This is long overdue but has been on my mind since the Lactnet postings from 2/27 about the nipple shields.  I want to thank Kathleen Bruce for directing some of the people to the archives for an expanded view of shield use.  I need to share what I am encountering as a full-time hospital IBCLC in an area that is still dealing with old information about nipple shields.
Background:
I have worked extensively with breastfeeding mothers and babies for over 28 years.  I have been certified as an IBCLC for 15 years. I have worked very hard to develop a good reputation in the community with other entities including home health nurses, PNP's physicians, LLL, CLE's, independent IBCLC's, etc.  Based on the extensive information about nipple shields over the last 7 years since the Journal of Human Lactation devoted an entire issue to shield use and with the many posts on Lactnet, I have carefully studied and worked with shields.  We give moms a preprinted form about nipple shield use and care with specific information about pumping and supplementing. I have an extensive phone follow up program and return visits as needed. I keep written reports on computer so I can access the information by a click of the mouse. I know just where moms are at and what are their plans of care.  I also keep statistics about the length of time the mother and baby use the shield and how long she continues to breastfeed. I call an average of 3-4 times once they are home and bring them back in if home care is not going out to weigh baby or they have any problems at discharge. 
Dilemma:
My greatest problem is the community attitudes. For example, I worked very hard with a mom of twins in Level II nursery.  Based on Paula Meier's research about nipple shield use in the NICU, these babies were placed on shields.  They progressed quickly and went home nursing, probably before they would have, had we not used the shields. The boy, I'll call Evan, was very tiny and the girl, I'll call Erin, larger and more aggressive.  The mom had a very busy life style.  Grandma was a retired L&D nurse.  Mom had a home health nurse visit her a week after discharge (I also call each mom 1 week after discharge from the Level II nursery or sooner if needed). Evan's weight gain was slowing but WNL and mom was not pumping as much as before (understandable with twins).  She began to worry about her supply.  The home care nurse told the mom that "there is a problem with Jane at 'X' hospital" with nipple shields and recommended she go to "Y" hospital for them to help her get off this (dreaded) shield.  Mom called me (not mentioning this home care nurse) and said "my mother (retired from L&D 10 years ago) and others in the community, have advised me to get the baby off the shield immediately that this is the cause of the low milk supply".  I could not see her that day and tried to reassure her that I believed it was not the shield creating the decrease but rather the way baby was attached to the shield. I felt the baby was too small to be weaning from the shield yet. (Barbara Wilson Clay has addressed attachment issue before on Lactnet and I too have experienced that as the problem, not the shield.) She was panicked enough to call "Y" hospital for a visit.  During their visit, they found that baby had slipped down onto the end of the shield and was not stimulating the areola. They agreed baby was too small and needed to stay on the shield.  She also had gotten busy with outside work and had almost quit pumping. (After discharge from SCN of preemies, I often recommend as least some continued pumping until the babies were bigger and closer to their due date.) With the change in the positioning of the baby at the breast and increased pumping, the milk supply increased and the situation turned around. She called me back to share this and her confidence in me was restored.  However, this was after she shared her negative feelings with many other SCN moms.
I have 3 concerns about what happened:  #1 The nurse made a snap judgment about the shield and didn't even look at the baby to see if there could be another reason for the problem that might have been corrected with that home visit.  #2 She worried the mom unnecessarily. #3 she undermined all the work I had done. This also caused a negative ripple effect with the other mothers in the hospital and community.
        I used to automatically see every mom 2 days after she got home to weigh baby and check progress.  Most of our moms have a home care visit 2 days after discharge. The babies are weighed and a feeding is observed. I felt it was doubling up on cares and causing greater expense to the insurance companies and possibly to the parents. If any problems were identified, I let the mom know I wanted see her again. I found that most babies came off the shield, on their own, once things settle down and they start regaining trust at the breast. Now I feel that I might have to go back to seeing every mom if the home care nurses continue to undermine my work. 
