal.  He occasionally spits (usually after those large supplements) but never out his nose.  He has been to his doctor for "nasal congestion" and reflux or "other problems" have been dismissed.  (He can pace bottle-feed on a gently flanged nipple without leaking or other difficulty.)  We have experimented with nipple shield and he transfers even less milk with a properly fitted shield, yet he can drain a bottle in <15 minutes.  This is very perplexing to me.  If he can generate vacuum to transfer milk from a SNS and a bottle, why can't he transfer milk from the breast?  His palate is wide and smooth.  I initially thought the stridor and nasal congestion was from over-feeding, but do not understand why it begins during breastfeeding (when I can later confirm that he transferred only a small amount of milk).  My gut feeling is this is somehow all connected together but I can't put my finger on exactly how.  What am I missing?  

Suggestions welcomed!

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