Estimated reading time: 22 minutes
Updated January 2016
Diana West, BA, IBCLC and Diane Wiessinger, MS, IBCLC
Photo: Johanna Sargeant
Long-term at-breast supplementing for the breastfed baby
For many different reasons, some babies don’t get enough breast milk to gain well. Sometimes the problem is the baby’s difficulty with removing milk well; sometimes the mother isn’t making enough milk. Realizing that your baby needs more milk can be upsetting, especially if your milk supply is low.
Naturally, you want your baby to have the nutrition he needs and it’s great that there are alternatives to your own milk, but at the same time it can feel disappointing to discover that your breasts aren’t making enough milk for your baby. Still, your baby needs enough food to both grow well and have the energy to breastfeed effectively. So he’ll need supplementary feedings.
In some cases, supplementation is only needed for a short time, while measures are taken to increase milk production. In other situations, such as limited breast tissue, breast surgery, induced lactation or a metabolic problem, there are limitations to how much the mother’s supply can be increased, so supplementation may be needed indefinitely.
There are many ways to supplement breastfed babies who need it, but most women who need long-term supplementation choose either bottles or at-breast supplementing. There are advantages and disadvantages to each, depending on your circumstances and personal preference. You may even use different devices at different times.
Why choose at-breast supplementing?
While bottles can often be combined effectively with full-term breastfeeding, many mothers who need to supplement want nothing less than a full breastfeeding experience. At-breast supplementing not only allows a mother and her baby to have an exclusive breastfeeding relationship, it can also maximize the amount of milk that the baby removes from the breast because he spends the whole feeding at the breast. And it eliminates issues of nipple confusion and flow preference. At-breast supplementing is especially helpful if your low supply is for a “mother reason” such as limited breast tissue, induced lactation or a metabolic problem, but supplementers can be used in any low-milk situation, as long as the baby is able to draw enough milk from the device.
At-breast supplementing can be used indefinitely—for as many weeks, months or years as you both like, with as much milk as you’re able to produce and even if you produce none at all—without your baby losing interest in nursing at your breast. It is, after all, his food source!
The development of at-breast supplementers
In 1969, John Avery and his wife, Jimmie Lynne, were preparing to adopt a baby. As Jimmie said, “We had no concerns about being able to love our adopted children. My greatest disappointment was not being unable to experience pregnancy and birth. It was realizing that I wouldn’t be able to breastfeed.” So John devised a way to run a small plastic tube from a small container of supplement to the baby’s mouth as he breastfed, giving him milk. When the baby came, it worked wonderfully, and they realized it could help many other women as well. After several years of research and design, they developed a commercial product they called the Lact-Aid®, which is still available today (lact-aid.com).
In the 1980s, Medela, Inc. developed a similar product, called the Supplemental Nursing System™ (SNS), which is available in retail stores and hospitals throughout much of the world. It’s likely that other companies will eventually create other at-breast supplementer devices.
At-breast supplementers can also be made inexpensively using a #3.5 or #5 french gavage tube (available from a health care provider) inserted into a regular bottle. However, most mothers who supplement long term prefer the convenience and durability of a commercial at-breast supplementer. Even though it’s an added expense, it’s still far less than the cost and consequences of exclusive formula feeding.
Why doesn’t every supplementing mother use one?
At-breast supplementers do have their drawbacks. They take more effort to set up and clean than bottles would. It can take you and your baby a few days, or even a few weeks, to learn how to use them well enough to feel comfortable. You’ll need to watch your baby’s weight gain carefully at first to make sure he’s getting enough milk. A supplementer can leak if not properly assembled. Breastfeeding discreetly in public takes some coordination and advance planning. Despite the drawbacks, many mothers have found that at-breast supplementing gave them a very nearly normal nursing experience, while a bottle is … a bottle.
Choosing an at-breast supplementer
The two commercial at-breast supplementer products currently available are similar in function, but very different in design. The SNS uses a flat, rigid bottle with firmer double tubing extending to both breasts. The Lact-Aid uses soft disposable bags for the reservoir with a single soft tube extending to the breast. Whichever you choose, it helps a great deal to work with someone experienced in their use while you’re learning the ropes.
