Update:  Followed up again today with the previously 5-week old infant (now 9 weeks), with the history of reflux, over-producing mom, and repeated weak seal lacking vacuum.  It was general consensus by most that this mother's rapid MER and state of over-production were likely the primary root cause of our problems at the time.  It has taken persistent coaching and encouragement, but mom has finally cut out the pumping.  At first, she was only willing to cut out the after-feeding pumpings, but added in pre-feeding pumpings "to make sure she gets her hindmilk".  When she slowly began to notice the improvement in latch with this change, she trusted the advice to just cut out all the pumping.  Baby had a brief period of foremilk overload and survival nursing skills akicked in again, but as supply/demand began to even out, things have improved.  Today, this little girl weighed 11lb 11oz (birth weight was about 8lb 6oz).  She latched in a beautiful upright, anatomically comfortable position and latched on with eagerness.  During initial let-down, she briefly backed off to "recover" from the flood and then demanded to continue right away and completed feeding with no additonal interruptions.  She gained 88 grams on one the one sided feeding and was content, alert and playful.  I stayed over to visit with mom, and just about 90 minutes later, she was stirring awake to request another feeding.  Now, here is the interesting part.  There was still some soft "clicking/smacking" noises intermittantly throughout the feeding (as you may recall, mom initally had consulted me about "all the air she is swallowing while nursing.")  It is much less than each previous time that I have observed her nurse.  There is a vacuum seal now with or without the sounds.  Having recently learned much from Dr. Lawrence Kotlow's PowerPoint, it is now obvious to us that she has a very tight upper lingual frenum.  As did her sibling, now aged two, with two very seperated upper incisors!  Thank you for all your help thinking this one through.  

Shannon Sanford, RN, IBCLC
Texas

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