Tube-at-the-breast systems

How do tube-at-the-breast systems work?

A tube-at-the-breast system consists of a container that holds milk and a tube that runs from the container to the mother’s nipple. The baby breastfeeds with both the tube and the nipple in the mouth. These systems can be used when the baby needs a milk supplement. They can be especially helpful when the mother has a very low milk supply or wants to breastfeed a baby she has not given birth to. They allow the baby to stimulate the breast and generally do not interfere with breastfeeding. On the other hand, the systems can be expensive, a little fiddly, hard to clean, and some babies can’t latch onto the breast with the tube in place. They cannot be used if the baby cannot latch and suck. There are two commercial products available or mothers can make their own. The flow rate of milk through the tube can be adjusted to allow a normal feeding time.

A) Describing the tube-at-the-breast system

A tube-at-the-breast system.

A tube-at-the-breast system consists of a milk reservoir and a fine tube that runs from the reservoir to the mother’s nipple. The baby breastfeeds with both the breast and the tube in the mouth. The baby must be able to latch onto the breast and breastfeed normally for the system to work. It can also be called an at-breast supplementer.

There is a small amount of evidence that these systems may be effective for milk supplementation. (Penny 2018).

A tube-at-the-breast system can be especially helpful when:

  • A baby is willing to latch but not willing to continue breastfeeding because the mother has a very low milk supply.
  • A baby is becoming increasingly reluctant to breastfeed because of extensive bottle preference.
  • A mother wishes to resume breastfeeding after having stopped.
  • A mother wishes to breastfeed a baby she has not given birth to.

Some mothers like these systems and others don’t find them useful but rather time-consuming, complicated, messy and cumbersome and expensive (Borucki 2005).

B) Pros of a tube-at-the-breast system

Tube-at-the-breast systems:

  • Generally do not interfere with breastfeeding.
  • Allow the baby to stimulate the breast while breastfeeding.
  • Keep the baby interested in breastfeeding when the milk supply is low or very low.
  • Prevent the baby from becoming used to other supplementing systems such as bottles and rejecting the breast.
  • Can be faster than supplementing after feeds. 

C) Cons of a tube-at-the-breast system

Tube-at-the-breast systems have some disadvantages:

  • Commercial systems are expensive.
  • The baby must be able to latch onto the breast and suck with the tube in place.
  • Some babies:
    • Just suck on the tube.
    • Can’t latch onto the breast with the tube in place.
  • The systems must be filled and cleaned.
  • The systems may be difficult to use with older babies, who may pull on the tube and be distracted by the milk reservoir.
  • The flow rate needs to be neither too fast nor too slow.
  • They may become contaminated with bacteria if not properly stored and cleaned.

Supplementing a baby after breastfeeding with bottle or cup and using the baby’s hunger signs is a good way to know how much supplement to give. This will also provide mothers with a rough estimate of how much milk the baby is taking from the breast.

The amount of supplement needed is harder to know when using a tube-at-the-breast system. If the baby has taken in too much supplement, the baby may not feed well or at all on the second breast and the mother would have to express that side. If the baby has taken in too little supplement, the baby will still be hungry after the second breast or will breastfeed for excessively long times. Mothers should adjust the supplementing amounts accordingly.

Some mothers will therefore supplement after feeds for a few days with a bottle or cup for example and thereby establish the amount of milk supplement the baby needs, and then change over to a tube-at-the-breast system.

D) Equipment

Homemade tube-at-the-breast system.

1) Commercial tube-at-the-breast systems

There are two commercially available products:

  • The Supplemental Nursing System™ made by Medela
  • The Lact-aid® system

Both have advantages and disadvantages. More information is available on their respective websites. 