Rigid container supplementers
A hard-sided supplementer, like Medela’s SNS, has a rigid, rectangular plastic bottle that holds the supplement. It hangs upside down from an adjustable cord around your neck. Two tubes extend from the inverted bottle’s cap; one tube is positioned in place at each nipple and held with skin-friendly tape. Slits in the inverted cap allow you to pinch shut one or both tubings to stop the flow. A valve in the cap allows air to seep in as milk flows out. Milk out, air in: that’s the basic principle of the rigid container system.
Because it has hard sides, the SNS is easily filled and stored in the refrigerator or carried in a cooler with little risk of spillage. However, because milk flows only from the bottom of the bottle, you must sit fairly upright to use it, or hold or set the container upright when you lie down. The reservoir comes with volume markers on the side so you can easily see how much supplement your baby is taking—especially useful at first while you’re finding your way, much less important later on when you know your baby’s needs and style.
SNS tubing comes in three different sizes to help you regulate the flow of milk, so that your baby isn’t overwhelmed with milk and doesn’t have to work too hard for it. You can also change the flow by raising or lowering the bottle—higher for a faster flow, lower for a rate that requires your baby to suck more vigorously. The milk should flow at a rate that requires baby to suck actively, without making it too difficult for baby to obtain milk. The wrong flow can encourage ineffective sucking habits.
Which size tubing you’ll need depends on your baby. A baby who is seriously underweight or who has a weak suck might be fed with the larger tube, while a baby who is gaining well might use the smaller tube. Most mothers start with the medium size tubing. If milk flow is not sufficient with any one tube size, even when the bottle is as high as it can go, another option is to tape both tubes of a given size together on one breast, or to tape one tube to the side of the bottle, facing upwards and unclamp it, allowing air to enter the reservoir more quickly. Milk exits only when air enters, so the faster air flows into the reservoir, the faster milk can be removed from it.
What if someone notices the supplementer and actually asks about it? That can be an opportunity to enlighten others about the benefits of breastfeeding that are made possible by this special device.
A rigid container supplementer may make a gurgling sound as air enters the reservoir, because the air bubbles through the remaining milk. It’s a comforting reassurance that everything’s working well. Your baby’s active swallowing and a cool sensation around your nipples as supplement flows are other ways of knowing that your baby is drinking well.
Bag container supplementers
Bag-style supplementers, like the Lact-Aid, use disposable sterile plastic bags to hold the milk. The Lact-Aid has two size bags: 135 ml (4.5 oz) and 210 ml (7 oz). The bag is suspended from your neck by an adjustable neck strap and is closed at the top with a clamp ring. A straw-like extension tube runs inside the bag from the sealed top to the bottom. A second long, thin tube extends from the top of the assembled unit to your nipple. There is only one tube with each unit; mothers nursing twins at the same time can use two Lact-Aid units, one for each breast.
The rate of flow is controlled by adjusting the height of the bag with the neck strap—higher on your chest speeds the flow, lower is slower. Although there is a clamp to stop the flow of the supplement, it is generally not needed because the supplement is drawn through the top of the unit and so it flows only when your baby is sucking. For this reason, you can nurse lying down without worrying about leakage, so long as you don’t squeeze it.
Which design is best for you?
Over the years, mothers who have used both styles have made comments about them to LLL Leaders and lactation consultants, on Internet bulletin boards and email lists. Here are some of their most common comments.
The cost for the two current commercial products is about the same—there is more upfront cost with the SNS (unless you buy it from parts rather than buying the complete kit), but there is an on-going expense of disposable bags with the Lact-Aid.
Practical tips for using an at-breast supplementer
Most of the following tips apply to both types of at-breast supplementers; some are specific to one style.
