Jeanette, 
Yes!  Good observations.  A couple thoughts from me...
Part 1:  In my experience, I believe that low oral tone/strength has a disaterous effect on breastfeeding, and is usually not recognized.  Not only does lack of lip tone/strength cause loss of vacuum, but many of these babies compensate for this low tone by pinching the nipple between the tongue and palate.   (the back of the mouth works overtime since the front of the mouth isn't doing it's part)  Sometimes we can have a clue by looking at the baby's mouth.  Are both lips visible?  Can you see the entire top lip at rest, or are the "sides" hidden?   Are the baby's lips visible while breastfeeding, or do they roll in?  With the bottle?  Ideally, we can see the the entire lip (top and bottom) while the baby feeds.  Sometimes the problem is not the lips, but the jaw.  If baby has an exaggerated downward movement, sometimes the lips will follow and break suction.  

Trying the usual things doesn't work, because the baby needs targeted strengthening, not just calories.  In the meantime, baby may not gain appropriately, and mother's milk supply may be in jeopardy.  After all, baby nurses "all the time" and mom doesn't realize things are going down hill while they try "the usual."   I agree with you that these babies often do not obtain enough milk with compression during nursing, and the sns usually doesn't help, either.  

A referral to an SLP or OT is a great place to start.  There is also a program in the US that can be helpful.  In Idaho, it's called the Infant-Toddler Program--but it is a federal program funded through IDEA.  It takes a doctor's referral, but then, often, the state pays for initial services with the SLP or OT.  Of course, there are qualification guidelines, but what a great resource to have.   I keep the referral form as well as a form letter I made for docs, to speed up the process.  I also have developed a working relationship with a couple SLPs/OTs who help speed up the process by adjusting their schedules to see new babies.

Part 2: the bottle.  Babies can have a terrible lip seal on a nipple for a few reasons.  With the babies you saw, it is probably related to low tone.  But for any baby, if the nipple shape isn't a good match for the baby's mouth, or if the nipple length is too long, or the base too wide, the lips will not seal; we will observe gaps in the corners of the baby's mouth, or leaking with a poor seal.  A different nipple shape needs to be tried in this case.  Also, if the flow is too fast, soem babies will keep the lip seal loose so the excess can run out.  Sometimes a baby will have a good seal on the breast but not the bottle, so a different shape is needed.  But often (like with your two babies) we don't noticed a poor seal on the breast if the baby is snuggled in tightly.  Chances are your babies have a poor seal on both breast and bottle.  However, you might be able to improve the baby's seal by choosing a different nipple in the meantime.  It won't improve strength, but will at least get the baby using better mouth placement while mom seeks further help.

Sorry I don't have a fast solution to share.  But yes--you are on to something!  
Amy Peterson, IBCLC
co-author Balancing Breast and Bottle: Reaching Your Breastfeeding Goals (written with an SLP after years of working together to resolve problems like the ones you decribed)





 

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