The hoarse cry is extremely significant.  Hoarse cry, with or without
short cry duration, is a sign of a respiratory problem.  Some
possibilities include laryngomalacia and vocal cord paralysis.

The ears are also significant.  Most human genetic syndromes include
"lowset, malformed ears" as one of the signs.  (It was a joke in my
human genetics course.  Dr. Johnson would be listing the features of a
syndrome, then say "and.." and wait for the class to respond with
"lowset, malformed ears".  Made it impossible to forget this fact.)  Are
the ears lowset as well as malformed?  Usually the center of the ear
canal falls at the center of the eye in newborns.

As for the sensory deficits, while the facial nerve is a motor nerve
(according to my ancient Grant's Atlas of Anatomy), if there was
incorrect migration or differentiation of tissues sufficient to cause
absence of the depressor angularis oris muscle, there could certainly
have been incorrect signals to allow innervation by the sensory nerves
to occur.  With the baby's history, it does seem more likely that there
is actually a facial nerve palsy from the trauma of the forceps birth,
rather than a congenital absence of the muscle.  But then again, one
does not rule out the other.  If it is just a palsy of one (particularly
the mandibular) branch of the facial nerve, it should improve with time,
and the tongue should not be affected.

So what do we do for this little one?  The respiratory problem heralded
by the hoarse cry is probably at least partially responsible for the
slow feeding.  Feeding is aerobic exercise for babies, and those with
respiratory problems have low aerobic capacity.  They generally feed in
short sucking bursts, and then take long respiratory pauses, sometimes
with harsh "catch up" respiration. ( I have some great video of this
that I show during my anatomy and sucking lecture.)  They tire quickly.
 THe stress on the respiratory system increases proportionally with the
speed of fluid flow and bolus size.  Therefore, one must be careful in
using a supply line or lact-aid or sns with infants with respiratory
problems.  I'm not saying never to do it, but do carefully evaluate the
effect before leaving mom to use it alone.  From a respiratory
standpoint alone, the Haberman feeder can be a good tool to use, as it
allows the feeder to regulate the flow to what the baby can handle.  It
makes sense that this baby feeds better in sidelying, many babies are
able to handle flow better this way, perhaps because they allow excess
milk to flow into their cheek pouches, and perhaps because this position
prevents milk from flowing straight down their throats so they have more
time to organize a swallow.  In this baby's case, perhaps laying on the
side of the facial nerve palsy or muscle absence defect (which ever it
turns out to be) provides support to the face that allows the mouth to
function better.  I'd encourage mom to use that position when she can.
 For other feeding positions,  modify the dancer hand position to
provide support from mom's thumb along the side of the mandible to the
angle of the lip, right where the missing muscle would otherwise be.

I agree with limiting the breastfeeding time to better use mom and
baby's energy, and complement with an easier method for baby.  Did the
baby have any stridor while bottle feeding?  Any signs of stress during
bottle feeding (splayed fingers, wide eyes, noisy swallowing?).  If so,
I would try the Haberman, or at least pace the bottle feeding by holding
the bottle horizontally so the nipple is only half full of milk, and
take the bottle away whenever the baby displays stress (if the nipple is
rested on the baby's philtrum, just above the upper lip, the baby will
not cry, but will just root again when he is ready for more milk). (I
saw a little baby with a respiratory problem recently who was so
grateful for the pacing, he cooperated with it to the point of spitting
the bottle out when he needed a break.)

Finally, to the tongue issues.  One of the possible sucking
compensations for tongue tie is to use a munching movement of the jaw.
 Not truly tonic, as there is no difficulty releasing the bite, more a
normal phasic bite applied to the breast rather than solids.  Mom tends
to get some sore and/or bruised areas on her areola from the infant's
gums when they use this strategy.  The pistoning tongue movement can
also be a feature of tongue tie, especially when the posterior tongue
rises asymmetrically with the anterior tongue (the front stays down
more, and the back humps up more).  Is this what you noticed?  If a
tongue tie is interfering with this baby's sucking skills, and you have
an experienced doc to refer to for evaluation, I'd certainly recommend
this.  In the meantime, fingerfeeding may help, if baby can move milk
efficiently enough.

Good luck, this is certainly a challenging, multifaceted case.

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