Concentrated and ready-to-feed formula is less likely to clog tubing than powdered, although powdered formula works well when it is thoroughly mixed with water. Gentle shaking for one or two minutes is usually enough to get the lumps out. The Lact-Aid comes with a strainer for use with powdered formula. If you find that a significant quantity of formula stays in the strainer, you will need to blend it more thoroughly to make sure it contains the correct balance of nutrients.
Amount of supplement
An average baby nursing at an average breast takes as much as he needs, as often as he wants. That’s true of babies who are supplemented at the breast, too. There’s no need to worry about how much he gets at any given feeding—you just need to watch his weight gain over time to make sure he’s getting enough over all.
The real challenge at first is knowing how much supplement to put in the container. If your baby has been supplemented by bottle and is growing well, then you have a good feel for how much he’ll need. Start with that amount, and don’t be surprised if he takes less. In most situations, he’ll be breastfeeding longer than he did when you also gave a bottle, so he’s likely to take more of your milk. Over time, this may increase your supply.
When you first start at-breast supplementing, keep an eye on your baby. He shouldn’t have to work hard. Look for a swallow (a longer, deeper suck and probably a whispered “keh” sound) with every one or two or three sucks for most of the feed. He’ll take pauses, of course, just as you do during a meal. But if he’s sucking four or five or more times for each swallow, or having trouble swallowing or breathing, something needs to change. Babies with cleft palates, weak sucks or other conditions that make it difficult for them to suck well may be unable to gain weight adequately without special modifications or other devices.
Expect a feeding to last about as long as just breastfeeding or bottle-feeding. That’s one of the beauties of at-breast supplementing. You’ve breastfed and given supplement in the same amount of time. And don’t hesitate to offer snacks (at the breast) as well, with or without the supplementer in place—that’s all part of the casual way breastfeeding happens.
Many mothers have found innovative ways to use their hardsided supplementers in public. Wearing loose clothing or multiple layers makes the container virtually invisible.
To pump or not to pump
Pumping in addition to nursing and supplementing may help increase a low milk supply. If your supply is full but your baby doesn’t nurse effectively, pumping will enable you to supplement with your own milk rather than formula. If your baby nurses efficiently and your supply is low, you may decide that the pleasure of nursing your baby is all the “pumping” you want or need to do.
Warming the supplement
You don’t need to warm the supplement! Before it reaches your baby, it’s held against your warm skin and flows through a thin tube that also lies on your skin. You become the warming unit. For the same reason, however, the hard-sided supplementers can start to flow rapidly when you first open the tubing.
If you have just prepared a powdered supplement using boiled water, according to the guidelines in the “Safer Supplementing” box below, your job is to cool it, not warm it. In that case, be sure to cool it to body temperature or below, to prevent burns.
Formula grows bacteria much more readily than human milk does. Contamination can happen either at home or at the factory. Infection from factory-contaminated powder occurs mainly among hospitalized, premature, or very young babies. It is extremely serious, but it’s also extremely rare.
The World Health Organization (WHO) has devised a way to reduce the risk. Part of its method involves mixing the formula one feeding at a time, and preparing it with freshly boiled water just before use. Not a simple thing, especially when your baby is crying to be fed! And it means that you or your partner should not prepare a day’s worth of supplementers at one time.
This is one of thousands of parenting dilemmas you’ll face. You’re choosing at-breast supplementing to maintain a breastfeeding relationship and to optimize your baby’s access to your milk. But the WHO-recommended method is time consuming. You can use the more expensive but sterile liquid formulas (be sure to dilute the concentrate according to directions); you can vary the type of formula you use according to time of day or schedule, to make your day as streamlined as possible. Make your decisions with sound information, and with a careful look at your options and a realistic look at your goals.
