The practice where I'm doing my training has been both faulted and also
been a referral source because they have worked extensively with the SNS.
So, I have had a chance to observe my supervisors working with and work
myself with many mothers using the SNS.

I've found some of the suggestions regarding use of the SNS during breast
reduction very interesting, yet it seems that there is enough variability
in response to breast reduction surgery that some of these suggestions may
not always work with all women.

While many women who have had breast reduction surgery can fully
breastfeed, it does seem to me that we need to prepare them for the
possibility that they may need to use some supplement for a long period of
time. We do start them off with a let's just try this approach and see how
you like it in the beginning. Most mothers do get used to the SNS within
about 48 hours (unless they associate it with negative hospital experiences
such as IV tubes, etc.) We've never heard a mother say she loved the
device, but many consider it a necessary evil and preferable to the
bottle.  For mothers who aren't able to increase their production
sufficiently to eliminate supplement, we often discuss using the Lactaid in
combination with or instead of the SNS.

I've observed, but don't know if there is research to support that mothers
who heavily focus on increasing production do not do as well as mothers who
focus on the enjoyment they get from breastfeeding and set shorter term
goals towards the eventual goal of minimizing supplement use.

Instead of creating reliance on a lactation consultant for what might turn
out to be long term supplementation, it seems to me that a more powerful
approach would be to empower women to observe their infant to determine
when and how to use the SNS at any particular feeding. The way we try to
empower women is to work with them frequently when they initially start
using the SNS to recognize the signs of effective feeding and satiety in
their infant.  We generally find that the infant does better in the
beginning of a feeding and then will need extra assistance as he/she drains
the breast.  The clue for when the infant needs the SNS, is when the infant
is no longer feeding effectively, but is still showing signs of hunger.  If
a mom can recognize when this occurs, she can observe far more feedings
that a lactation consultant could possibly manage and can determine for
herself when to add the SNS.  Who better than mom to really get to know her
infant?  We have observed all sorts of patterns, infants that don't need
the SNS at night, but do during the day; infants that don't need the SNS in
the morning, but will need it earlier and earlier in the feeding as the day
progresses, infants who are like clockwork and would survive parenting via
one of those "scheduling books", and infants who are different at every
feeding. As a mother's production increases, what generally happens is the
infant spends longer and longer on the breast alone without needing the
tube.  We also teach the mother to recognize when her infant needs a change
in the rate of flow and focus on helping her to fine tune the latch if we
drop down in a tube size.

Helping a mother to observe her own infant's behavior avoids the problem of
basing the amount of supplement on theoretical calculations extrapolated
from one test weighing that may not reflect the infant's average intake at
every feeding. While some infants do take in a similar amount at every
feeding throughout the day, many others do not.  Moreover, research shows
that infants' growth varies considerably from one day to the next (day to
day measurements are not like that nice smoothed curve on the charts, these
are sharp peaks and troughs) and hence their needs may vary from one day to
the next as well.

We do follow up with weekly weight checks. Usually mothers who rent an
infant weighing scale become extremely anxious because the temptation to
weigh their infants frequently is too great and they go through frequent
moments of elation and despair.

Most often, when an infant is not growing well, we find that the mother has
tried to challenge the infant a little too quickly and has been leaving her
infant on the breast for extended periods of time when the breast has been
already drained.  Mothers often feel that if they just make the infant work
harder, the infant drain the breast better.  We find that an infant that
isn't ready for that challenge just gets tired and will either start crying
a lot or sleep longer.

Similarly, we find that if an infant is ready for a greater challenge and
the extra support isn't withdrawn, they will often develop compensatory
behaviors that lead to setbacks.  For instance, if the flow is too fast,
they may start retracting their tongue to reduce the flow.

Finally, as I've posted before, my supervisors modified the tube placement
and use of venting - modifications which I'm hoping to study in a formal
research study at some point when my son is going to nursery school 5 days
a week instead of the current 2 days a week.

Susan Burger, PhD, MHS

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