I as a Lactation Consultant I have a love hate relationship with the SNS and
only use it as a last resort. I use it the most with babies that cannot
extract the milk from the breast. They spend all day at the breast nibbling
and asleep and they can only do a nutritive suck with the let down and are
loosling weight.  I use it after we have tried breast compressions ala Jack
Newman and fenugreek to boost if mom's supply  if low. I also usually ask Mom
and dad what they want to do. I give several scenarios and let them chose. I
use the SNS to get the baby into a nutritive suck pattern. I usually start
with a medium tube with the second tube closed and then evaluate the suck.
(If the baby cannot do this then I go to the large tube with the second tube
closed. Still no nutritive suck then large tube second tube open.  That
usually does it. ) If the baby is nutritively sucking then I stay at the
starting tube for a week the following week we see if the weight was good and
then move to the next decreasing tube with the second tube open and taped to
the top of the bottle so a vacuum does not form. Reassess in the next week
weight good and feedings not going longer than about 45 min, then close the
second side. The baby stays on the SNS as long as he needs it. Usually last
step is small tube second side closed and baby taking less than an 1/2 and
ounce or less from the SNS, I tell Mom baby does not need the SNS. Funny
thing happens, after all the complaining, they do not believe me and have to
wean themselves from the SNS. They all usually stop the SNS in another week
or two by skipping a feed using it and seeing how the baby acts. We also
might do things like skip using the SNS in the morning feeding as moms
usually have a lot of milk then. Sometimes this gives the Mom a psychological
boost. The fastest a baby has gotten off the SNS for lack of a nutritive suck
was 6 weeks, the longest was 9 months.

I have had two Moms use the tube under the breast. They came from the Eastern
part of the US. I found this not to work well as the babies did not get into
a nutritive suck pattern. Also my understanding of the SNS is that it works
as a capillary effect. When the breast is following the formula will not flow
or slows down like a tributary feeding into a river that is fast flowing.
When the baby is sucking nutritively, by himself then the SNS does not drain
(If mom's milk supply is good). The SNS flow forces the baby to suck
nutritively. When the baby does not suck nutritively the breastmilk does not
come out ant the SNS drips into the babies mouth which then gives the baby
enough milk in his mouth for his reflex to swallow to occur. Once he swallows
the reflex to suck occurs and the process begins again.  This is how it was
explained to me 15 years ago in "Lactation School" and it makes sense to me
and I have seen it work.
I learned these things by thinking about a way to get the baby off the
breast. In "Lactation School" it was start with Medium tube and the baby
eventually will not need it. Perhaps but the changing seems to help the baby
and the Mom feel like they are making progress.

One more thing. I have noticed that with Nutramegin and Augmentin, the
formula flows slow and it is difficult to get the babies in a nutitive suck
pattern, even with the large tube and the second tube open. The ped and I are
trying to figure out a way, heating doesnot seem to be effective. We know
that the problem is the formula and not the baby as with breastmilk in the
SNS the baby does great. Any ideas?

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