Guidelines for safer supplementing
|Type of supplement||Safety instructions|
|Refrigerated human milk is the sturdiest of all.||Use within eight days if refrigerated at less than 4° C (39° F). If your baby has drunk from it, refrigerate for use at the next feeding or use within two hours unrefrigerated (the warmer the temperature, the shorter the time; times are unresearched).|
|Frozen human milk||Use within 24 hours of thawing or refreeze. If baby has drunk from it, see above.|
|Powdered formula isn’t sterile; some cases of infection with Enterobacter sakazakii have resulted from formula-feeding without sterilizing.||Boil tap water (not bottled water). Mix with powder while water is still at least 70°C (160°F). Measure water and powder carefully, swirl to mix. Use immediately, after cooling to body temperature or lower. If immediate use isn’t possible, refrigerate for not more than about four hours before use. Reuse leftovers within two hours or discard.|
|Formula concentrate is more expensive, but is sterile until opened.||Mix according to directions, using tap water that has been boiled. Store in refrigerator for up to 24 hours. Reuse leftovers within one hour or discard. Follow instructions on shelf life and refrigerator life for unused formula.|
|Ready-to-feed is the most expensive formula type, but is also sterile until opened.||Store in refrigerator for up to 24 hours. Reuse leftovers within one hour or discard. Follow instructions on shelf life and refrigerator life for unused formula.|
|Whatever milk source you use, be sure to use clean equipment,
even when sterile equipment is unnecessary
Storing filled containers in batches
To save set-up and preparation time, many mothers who use at-breast supplementers fill several containers with supplement each day and refrigerate them so that they can be used throughout the day, eliminating the need to prepare them individually. It’s much easier to prepare containers of supplement ahead of time, rather than trying to do so while your hungry baby is crying and you’re feeling anxious. From the baby’s perspective, minimizing the time he must wait or cry to be fed reinforces his trust that his needs will be met and maximizes the harmony of your breastfeeding relationship. Preparing a batch of supplementer containers for the refrigerator can be a wonderful daily gift from your partner!
You can purchase extra SNS bottles separately from full SNS kits, and extra Lact-Aid units in addition to extra bags. Even with a single bag unit, you can tie together several supplement-filled bags with a twisttie or clamp to give them more stability, and store them upright in the refrigerator in a stable container like a coffee mug. Lact-Aid also makes a storage rack for filled bags in the refrigerator.
Remember that if you’re supplementing with formula, it’s important to use the prepared containers within 24 hours; prepared formula doesn’t have a long “shelf life.”
Traveling with filled containers
Filled hard-sided containers can be stored in any insulated cooler, even the ones built into some diaper bags. Soft-sided units can be transported in the special insulated cooler offered by the manufacturer for transporting filled bags, or they can be put into plastic containers that have screw-or snap-on lids to keep them upright and protect them inside a regular insulated cooler.
You can watch an online video by Dr. Jack Newman demonstrating how to use an at-breast supplementer. In most cases, it’s easiest to put the tube in place on your nipple and then bring your baby to the breast. Traditionally, the tube is placed so that it enters the baby’s mouth under the center of his upper lip, but many mothers find latching easier if the tubing runs over the baby’s tongue—the exact opposite placement. As long as the tubing is within the “sucking tunnel” formed by the baby’s upper lip and cupped tongue, the baby can draw milk from it. Placing the tubing so that it extends beyond the nipple, as the manufacturer recommends, may allow the baby to use it like a straw and avoid sucking correctly on the breast itself. If you wait until after your baby has latched on and begins sucking before you let the supplement flow, your baby may be less likely to discover and rely on the straw effect.
Babies usually become accustomed to the feel of the tubing fairly quickly. If you should find, though, that your baby is confused by the tube, or that it makes it difficult for him to latch on, you can latch him on first and then try slipping the tube into the corner of his mouth when he seems settled. This does not work for all babies, particularly when they are latched on well and have a tight seal on your breast. If you insert the tube after your baby has latched, aim it toward the back and top of his mouth. Whether you run the tubing under baby’s upper lip or over his lower lip, or thread it into the corner of his mouth after he latches, the tubing must extend approximately to the end of the nipple and must stay within the “sucking tunnel,” or he will be unable to draw supplement from it. Once you are satisfied with the position of the tube and your baby has begun sucking, you can release the clamp and allow the supplement to flow.
