I have mother's permission to post to ask for suggestions.
Baby is 2 months old and has never seemed to relax and enjoy feeding.
According to mother she chokes, and 'gasps for breath' during feeds.  She
also spits up more than mother feels is normal.  Mother had been very sore
earlier but is better now, after first trying silicone nipple shields and
then going over to pumping and feeding by bottle for the past few weeks.
Mother's soreness was exacerbated by shields, but baby seemed less stressed
when they were used.  Still, the pain led to mother deciding to pump
instead.  Weight gain has been excellent though has fallen off a bit since
bottle feeding of EBM began.  Baby is active, alert, and cheerful otherwise
but doesn't have a pleasant time breastfeeding.

She contacted me nearly a week ago, because she is unsatisfied with pumping
and bottle feeding, and baby was not enjoying attempts to get her back to
the breast.

I observed a feed the next day, and could not see anything obviously wrong
with latch visually, but there was a clicking sound with suckling and mother
felt discomfort when it was heard.  Baby was wiggly at the breast, squirming
as if trying to find a better position, though very willing to latch
repeatedly.  We tried maximizing extension of the neck and using an
exaggeratedly asymmetric latch, which made little difference in baby's
behavior.  Her oral cavity looks normal to me, and there is full tongue
mobility.
When the MER occurred, baby let go of the breast and just waited.  When she
is on the breast, milk frequently runs out of her nose.  This also happens
with bottles, according to mother.  At that point the baby will cry and
choke.  She also makes snorting noises like a little piglet when she is
hungry.

It looked to me like a combination of a few problems: overactive MER, likely
overproduction as well, and possibly a suck/swallow/breathing difficulty,
perhaps some kind of obstruction or laryngomalacia in baby.  Overlaid on
this was that baby was now accustomed to the flow and technique of a bottle.
I suggested several things.
1) one-sided feeding for 3 hours at a stretch to reduce overproduction
2) manual stimulation of MER, and waiting for it to subside before offering
baby breast
3) BFing positions with baby higher than breast
4) using finger feeding rather than bottles if baby doesn't stay on breast
long enough to soften it, or to satisfy her hunger.

After some days of doing this, mother reports baby seems to be less restless
and fussy since she started one-sided feeds.  Baby tolerates finger-feeding
better than any other method to date and is taking about twice as much milk
as she did from bottles, but mother would love to have her back at the
breast.  When she offers, it is just as stressful as it always has been, and
baby takes ages to feed, because she 'just latches and then doesn't DO
anything'.  Mother can feel that baby is using her tongue actively and
seemingly correctly while finger-feeding, but at the breast it seems she
doesn't do so.  Mother also reports, somewhat ashamedly, that baby uses a
pacifier, though only after mother is convinced that baby doesn't want milk
and won't settle by any other method.

I must be missing something here, I feel.  All suggestions welcome.  Please
cc me privately when you post to the list so I can find the responses
without sifting through digests.

Rachel Myr
Kristiansand, Norway

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