Karleen's post brings up an important point about the SNS.  One must pay
attention to whether it is helping the baby improve its suck or whether the
baby is getting used to the SNS flow.  This is a problem with ANY
supplemental feeding device.

I think it absolutely key to monitor progress in a breastfeeding support
group or small group clinic to make sure that the baby is starting to
transfer more milk from the breast and not relying on the SNS. I was
actually surprised at the amount of milk transfer using the largest tube.
Typically I see very little milk transfer using the large tube - but some
babies do NEED it until they get their act together. Then you can switch
them down to a smaller tube.

In terms of keeping the baby from "sucking on the tube", follow up is
critical to make sure that an appropriate flow is achieved.  That means the
baby doesn't tire out from working too hard and that the flow is slow
enough that the baby isn't getting too much milk too fast.

Also, from having followed up at least 4 recent cases of women who saw LCs
who used the SNS or die approach - sometimes switching to the bottle works.
All of these women had been using the tube on the breast for 3+ weeks with
no progress. Their babies were not compressing at the breast.  To put it
graphically - their sucks sucked.  For these particular babies it worked
like a charm.  I find you have to switch approaches when what you're doing
no longer works.

In terms of data, I really must go through and compile the information from
my clients, because I do NOT find that limiting supplement works when you
are using the SNS.  I have countless cases of mothers exhausting themselves
and their babies and it not working at all.  I have at least 4 clearcut
examples of mothers who I have seen recently who spent at least three
months trying that approach and it only worked when they stopped limiting
supplement, let the baby actually get as much food as he or she needed, and
worked on getting the supply up with a combination of pumping and/or
domperidone. These women went through setback after setback.  To date, I
have not seen a single case where the limit the supplement approach has
worked. AND I have made sure to follow up on every last single client since
I started at Elizabeth Seton.

What I've seen in our support groups is a population of women from our
clients and from other LCs.  Some give up on the SNS after seeing other LCs
and work back to the breast from the bottle.  I have not seen any of the
women who were supplementing AND had low supply who just kept the baby on
the breast without pumping get up to full supply. When I worked with my
supervisors, I did see an occaisional case where they did get back to full
supply, but these women spent a fortune on LC visit - 2x/week for months -
and frequent finessing of tube sizes and variations in time on the breast.
While it works - I find that this is really disempowering for women -
always relying on the expert to tell you how to switch tubes - how long you
should do breast alone - frequently checking up on everything you do.

The reasons I think frequent setbacks happen when supplement is limited are
as follows:

1) Baby tires from doing lots of ineffectively suckling at the breast.
2) Tired baby does not feed as effectively at the next feeding because
caloric intake is lower than needs.
3) Mothers milk supply is not as stimulated by the ineffective feeding as
it is by effective feeding at the breast and/or the pump.

Now, this is really going to push me to demonstrate this in a solidly
designed study because there is nothing worse than dealing with an exhaused
mom, underfeeding baby, and low supply after months of work.

Don't get me wrong, I love the wearing the baby in the sling, frequent
feeding, etc. - but you have to keep in mind that any woman who is using
the SNS is NOT doing natural breastfeeding and her work load is MUCH higher
than that of women who can feed without the tube.  I don't think it is
reasonable to expect women to do more than was naturally intended and
expect them to succeed.  I'd rather pace things and have them continue that
push them and their babies over the edge and have them not succeed.

Best Susan Burger, PhD, MHS, IBCLC

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