Hi Shannon,
These are the tough cases. Your assessment appears to be very
thorough. Here are some thoughts.

1. The baby may have a submucosal cleft or other hard to detect
anatomical variation, maybe tracheo/laryngeomalacia. May need a
swallow study?
2. The baby may have more trouble while bf, compared to bottlefeeding,
because the breast's flow is variable and the baby may 'shut down'
when he experiences the MER. If he experienced difficulty or
discomfort in breathing when the MER occurred, he may have learned to
suck in such a way as to not stimulate it???
3. I worry that mother may not be willing or able (full time
employment, referrals for baby and difficulty getting to and paying
for those) to work through these difficult issues. So I would try to
ensure that, even with bottlefeeding ebm, she knows how to feed/mother
responsively and does a great deal of comfort bf, skin to skin,
carrying, and responding to baby needs day and night, and for example,
never propping a bottle in later months (not safe for this baby
especially! but never a good idea).

p.s. I really like the description "suppressed milk supply." I don't
think I have heard that term before but it is more accurate than low
milk supply in this case.

Laurie Wheeler RN MN IBCLC
Mississippi USA

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