If you find, as some mothers do, that your baby pushes the tube out of position with his tongue, try holding it in place with your finger against your breast just beyond his upper lip. You can also experiment with moving the tubing to the opposite side of the mouth (top or bottom), since he may not be able to “suck just the straw” from a different location.
If you have large breasts and find it is difficult to support your breast and latch the baby while keeping the supplementer in place, try pressing your free hand flat against your chest, above your breast. While pressing against your chest, slide your skin up toward your neck. This will lift your breast, keeping your hand out of the way to give your baby plenty of room to latch on.
Securing the tubing
You may not need to use tape to keep the tubing in place, but many experienced users of at-breast supplementers of both styles find that the system works better when the tubes are secured.
The tubing will stay in place most firmly if it is taped along the tubing instead of across it. Tape the tubing all the way down to the nipple base to keep it from moving during latching—your baby isn’t likely to notice or care about the feeling of the tape on his lips.
One problem with using tape to secure the tubing is that it can be irritating to your skin, especially when it is being applied and removed many times a day. To reduce irritation, Catherine Watson Genna, BS, IBCLC, recommends wetting the back of paper tape with a damp washcloth when you are ready to remove it. The saturated tape will fall right off.
Another way to prevent irritation is to lay one long piece of tape on your breast as a “base,” and then to put the tubing on top of it and use another piece of the tape on top of that. The top layer of tape is easy to pull off of the bottom layer. The base is changed only as needed.
At-breast supplementing not only allows a mother and her baby to have an exclusive breastfeeding relationship, it can also maximize the amount of milk that the baby removes from the breast because he spends the whole feeding at the breast.
Or try using adhesive or butterfly bandages to hold the tubes. Just position the bandage horizontally where you would otherwise use tape and slip the tubing under the non-adhesive portion at each feeding. The adhesive bandage can be left in place as long as it stays secure, often a week or more.
Other mothers prefer to use hair setting tape (which can be found at a beauty supply or drug store) because it stays in place nicely during the feeding, but doesn’t cause discomfort with repeated applications and removal.
Because good tube placement is key to having the supplementer work well, women find many creative ways to tape. One mother, reluctant to undo a good “tape job,” found a way to clean the tubing while leaning over the sink, tubing still in place. Another measured the tubing to the end of her nipple, taped it well away from her nipple, caught the flopping end of the tubing in her baby’s mouth, then brought him the rest of the way to breast, in a very smooth two-step latch. Yet another ran a marking pen over the tubing and across her breast after an especially easy nursing; the next time, she knew that if she lined up the marks on breast and tubing, she’d have exactly the right length for good flow.
An alternative to using tape or adhesive bandages is simply to use your nursing bra to keep the tubing in place. Slip the tubing between the panel of the bra and your skin.
Babies of almost any age like to play with the tubing of an at-breast supplementer, sometimes pulling it out of place. Here are a few ideas mothers have used to minimize tube grabbing.
- Make sure your baby’s shoulders are pressed in snugly against you.
- Tuck your baby’s lower arm between his body and yours so that only one hand is free.
- Hold your baby’s upper arm with the hand of the arm you are cradling him with.
- Cover the tube with your hand as your baby begins to nurse and until he settles into nursing. Once he is settled and nursing well, move your hand away from the tube and gently hold his upper hand.
- Wear a snug nursing tank top, or snug top with access holes, over the bottle/tubing arrangement.
- Wear a brightly colored neck scarf to attract baby’s eyes and roaming hands.
- Give an older baby something else to hold in his hand while nursing, such as a soft toy or a necklace with large beads (a “nursing necklace”).
- Run the tubing on the tongue side of your breast rather than the upper lip side, so there is less for him to see or reach.
How long will you need it?
Depending on how much milk you’re producing and how interested your child is in solids, your need for a supplementer may end shortly after your child starts solids around the middle of his first year, or may continue for some months beyond that point. For a small percentage of toddlers, supplementation will still be necessary into their second year. Not all children are ready to eat solids regularly at this age; some may resist drinking from a cup and some continue to want a significant flow of milk when they nurse.
