Marilyn, this is an extremely difficult and uncomfortable position to be in.
Be very careful suggesting a 2nd opinion, although certainly this baby
deserves one. If mother gives any indication that she is uncomfortable or
unsure about what the doctor is recommending and why, that is your chance to
say "are you thinking that you might want a second opinion? That is
certainly understandable and well w/i your rights."
Depending on how well you know the doctor and how much experience you have,
you could certainly suggest a couple other options and ask the physician if
s/he would consider those with very close followup for weights. You would
want to share that the mother truly wishes to continue bf.
This case seems to have many behavioral issues, that to me carry more weight
than the clinical ones. First, the baby lost 12 percent which is
significant. Not sure what the time frame was, but if that was lost in first
3 days, this dyad should have had followup. Subsequent to that, I calculate
154 oz gained in 90 days which is 1.7 oz per day, a good wt gain. So it
seems again to me the behavioral issues are interceding.
Mom seems to have normal supply, pumping 3 oz does not seem low to me. She
can pump 6 oz which is very good. (My kids grew great, I never could pump
much).  Even with a good feeding, if baby is only taking 5 or 6 a day, that
is not going to give the baby enough intake. Then you have the issues of the
baby being "ultra sensitive" perhaps a sensory disorder. The mom also seems
to be modest about feeding in public, and laid back (for lack of better
term) about baby going long stretches (to me) without eating. The situation
is surely multifactorial with tracheomalacia etc.
I would try to make the argument (if mom likes the sns) that as long as the
baby is getting the prescribed volume, the delivery system is up to the
mother. As long as you can assess and report that there are no increase in
untoward s/s when using the sns. On the other hand, if there is no way
around using a bottle, you could make the case that mother has  a good
supply and would s/he consider giving pumped milk supplement (instead of
formula) for 48 hrs and do a wt check. You might have to reassure the doctor
that the mother's milk is of a high quality and that baby just needs more
volume. Some of this is "all in the delivery" in that if you present your
case with politeness, respect, and confidence in your assessment, s/he might
listen.
Also, you would be surprised (or maybe not) how often the doctor does not
get the whole picture, but the LC or nurse talks longer and more to the
mother and picks up on other clues. In your case, does the doctor know that
baby is going long stretches w/o eating? That baby reacts adversely in busy
or noisy environments etc.?
If there is a developmental peds who is bf friendly, that would be a
suggestion to mom, so as to check out the behavioral issues. Also, there are
some docs who specialize in bf medicine, not sure if there would be one
nearby. We have one in Jackson Mississippi.
Hope some of this helps you,
laurie
Laurie Wheeler RN MN IBCLC
Mississippi USA

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