2) Homemade tube-at-the-breast systems

a) Materials

You can make your own tube-at-the-breast system using:

  • A bottle to hold the milk
  • A regular flow nipple with one hole  
  • A feeding tube such as a 5 or 6 French size that is 50 or 90 centimeters (19 or 35 inches) in length
  • A syringe that fits the port to use for cleaning after feeds.

b) Assembling the system

To assemble the system:

  • The feeding tube is pushed through the hole in the nipple from the milk side.
  • Sharp tweezers can be used to pull the tube through the nipple.
  • The port is left on the tube to keep it from sliding through the nipple. It will sit in the milk. 
  • A soft cord is attached to the bottle with tape or elastics so it can hang around the mother's neck.

c) Other pointers: 

Other pointers:

  • The feeding tube can be cut if it is too long.
  • A binder clamp can be used to pinch the tube and keep the milk from flowing until the mother and baby are ready to breastfeed. 

Some mothers use a syringe with a sharp tip to replace the tube-at-the-breast system. These are also used for finger feeding. This can be a bit cumbersome if the mother does not have a helper, as only one of the mother’s hands is available to hold the baby at the breast as the other needs to hold the syringe. This can also increase the risk of injury to the child.

E) How to use a tube-at-the-breast system

A baby breastfeeding with a tube-at-the-breast system

Before the first use and after every use, the syringe should be washed. To do this:

  1. Pull the plunger out of the syringe.
  2. Take the black cap off the plunger.
  3. Wash all three pieces with hot, soapy water.

There are a number of options when using a tube-at-the-breast system. Families need to figure out what works for them.

When first using the system, mothers may wish to have it in place before bringing the baby to the breast: 

  1. Fill the reservoir or bottle with milk and ensure it will not leak.
  2. Hang the reservoir or bottle around your neck.
  3. Place the tube so that it is about 2 millimetres (1/4 inch) past the end of the nipple and it will enter the baby's mouth at the middle of the top lip.
  4. Using gentle skin tape, tape the tube to the breast. 
  5. Position and then latch the baby.
  6. Ensure the flow rate is not too fast or too slow.

Other mothers will latch the baby first and then insert the tube into the corner of the baby’s mouth.

F) Flow rates

To ensure continued milk production, you want the baby to breastfeed about:

  • 15 to 20 minutes on each side for babies under one month.
  • 10 to 15 minutes on each side for babies over one month to six months.
  • 10 minutes on each side for babies over six months of age.

If the flow rate is too fast, the baby may not breastfeed long enough on each breast and leave excess amounts of milk in the breast. Unless the mothers expresses, this can reduce the milk supply over time.

The flow rate may be too slow resulting in long feeds, tender nipples, and even an underfed baby.

Therefore, mothers may need to decrease or increase the flow rate. It may take a little experimenting to achieve this.

1) Decreasing the flow rate

To make the milk flow more slowly, you can:

  • Lower the milk container.
  • Shut off the second tube if there is one.
  • Occasionally pinch the tube to block the milk flow.
  • Use a tube with a smaller diameter size.

2) Increasing the flow rate

To make the milk flow more quickly you can:

  • Lift the milk container.
  • Squeeze the milk container periodically.
  • Use a tube with a larger diameter.

If you are using a system with two tubes, you can open the tube on the breast from which the baby is not breastfeeding. This lets air into the bottle so that a vacuum does not build up.

Using both tubes on one breast is not generally advised as it is more likely to cause latching problems and therefore interfere with breastfeeding. 

G) Cleaning a tube-at-the-breast system

Before the first use or after each use, clean the system.

1) Cleaning a commercial system

To clean a commercial system:

  1. Using warm soapy water, wash the reservoir and all other parts.
  2. Push warm soapy water through the tube by putting it in the reservoir and squeezing it through the tube.
  3. Rinse by repeating the above steps using clean water.
  4. Dry the tube by squeezing the empty reservoir to push air through it.
  5. Leave to dry on a clean towel.

2) Cleaning a homemade system

To clean a homemade system:

  1. Using warm soapy water, wash the bottle, nipple, and port.
  2. You may need a soft, clean brush to thoroughly clean the port.
  3. Push warm soapy water through the port and the tube using a syringe.
  4. Rinse by repeating steps 1 and 3 using clean water.
  5. Dry the tube by pushing air through the port and the tube using a syringe.
  6. Leave to dry on a clean towel.

References

Borucki LC. Breastfeeding mothers' experiences using a supplemental feeding tube device: finding an alternative. J Hum Lact. 2005 Nov;21(4):429-38