UPDATE (with apologies for a long post)

First of all, thank you to the Lactnetters who shared their time and expertise! It is so very valuable to have this community! I am deeply committed to this as a forum for learning, so I want to share what we have learned since my post.

It didn’t turn out to be overactive letdown, oversupply, or allergy issues. In fact, mom had undersupply issues. Mom took the baby to the ER on about day 38 because of baby’s nonstop feeding issues (detailed in original post below). In the ER, baby was diagnosed with laryngomalacia (LM). 

From The Childern’s Hopsital of Philladelphia: http://www.chop.edu/conditions-diseases/laryngomalacia, “Laryngomalacia is a congenital softening of the tissues of the larynx (voice box) above the vocal cords. This is the most common cause of noisy breathing in infancy. The laryngeal structure is malformed and floppy, causing the tissues to fall over the airway opening and partially block it.”

Most babies with LM don’t have feeding issues, but it is easy to imagine that if breathing is impaired, feeding issues become more likely. I suspect that this baby “made do” with less and less milk because that is all that she could tolerate and still keep up with her breathing. Mom’s body, then, responded by producing less milk. 

Baby’s weight history 
Birth: 8-7 (pounds-ounces)
3 days old: 8-1
14 d.o.: 8-10 (gained 0.8 oz./day since last weight)
32 d.o.: 9-3.6 (gained 0.5 oz./day since last weight -  on a very accurate scale at LC office)
38 d.o.: 9-4.4 (gained 0.16 oz./day since last weight - though we suspect that this scale in the ER might have under-weighed baby)
From the above, you can see that baby’s growth rate was slowing more as time went on. Baby was having fewer wet and poopy diapers - one poopy diaper in 24 hours a day or two before the trip to the ER. I’m so glad that mom elected to go to the ER to get help. Without that scope there, we wouldn’t have known what was wrong.

What has worked is to:
1. Make sure that baby is calm before trying to feed her. 
2. Feed baby from a bottle with a slow flow nipple. Baby receives predominantly breastmilk, but sometimes formula is needed as she is in a catch-up phase of growth. Mom continues to increase her milk supply with tons of pumping with a hospital-grade pump, and is up to 25 ounces per day - hooray! I have encouraged her that one day in the not-too-distant future, her supply will catch up with baby’s need (baby drinks 26-32 ounces per day). On a side note, mom was just diagnosed with iron-deficiency anemia, and I would guess (from my reading) that this may have slowed the process of boosting her milk supply. (It seems to me that there is seldom only one issue!)
3. Feed baby on her side (with her head higher than her torso) so that milk can pool in her cheek before she has to swallow. 
4. Watch for splayed fingers or toes, or a wrinkled forehead as signs of stress, and slow the feeding. (For the most part, baby is pacing her feedings well, but if she gets overwhelmed, mom and dad tip the bottle down to reduce the milk in the nipple, allowing her more time to breathe.)

In my first post, I said that there were feeding issues, but no stridor, and indeed, none was observed at first. In the following review, 4 of 21 (19%) infants with laryngomalacia presented with feeding issues BEFORE the onset of stridor: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1546273/pdf/archdisch00819-0057.pdf

Baby has an appointment with an ENT to assess for further tongue tie release, but we are keeping in mind the risk vs. benefit ratio of this procedure. TT release, if needed, will improve tongue motion, but at least in the short term, breathing and therefore feeding, will be more difficult due to pain.

Thank you again, wise ones, for many kind suggestions. Two heads really are better than one! And hundreds of heads... well, that borders on miraculous! 

Carolyn Donohoe Mather, MAS, RDN, LD, IBCLC
Honolulu, Hawaii
[log in to unmask]


Original post below:
PTP. Baby is 30 days old. It is taking mom 1.5 hours to get in 10 minutes of nursing at each breast, and she is exhausted. Baby has been exclusively breastfed. Breast only, until today when mom tried giving baby a bottle with pumped milk.

Current problem appears to be forceful MER. This is why I think so:
-Baby starts nursing, but about 2 minutes into the feeding, she begins gulping, breathes faster, sometimes holds her breath so she can keep gulping, then releases and cries. 
-At beginning of feeding, baby nurses 2-3 minutes, sometimes up to 5 minutes, then takes 20 minutes to burp and settle. With each new attempt, baby nurses for a shorter and shorter time before releasing the breast and crying. Each time mom spends 20 minutes trying to burp baby, change diaper if needed, and then try again. Burping really helps; baby is much more content at the breast afterwards if she has burped. Baby sometimes won't resume nursing until burped.
-Breath sounds are sometimes wet and gurgly. No stridor.
-(Forceful MER didn't seem to start until week 3.)

What we have discussed and/or mom has tried so far:
-Laid-back breastfeeding position (gravity probably helps, but not enough)
-More frequent (smaller) feedings 
-Mom has tried taking baby off right before the first MER, but finds it hard to coordinate
-Pump to relieve pressure only, then nurse on softened breast (have discussed the risk of increasing mom's milk supply, and the alternative of donating breastmilk if she has a large supply)
-pressure with a flat hand to reduce flow (a la Carol Chamblin, IBCLC)
-tried using a nipple shield, baby refused to latch
-as an experiment, tried to feed baby pumped milk, baby refused bottle with Medela Calma nipple, second time, baby licked the nipple and sucked enough to get some breastmilk on her lips, not sure if she ingested any milk

History and more details (for those who want all the info):
Mom primipara. Baby born full term 8# 7oz., nursed within first 30 minutes. Minimum weight at 3 days = 8# 1 oz. At 14 days wt = 8# 10 oz. Early breastfeeding went well, baby passed meconium on day 1. But baby began to have clicking sounds by day 3, even when appearing deeply latched. Tongue had good extension, but restricted elevation, so tongue-tie release was requested. About 5-7mm of the anterior frenulum was clipped with scissors. Elevation improved somewhat, breastfeeding sounds also improved somewhat, mother's pain reduced and nipples healed, so we left it at that. Baby has good movement of her neck to both sides, ruling out torticollis. Baby still has 4+ poopy diapers and multiple wet diapers, suggesting overall good intake. It takes mom 15 minutes to pump 50ml from one breast using a Medela Pump in Style.

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