With a baby this underweight, I would very generously feed (easiest method)
probably by bottle or nursing supplementer at breast. I would likely offer
quite a bit more ounces, if milk transfer is 1 oz and pumping is up to 1.5
oz, I would likely supplement for around 20 to 25 oz total, or more if baby
wants. I would have very frequent weight checks, daily for a few days, and
then bi-weekly or weekly.

If I can prove that the baby is being offered sufficient volumes of milk
(breastmilk from breast, but I really would focus a couple days on ebm,
formula) BUT the baby is still not gaining weight well, then baby needs a
full medical evaluation for disease. This I would ascertain in about 24
hours.

The baby's activity may be his usual behavior pattern, but I doubt it if
several health care providers have identified an increased muscle tone or
activity or unusual movements. Or the baby's activity may be metabolic
disease or fretful hunger.
You said, "Consider pumping in middle of night when baby appears to prefer
sleeping and feeds less effectively" -- this could mean baby is missing a
significant amount of feed opportunities. And you said, "since baby seems
to keep large feedings down well" -- this could mean baby is finally sated
when he gets a good volume. Some mothers who are lean and athletic and do
not themselves consume an overabundance of calories, can sometimes
misinterpret the volumes necessary to grow an infant, the feeding cues, and
the value of the infant putting on weight steadily.

I wouldn't worry yet about the shallow palate or the nipple shield per se.
However, it would be very valuable to have an in-person assessment, as you
might see something very significant in person.

Laurie Wheeler RN MN IBCLC
MISSISSIPPI USA

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