Despite the drawbacks, many mothers have found that at-breast supplementing gave them a very nearly normal nursing experience, while a bottle is … a bottle.
Some older babies become less accepting of the at-breast supplementer, preferring a bare breast despite its lower supply; others recognize that the tubing means a good milk flow and work with the mother to keep it well positioned. Eventually, the time will come when your baby is happy to give up the supplementer for many or all feedings. The way this happens plays out in as many different ways as there are children.
At-breast supplementing in public
While it may be tempting to set up your at-breast supplementer before you leave the house and wear a filled container so that you can nurse easily in public, it is not safe to do so if it will be more than an hour until the next feeding, especially if the supplementer contains formula; bacteria grow quickly in a warm environment. It’s important that formula supplements remain chilled in an insulated cooler until they are ready to be used.
Many mothers have found innovative ways to use their hardsided supplementers in public. Wearing loose clothing or multiple layers makes the container virtually invisible. You may want to set up the container and tubes in a private place, such as the restroom, a baby feeding room, or a changing room, before moving into the more public areas of a restaurant or shopping center.
Because the bag-style unit is thin and flat when filled with supplement, it can be hidden under clothing even more easily. Some mothers make decorative cloth pouches to contain the unit so that nursing in public is even more discreet. A small metal clip can be sewn onto the pouch so that it can be attached to your bra, eliminating the need for the strap. Filled units can then be removed from their storage container and placed in the pouch through the slit of a nursing top or from the bottom of a blouse. Many mothers find it very useful to practice in front of a full-length mirror before they nurse with an at-breast supplementer in public.
At-breast supplementing discreetly becomes more difficult when the child grows older and is more active and distractible. The key to supplementing an active baby in public is to find a relatively quiet place to nurse, with fewer distractions, especially when baby is tired and hungry. Keeping a finger on the tubing or wearing that snug tank top over tubing and supplementer prevents him from pulling it out of position. Many mothers find that feeding an older baby a half-hour or so before he is normally hungry keeps him in a better mood so that he is more cooperative during the feeding.
What if someone notices the supplementer and actually asks about it? That can be an opportunity to enlighten others about the benefits of breastfeeding that are made possible by this special device. You don’t need to volunteer details about your situation. Just focus on the fact that it allows you and your baby to breastfeed when you might have missed out otherwise. The usual reaction is complete amazement that such a device exists, followed by sincere admiration and warm acceptance. That will feel mighty reassuring that you’re doing a great thing for your baby and yourself!
Most important of all, though, is what you and your baby think of the experience! An at-breast supplementer can feel like a fiddly feeding device at first … but it can come to be the reliable friend that helps you keep breastfeeding going strong.
Increasing Your Milk Supply LLLI Information sheet outlining the process of milk production and what a new mother can expect as her body adjusts. Addresses how to measure intake, factors that contribute to a low milk supply, and more.
Diana West, BA, IBCLC, is an LLL Leader and co-writer with Teresa Pitman and Diane Wiessinger on the eighth edition of La Leche League International The Womanly Art of Breastfeeding and of Sweet Sleep. She is co-author with Lisa Marasco, MA, IBCLC, of The Breastfeeding Mother’s Guide to Making More Milk, and with Dr. Elliot Hirsch of Breastfeeding After Breast and Nipple Procedures. She is also author of the Clinician’s Breastfeeding Triage Tool and Defining Your Own Success: Breastfeeding After Breast Reduction Surgery. She lives with her three sons and husband, Brad, in the picturesque mountains of western New Jersey.
Diane Wiessinger, MS, IBCLC, has been a La Leche League Leader since 1985 and works as a Lactation Consultant in private practice, in Ithaca, New York. She is the author of many articles about breastfeeding, as well as being a popular speaker. Diane began her studies observing animal behavior over 30 years ago. She is a co-writer of the eighth edition of The Womanly Art of Breastfeeding and Sweet Sleep. See her collection of “Common Sense Breastfeeding” handouts.