Mary,
I share your concern about taking this baby off the breast. When a baby uses
proper suckling mechanics but is unsustained or ineffective, I prefer to
supplement at the breast.  Taking a willing baby off the breast might cause
unwillingness to breastfeed later.  Of course, I understand some moms need to
pump to allow nipple damage to heal, or to prevent further injury if the baby
is not responding to management improvements. IMHO, nipple damage is a signal
that the infant is not using proper suck mechanics, or not latched properly.
Positioning and support is essential to allow the infant the stability they
need to use their muscles properly, thus the role of malpositioning in sore
nipples.
        My usual procedure is to try the simple things first- improve
positioning and latch (deep attachement to breast); increase support (dancer
hand position, sublingual counterpressure, whatever); supplement at breast;
then direct suck interventions; re-assessing suck mechanics at each step.  I
prefer to utilize cup and fingerfeeding for infants who are unable to
breastfeed without great trauma to mom, choosing fingerfeeding for those who
need the tactile input on their tongue to stimulate tongue extension, and
choosing cup feeding for those who need to learn to eat with less tactile
input (kids addicted to bottle nipples particularly).
        For babies who exhibit unsustained suckling, I prefer to use active
supplementation- such as a syringe and feeding tube or a periodontal syringe.
 I find it is more effective than a gravity feed device, such as the SNS for
this indication, because mom can give a bolus when the baby stalls (as opposed
to rests or breathes).  I prefer gravity feed devices for relactation or long
term use.  Many of my clients are "working class" and cost of equipment is an
important factor.
        If baby is still doing serious damage to mom's nipples once
engorgement is resolved and positioning and latch are addressed, I would agree
with the need for some intervention for the infant's oral motor skills.  Suck
training a la Chele Marmet is just one of the effective options.
Catherine Watson Genna, IBCLC  NYC  [log in to unmask]