Jaye, The head sounds like this baby needs to be seen by a craniosacral 
therapist and a physical or occupational therapist. I would like to see 
if baby can do better with more flow at the breast -- but your 
description of aspiration bothers me. I find that babies used to bottles 
do not suck at the breast. They are used to swallowing the flow off the 
bottle nipple. It "looks" like sucking but if they do the same thing at 
the breast, they remove nothing.

What kind of bottles is mom using? I might suggest Dr Browns or a 
Habermann Feeder if baby is going gulp gulp gulp gulp then a quick and 
deep gasping breath on the bottle. Or pacing with a standard, non 
hospital bottle nipple, with only 3-4 sucks or jaw movements before 
removing the bottle nipple and placing it on his mouth. I like to watch 
these babies bottle feed as it can tell you a lot. Like if they gulp and 
gasp or if they are slow or if they can't grip with one of their lips or 
if they aspirate on the bottle. Bottle feeding problems are a huge red 
flag that gets the pedi's around here interested. If it is just breast, 
most pedi's ask mom in a negative way if she is sure she wants to go to 
all the trouble of seeing a SLP, etc.

That double nipple bottle (breast flow??) helped one of my babies who 
had trouble with swallowing. He did better on that bottle and choked 
less. But it can be tricky to put together.

With babies that seem to have oral motor issues, I like to do several 
test weights at the breast to see at what point baby stops removing 
milk. I find that SNSs don't usually work right with these oral motor 
babies, I guess their sucking is so ineffective or poor. But at the 
point where they are on the breast and not removing milk, I take them 
off and feed another way (usually bottle because we have to feed them in 
the easiest way as their weight gain is poor and feedings are so slow.) 
If you put these babies on a wide based bottle nipple and they can't 
grip with their top lip, this shows weakness and I always point that out 
in my HCP report as something I observed.

Also, I work with a lot of recessed chin babies because I seem to be the 
only one that can latch them on. (The trick is a deep asymetrical latch 
with the chin smooshed right in and the nose out, head tipped back a 
tiny bit, and body of baby tucked into mom's body. You put them on going 
in front ways or the old style and they can't latch right because their 
chin is hanging out.) I also see a lot of what I suspect are posterior 
tongue ties with those very recessed chins. One red flag is when the 
baby's top lip hangs out over the bottom lip with a gap or air space 
between them -- they don't meet at normal resting position.

This mother is fortunate to have your support and encouragement. She 
deserves a medal!
Kathy Eng, BSW, IBCLC

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