One can sometimes see this constellation in a baby who has trouble with 
milk flow. The bubble palate points to the presence of some tongue 
restriction, perhaps a posterior tongue tie. Sometimes infants with 
posterior tongue ties have more difficulty grooving the tongue than 
those with more obvious ties. As a result of the poor grooving, bolus 
control is imperfect, and the baby may aspirate. This is so painful, 
some babies start refusing to eat.

Signs that this might be the issue:
-increasing congestion throughout and after oral feeding.
-poorly timed respirations in relation to swallowing - isolated stridor 
caused by closure of the vocal folds when liquids contact them; gasping 
respirations after swallowing several times, etc
(you can get a really good idea what's happening with the swallow by 
listening with a stethescope over baby's throat or under the chin, which 
is called cervical auscultation. If you get used to listening to some 
infants that feed well and hear the one distinct sound of a clear, well 
managed swallow, you can learn to recognize incomplete clearing 
(multiple swallows needed to clear the pharynx) and poor coordination of 
swallowing and breathing).

If this does not seem to be the issue, perhaps there is sensory issue 
(though the hyper gag is commonly seen in infants with tongue 
restriction and palatal anomalies), or perhaps an anatomic respiratory 
issue such as velopharyngeal insufficiency, which can cause nasal reflux 
and lead to feeding resistence.

Sometimes the feeding resistence can be overcome by allowing the baby 
more control - offer the breast often but make no attempt to put the 
baby "on" the breast, let her latch or not latch.
Distraction is often helpful with 5 mo olds, play with some novel toys 
near the bare breast, and see if bringing her defenses down allows her 
to latch.
Maintaining a good milk supply is helpful, but if baby has difficulty 
handling milk flow, she might prefer the breast be partly pumped.
Allow her to come off the breast whenever she wants, make sure mom is 
not holding her head. A  good position is mom supine and baby prone on 
mom's chest. They can nap that way in bed or on the floor to help baby 
feel safe and make the breast available.

If none of this helps, Marsha Dunn Klein is an occupational therapist in 
Tucson, AZ who is skilled in getting to the bottom of and helping with 
feeding refusal. Her website is http://mealtimenotions.com/ . She is a 
lovely, gentle, and skilled woman, who understands the emotional 
importance of feeding and trusts that babies and children have reasons 
for their decisions about feeding.
Catherine Watson Genna, IBCLC  NYC

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