Jo, Is the baby trying to recover from a birth injury like a cephlahematoma or forceps brusing? Sometimes these or similar injuries make for very tight nursing patterns. Mostly I just support the milk supply and reassure mom that things will get better as baby recovers. Try to keep the baby at breast as much as nipples can tolerate it, but don't let mom suffer too much, either.Let her have 24 -36 hours on a pump to heal up if nec. then try again, or see if she can handle everyother feed on breast, etc. If baby is flexed at the hips this stabilizes the head and shoulders. If head is thrown back jaws will be tight and lips will pull in. For looser lips flex the hips. An interesting irony about extreme reactions to stimuli is that they are sometimes caused by low tone -- i.e. baby can't get good feedback because of some (hopefully temporary) neurological issue. Consequently, baby over-reacts to things with exaggerated responses in order to 'feel' the nipple in his mouth. Could be baby has the opposite problem and is hypertonic -- overwhelmed by so many stimuli that he too has exagerated responses. I look at body posture to see what baby does when not at breast for clues. I still think LCs need more interaction with PTs and we need to read the PT lit. Could be something simple like the breast is heavy and not being well supported and baby has to clench to hang on. Could be baby is just latched too close to nipple. What shape are the nipples when baby comes off? If they are round then that's not it. If they are shaped like an orthodontic (sic) teat w/ a flattened edge and a crease across the tip, then baby is mashing nipple with bottom jaw closure and nursing w/ a small mouth because of basic posistioning and latch problems no matter how it looks to the observer. There is no one answer that is always going to be 'right' in these situations. Just lots of careful observation needed. One of my favorite ref about positioning is Felicity Savage King's, Helping Mothers To Breastfeed (Nairobi, Kenya.). It gives permission to copy for ed. purposes, and I've had slides made of some of the extremely intelligent illustrations. I've really seen light bulbs go on when I've taught positioning with these illustrations. I certainly hope the ILCA conf. bookstore will stock this book again. That's where I got mine, and I've about worn it out. Barbara Wilson-Clay, BSE, IBCLC priv. pract. Austin, Tx