Hi Karleen,

I know you asked Susan these questions, but let me see if I can help a bit.

First in regards to the flow.  If the tube is placed on the breast so that
it is in the center of the upper lip or lower lip, when the baby compresses
the breast the pressure between the gums and the breast should be sufficient
to pinch off the flow from the tube.  As the compression part of the suckle
releases, the vacuum in baby's mouth takes over.  (Try to close your lips
and this point and suck/create vacuum with the tip of your tongue against
the back of your upper teeth and your tongue low in your mouth.  See how you
have that little area on top of your tongue that makes a vacuum chamber?)
If the compression part of suckling worked well, that area is now filled
with milk and there is no room for milk from the SNS.  If baby got only half
of a mouthful of milk however, the vacuum will siphon half a mouthful of
milk from the tubing and if there is no milk, baby gets a mouthful from the
tubing.

On the other hand, some babies suck like a straw on the breast without
compressing as much as needed to squeeze milk from the breast.  For those
babies, they never pinch the tubing and therefore get milk from the tube
primarily and secondarily from the breast.

As far as increasing supplement increasing milk supply, I have also found
success with this method.  I am currently working with a post 36-week baby
who is now 4-weeks old and we are using exactly this technique.  For the
last week we are using expressed milk (EBM) in the SNS device only.  Prior
to this, mom was keeping baby at breast for long periods of time, using
1/2 - 1-oz milk in the SNS.  Baby did not get much more than was in the SNS
when the flow got slower, she sucked less efficiently and did not empty the
breast well.  Because baby was not effective at the breast, milk removal was
inefficient, mom had no time to use an effective pump to empty the breast
and milk supply stayed low.  Once mom increased milk in the SNS, baby fed
effectively throughout the shorter feeding, mom pumped to empty the breast
well and we were able to get baby off of formula.

Without the extra milk in the SNS, baby would probably still be taking hours
at the breast.  With the milk, mom went from 3h at the breast, off for 30
minutes to 30 - 40 minutes on the breast every 2 - 3h.  My starting
recommendation to moms when they are supplementing with an SNS is to put in
enough milk so that there is some left at the end of the meal.  I would
prefer to see baby quit because they are not hungry rather than because the
food ran out.  When the babies are chronically underfed, they do not seem to
have the energy to suck well or the patience to latch well.

I suspect that mothers in some parts of the world who adopt or relactate can
work up a supply without using an SNS.  In fact, one of the first
re-lactation moms that I worked with (must have been around 1988 or 89) was
able to re-lactate with a drinking straw.  She bottle-fed by choice but was
still leaking at 4 months and called to see if she could breastfeed.  We
talked and she chose to put baby to breast and discontinue the bottle.
Until she was making enough milk to keep baby happy, she put a straw in a
bottle of formula and put her finger over the end of the straw to collect
formula with she dropped into baby's mouth until baby was exclusively breast
fed.

Most of the moms that I work with for re-lactation, induced lactation though
are moms who adopt or have milk supply issues in addition to having hormonal
problems that made pregnancy difficult or impossible.  These are moms who
rarely are able to discontinue supplements (either formula or solids later
on) and using an SNS is one way they can keep baby suckling from the breast.

As far as a 2 yo who is still insisting on an SNS to breastfeed, I would
suspect there is something there that makes the child need the SNS.  It may
be the idea that "this is how breasts feel and work," it may be "if there
isn't enough flow, why bother," or another reason entirely that the child is
not verbal enough to communicate.  If the only way to keep a 2yo at the
breast is with an SNS and mother and child are happy, I would not argue the
point.  I do not see any more down-side to that than giving a cup of water
or milk after a feeding to a child who wants or needs more.

Sorry this is so long but it is such a fascinating field.  So many different
approaches work for so many different situations.

Linda Pohl, IBCLC
Phoenix AZ where we are finally getting a little of the rain we so
desperately need (anyone want to send some snow, we could use that too!)

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