I see this all the time in "older" premies.

I think they often learn to pinch to slow the flow from mom's fast flow or a 
fast bottle (or probably both in this situation.)  Avent is fast and the 
nipple is too long for most newborns in my opinion.

I have found a nipple shield useful in this situation.  Do you know if this 
other LC used a small or larger size?  I would use the 24mm.  It can help 
break the spray from mom's letdown.  I also definitely would have her do 
some "suck training" between feeds to work the gag backwards, and I am not 
familiar with Dr Browns, but often use the playtex ventaire stage one nipple 
either wide or narrow based bottle, and get it all the way into mouth, so 
lips touch the plastic ring.  If they can't do it at first, push it a mm 
farther each feeding until they do.

This is such a frustrating situation...especially with twins.  Parents are 
exhausted, and it is difficult for them to see that it is worth trying 
anymore.

Good luck-

Kathy Leeper, MD, IBCLC
MilkWorks- Lincoln, NE

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