suspect this is the most complicated case I've seen in 30 years...

Called by mom of 5 week old whose baby was dx'd with TT over the phone (no
comment). Mom was using a nipple shield but felt baby wasn't transferring
well. When I watched baby feed, I realized the poor latch was not all - mom
had Type II hypoplastic breasts http://www.sonic.net/~mollyf/igt/  Baby had
slid to the 3rd percentile (birth weight was 25th percentile) even with
supplementation (via bottle, medela regular-old nipple).

Baby's latch was all over the place, with or without the shield. A digital
assessment showed baby could trough, lateralize, lift the tongue to the
roof of the month, and bring the tongue over the lips. There was good
strength to the suck, and a normal waving of the tongue with the suck. Once
mom started stabilizing the breast, baby could stay on, and over the weeks
the feeds continued to improve.

Slowly but surely mom's supply has increased (fenugreek, blessed thistle,
then goat's rue and then domperidone) to the point where she is now able to
feed/pump enough that the baby has all mom's own milk. (And has had three
plugged ducts.) Down to 1-3 bottles (~1.25oz each) per day. Baby's
preference is to feed ~q 2 hrs during the day and sleep one long stretch at
night (~7 hrs) which she has been doing pretty regularly for the past 4-6
weeks.

Two weeks ago (baby 11 weeks) the mom described the baby as "fussing around
at the breast" but of course everything looked wonderful when I saw them.
Maybe a bit of what I interpreted as 3 month old behaviors - too nosey to
settle down.  And the baby was getting closer to the weight we wanted.

Yesterday mom came - quite understandably in-between melt-downs - and I got
to see what she was talking about. Baby was all over the place - latched
on, arched her back, squirmed, came off. Kinda latched on the end of the
breast, pulled off to look around - of course with the nipple still in her
mouth. Mom describes this as happening whether the room is dark, light,
quiet, noisy. (I wondered about sensory overload.)  She transferred 30 cc
of milk while doing this - more than she used to get when we did "four
sides" at a feed. She then settled down and had a bottle of mom's own --
although she is  kind of messing around on the bottle nipple too. And her
suck still takes a while to organize if you give her a finger to suck.

MOM ADDS:
she is focused on feeding, wants more, but it seems like she is
experiencing some weird pain or reflex that won't allow her to get it.
pulls off even when milk is flowing.
sometimes just barely touches her lips to the breast and pulls away.
latch is either too loose or too shallow, or she latches deeply but pulls
the nipple away from my body,pulling it taught and out of the back of her
throat.
baby sometimes tries to nurse with nipple in side of her mouth.
when she arches or pulls her head away, i feel like she is frantic and
experiencing discomfort (pain or trouble breathing)
she sometimes passes gas when she arches
if i express milk while she is gumming the nipple, she sometimes pulls off,
sometimes suck-swallows.
often is whimpering throughout the entire process, squeeling if i try to
keep her from pulling off,  and cries when i take her off for any reason.
we often do better when she is sleepy
we are having some success today while she is sleepy and i rock her or
carry her around

Overnight mom says the baby nursed calmly for a short time when she nursed
her standing up, walking around!

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