This baby clearly has problems coordinating suck, swallow, breathe.  I did a
little more researching and found an article in JHL from 1994 by Wolf and
Glass where they did a case study of a baby with laryngomalacia.  While I'm
not saying that this is the baby's problem, because the babies' symptoms are
similar wrt choking, sputtering and breathing problems (though I don't
recall that I heard you mention a stridor), it certainly has some
implications for other interventions that might help.  I think if this baby
is having this trouble with coordination, he could be tiring out after
handling the first let-down and unable to continue well.  One intervention
they used was one you said the HBLC recommended to the mom, but I didn't
hear if she's still doing it.  That is to pace the feed at the breast.  Take
him off after 4-6 swallows or whenever he starts to struggle.  Just as we
pace with a bottle to help a baby relax and trust that he's not going to be
overwhelmed, the same should work at the breast.  Also, neck extension is
especially important for a baby with such difficulties.  The (slightly
exaggerated even!) asymmetric latch might also help with swallowing and
breathing.  This mom will have to keep a towel or bottle handy for catching
milk when she takes the baby off periodically, but this would also ensure
the baby gets higher fat milk, rather than stopping the feed right at that
point.  That might lead to a more satisfied baby.  I must admit I don't
understand the reasoning for keeping the baby on during the highest flow
period, when it is most taxing to him and contains the lowest amount of fat
during the feeding, and removing him when the flow is slower and higher in
fat, which has already been identified as the easier flow for him to handle.
This mom surely needs to work on decreasing her supply but I would make sure
she is trying the above at the same time.

Marsha, whose research included a study that linked tracheomalacia and GER,
as well as milk intolerance and GER!

~~~~~~~~~~~~~~~~~Marsha Glass RN, BSN, IBCLC~~~~~~~~~~~~~~~~~~~~~
Mothers have as powerful an influence over the welfare of future generations
as all other earthly causes combined.
~~~~~~~~~~~~~~~~~~~~~~~~~John S. C. Abbot~~~~~~~~~~~~~~~~~~~~~~~~~

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