Hello, again, Cherie.
       When you observed a feeding session, baby gained only 2 oz. after
nursing on both breasts.  Although he coughed and sputtered at letdown, that only
indicates that he is having trouble managing the flow at initial letdown.  It
does not automatically indicate that mother has too much milk.  Taking in only
2 oz. after feeding from both breasts would not indicate that mother has an
oversupply.  He probably needed that second breast to feel full, and just
getting an extra trickle of higher-calorie hindmilk by staying on one breast longer
won't fill the baby if mom doesn't have an oversupply.
       You also mention that baby is moving his tongue back and forth on your
finger when you do a digital exam.  Although newborns sometimes move their
tongue back and forth in the first couple of days, they need to change to
basically holding still and moving the tongue in a wavelike motion, rather than
moving tongue back and forth (in and out).  If they don't make the switch in a
couple of days, these are the moms who show up by day 5-7, incredibly sore from
the friction of the baby's constant tongue motion!  This could definitely
explain why mom has red nipples that are losing some skin, and why mom reports that
baby's tongue feels like sandpaper.  Because he is not moving his tongue
properly, that might also explain why he is having trouble managing the stronger
flow of the initial letdown.  Sometimes babies move the tongue in and out if
they have a frenulum that does not allow free movement of the tongue.  Frenulums
can cause problems even if they are only a tiny bit extended; they don't have
to go all the way to the tip of the tongue to impede tongue function.  Some
of these babies know their tongue is supposed to be over the gumline, so they
push the tongue forward.  But then they get tired, and the frenulum snaps the
tongue back into the mouth.  Again, baby tries to push the tongue out where it
should be.  Throughout the feeding, these little ones are fighting valiantly
to keep the tongue out over the gumline, but the frenulum keeps pulling it
back.  This can lead to mom having very sore nipples, and baby getting too tired
to finish the feeding (such as when he fell asleep after 5 minutes on second
breast), and slow weight gain.  Other times, the inappropriate tongue motion has
nothing to do with the frenulum.  Some of these babies are helped by
CranioSacral Therapy.
       I have also worked with three babies who did not stool easily and did
not nurse well, and moms had to feed frequently to allow baby to accomplish
any weight gain.  In all three of these babies, it turned out that a vertebra
had twisted (probably during the birth process) and was riding on the nerve that
controls the intestines.  Because the vertebra was riding on the nerve,
messages could not move well along the nerve, and the babies did not stool easily.
Therefore, because they were not emptying well, they were basically "full"
from colon to stomach, and they did not have lots of room for large feedings.
(These babies varied in degree of problem, from being able to eat almost
normally, but not stooling often enough and exhibiting a lot of discomfort before
being able to stool, to only releasing quarter-sized [U.S. coin] spots of stool
frequently through the day, and only being able to eat for 2 minutes after
each small stool, at which point she was full again.)  They showed signs of
reflux (there can be discomfort without spitting up, or there can be lots of
spitting), because there was nowhere for the food to go, but up the esophagus!
These babies were all helped by a pediatric chiropractor, though in each case it
took twice a week visits for several weeks before the problem was completely
resolved.  Here, I am lucky enough to have a chiropractor to refer to, who works
marvelously with babies, sets his fees for babies low so that money is not
the reason you aren't getting help for your baby, and he even accepts the
state's medical card so indigent patients can still see him.
       This definitely sounds like a case where there is more than one thing
going on!  It will take some detective work to figure it all out.  How
wonderful that this mom is so patient with the baby and so committed to
breastfeeding.
       Dee

Dee Kassing, BS, MLS, IBCLC
Collinsville, Illinois, in central USA

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