I have changed my views about them over the years.  When my only
contact with nursing moms was as a League Leader, I would only work
with them after they had been home for a while.  My view then was
that there was no excuse for ever using a nipple shiled.  It was
just a case of the nurse being too lazy to try anything else.  Then
I bacame a nurse and was working with new moms myself!  My first job
as an OB nurse was in a hospital that totally banned nipple
shileds.  As a result, nurses would use a bottle nipple over the
breast and report that the baby was "nursing beautifully"!  At my
next job, they were readily available and I found them being used
anytime a baby wasn't nursing enthusiastically the first try. (In
both these cases I was a staff RN who happened to have IBCLC
certification, but no assignment or time available as an LC.)  Once
the LC position was developed, we removed the shields from the floor
and had them available only from LCs.  Once again, nurses would use
bottle nipples over the breast and in effect say it was the fault of
the LC because we "wouldn't let them use shields".  We will be
making them available on the unit again, but with some definite
guidelines/restrictions.  If they again become used too freely, they
will return to our office.
The first step was to write a policy/procedure regarding the use of
nipple shields.  Specific guidelines for "appropriate" and
inappropriate use have been written and given to all staff.  All;
nurses must read this as part of their breastfeeding competency.  In
addition, mothers must sign a form stating they have been told of
the need for follow-up to be sure infant is obtaining adequate
milk.  When an LC is on the unit, only she can initiate use of a
shield.  When a nurse decides to start one when we are not there,
she must leave word for us so that we can follow up with the mom.
Any mom going home using a shield is told to keep a diaper count.
We follow up by phone by 48 hours after discharge.  If the Ped
hasn't scheduled an early follow-up, we have the mom bring baby in
for a weight check before the baby is a week old.  (The exact timing
depending on the information we get talking to her on the phone.)
Any mom using a shield is encouraged to pump at least 5 minutes
after any feeding when it has been used.  In addition we instruct
her to rub her nipples briefly before applying the shield to
stimulate the nerve endings in the nipple and get the hormones
going.
When do I use a shield?  Of course, I wish I would never use one.
If we had the luxury of moms staying until baby had nursing "down
pat" it would be another matter, but unfortunately "not
breastfeeding well" is not considered valid reason to delay
discharge.  (If baby isn't feeding by any method, then they are kept
in the NICU.)
1. Flat nipples - no not in every case.  We know baby latches to the
breast, not the nipple.  However, it has been my experience that
some babies seem to need that stimulation in the back of their mouth
("S" spot) to keep them nursing past a few sucks.
2. Mom is going to give up is she doesn't see some kind of "success"
in the next 10 minutes or so.  I find that these moms don't always
give up eventually as one writer suggested.
3. Mom states she used one with another baby and in spite of all we
may say, insists that that's the only way she can/will nurse.
4. Baby has already gotten "hooked" on the bottle.  Shield can be a
transition back to breast if baby won't go directly.
These are probably the most common reasons I may resort to a
shield.  Of course in the ideal world, a shield would not be needed,
but sometimes it can the the "lesser of 2 or more evils".  With the
use of shields as with any time we have to wrok at geting a baby
latched, mom in encouraged to spend time with baby just snuggled
against the brest without trying to get latched.  Otherwise, if
everytime he is at breast someone is pushing or prodding him, he may
decided it's not such a nice place to be!
Incidentally, there have been some cases where the shield has been a
diagnostic tool.  In some cases digital oral exam shows nothing out
of the ordinary, but baby seems to be doing something "funky" at
breast.  If I try a shield and it's immediately pushed out of baby's
mouth, I can be prety sure (s)he's raising her tongue up in back.
Sometimes the fact that the shield is firmer can help baby learn to
keep the tongue down once we get it placed well-usually aiming it up
as we latch.
One writer mentioned using a shield when mom has large nipples.  I
am surprised by this.  It has been more my experience that when a
mom has a large diameter nipple, the shield can pinch it just as
with a pump flange that's too small.
I have rambled longer than I intended on this subject-sorry.
Winnie Mading, IBCLC

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