Leslie, this part of your post caught my eye and started me thinking:

<She has bilateral nipple cracks on the upper tips. Infant was observed to have shallow latch and difficulty maintaining a good seal. Infant tested for suck, very tight mouth and jaw, he chomps down and does not tolerate any stimulus on either his palate or mid-tongue (response = gagging).>


Is the baby's weight gain adequate? That is, is baby actually removing an appropriate amount of milk at feedings? Or is he being fed EBM by some other route? Is the MER overactive? If so, is an antigravity position used for feeding? Has a careful check been done for any possible degree of tongue-tie and/or lip tie? Catherine Watson Genna's book "Supporting Sucking Skills" explains several of the symptoms you have described.  To me, many of the symptoms you describe also suggest that some craniosacral referral would be helpful. It seems important to be sure that the nerves that control the jaw and the lips, and the suckling and swallowing muscles themselves are not trapped by cranial sutures that have not yet returned their normal alignment post-birth, as they should have done within 5 days or so, regardless of how she gave birth. There is a description of this in Linda Smith's book "The Impact of Birth on Breastfeeding."


Gonneke is the go-to LC I go-to when I have difficulty in management of oversupply. With several mothers thus far, I have noted a tendency to "not hear" what I have explained to them about limiting "pumping for relief". Their discomfort (or fear of returning discomfort) seems to command their attention causing them to become so fearful of it's return that they want to "pump just a little more, or pump just a little sooner, or a little oftener than advised, just to feel sure . . . ." to avoid the return of the discomfort. I have noticed with several mothers that they feel so much relief immediately after pumping that they are convinced they have at last, really helped solve the problem. Whew!!! For some moms, relief, even if for a short while, "speaks" more convincingly to them than I have done, and the anticipation becomes a powerful motivator to avoid any chance of reoccurence. And so they are easily tempted to "jump the gun" by repeating temporary relief by pumping, even if previously warned to avoid giving in to the temptation! 


I think this is one reason Gonneke cautions us in her ery thorough article to continue to follow the mother closely till the problem can really be considered resolved, by the intervention itself, and by the mother's understanding and acceptance of the intervention so that she doesn't "accidentally" reverse the process at some point in the near future.


With one mother who volunteered to keep a log of feeding intervals, etc. herself, it was very helpful to go over the log (which breast when, for how long, how long a time since last breast used, etc.) and/or any pumping and amount from each side. I tried to use the information from the log to go over with her where the problem areas occurred, to be able to explain and re-explain to her the simplified version of FIL that I use. 


I try to explain simply that one of the many proteins in breast milk has a double job. 

        1) If it goes into the baby, its good for him/her. 

        2) If it remains inside the breast for an appropriate length of time (till the one breast is just almost about to feel definitely "very full") the protein's job is then to act like a traffic cop at rush hour (and I put my hand up traffic-cop like) and send signals to the milk making cells "Slow down, slow down, we don't want that much milk so soon." 


(And of course, I use the reverse analogy for mothers trying to build supply.) I also explain to mothers in either situation that milk production in that "relatively emptied" breast is much faster in the hour just after thorough removal of milk 


I am convinced that FIL on the inside of the breast is a far more effective treatment than cabbage, or anything else on the outside of the breast (except for possibly a firm breast binder like the ones I used to apply appropriately from the bottom up, 6 decades ago as a student nurse;-) 


(Because I saw the gentle, firm, constant external pressure over a much larger area than a bra can cover, promptly bring temporary comfort to so many very swollen moms back then, I, for one, cannot feel totally convinced that they were [and are] wrong in each and every situation. I can see how a short term (several hour) application could have a positive effect on lymphatic drainage of excess interstitial fluid at least. (This is a standard part of lymphatic drainage therapy in the resting breast.) Perhaps when breast fullness is due to milk actually present within the glandular ductal tissue, it might be a different matter. Back then, frequent milk removal from both breasts was not part of the "routine". I wonder if there is still anyone else around who has ever actually used a properly applied breast binder on a mom? I have never used one in the last 40 years, but I have really been tempted to offer to apply one, at least for a few hours, with more than one mother.) 


But that kind of thinking is no longer "in" for an "enlightened"  professional, nor is it likely ever again to be considered appropriate as even an empirical method of treatment, at least where I practice.  (Sigh!)


I hope my thoughts are of some help to you and the mom and baby.


K. Jean Cotterman RNC-E, IBCLC
WIC Vlunteer LC  Dayton OH

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