       I saw a mom 2 days ago who was a para 4. She nursed 3 other children, each for 1 year. This baby was a slow gainer, wanting to nurse all the time.  I am sure you all have had this. I had to investigate her lifestyle and feeding patterns and watch baby nurse to see what the problem was. This mother was busy with the others, didn't pay attention to the latch so baby gradually slipped onto the end of the nipple and didn't stimulate the areola enough to keep in a good milk supply. If this had been a shield, with the current negative thinking, I believe the shield would have been blamed and the true problem would not have been investigated.
 In the middle of all this, a doctor called to say she had a mom who was put on a shield and now baby was not gaining. She wanted me to get the baby off the shield now.  We had talked about shields previously and a physician friend of hers, involved with LLL, told her the shields were not good.  Even after I armed her with information about shield use, she did not want her patients to have them. I agreed to not use them with her patients but this mom slipped through the cracks. She informed me that no other LC used shields in the hospitals where she rounds, I was the only one.  I had followed this mom by phone after discharge. Baby was gaining > 1oz/day and milk supply was good. 10 days later the doctor called saying baby was not gaining and I needed to get that baby off the shield.  The baby had gained 5 oz in 10 days.  Now I deal with a doctor who has greater expectations than what is acceptable practice.  I asked to follow up with this patient. I  also tried to share some of my observations about attachment on the shield that seems to effect the milk supply. She was so focused on her agenda that she did not want to hear anything else. I saw the mom and baby 2 days later. The doctor scared her so much she thought about quitting and going to bottle.  Once in my office, I was able to get baby off the shield but she could not sustain a latch. She could with the shield. We made a few little changes like switch nursing and breast compression and baby got 80cc at the breast (she needed 72cc for growth according to my charts). I followed up by phone and baby went on to do just fine, gaining 1 oz/day. Mom feels she would not be nursing now if it hadn't been for the shield.  Once again the focus is on the shield as the enemy, not on the baby's position on the shield.
     I feel we can all work together.  If there is a problem in the community, I have to believe most IBCLC's would like to know so they have the chance to correct it.  However, if the shield is not the culprit, then we all need to rethink how we deal with the mom and baby and what is said about the IBCLC. I too feel, like Barbara Wilson Clay, that I spend more time trying to dispel old myths and alleviate mom's fears, so I can go on to help a mom.
     I have always tried to support and recommend LLL even if I feel some may say things that I may not agree with.  To undermine each other is not good.  We all have important work to do.
  Lactation settings:
    I have done lactation work in both hospital and clinic settings.  When I switched to the clinic lactation setting, I saw a much different client, one who was now awake and ready to nurse. It is not right for outside entities that work with more alert babies 2-3+ days of age, to judge the hospital IBCLC. They are not there to deal with the sleepy, unorganized babies who have been born after an epidural or a medicated labor. Babies who have been assisted at breast, over and over again without attachment. Babies who are now about to shut down (or have shut down) at the breast because they have gone way too long.  Moms who are frantic, crying and about to quit even with encouragement. Even if they pump and or hand express, they can't get enough milk so babies are often cup fed formula. We do a lot of kangaroo care, waiting on the babies to be ready, teaching feeding cues, trying not to force.  We have an exceptionally good staff that tries to do it right. We have on call IBCLC's who come from other facilities to work at our hospital, including one from "Y" hospital, who comment on this. They are amazed by how well the staff works with our patients. I see the looks on the mom's faces that are so distraught at what they have been going through and then the look of total relief when the shield is used and now baby can attach and get colostrum immediately. They often ask why this could not have been done a lot sooner. Another common statement I hear is "a good LC should be able to get any baby on the breast". However, it is the MOM who has to be able to get baby on when I am not there. And yes, I spend a lot of time teaching and encouraging them to wait baby out and how to get baby on, over and over again. 
      How many moms and babies go home pumping and bottling or quit altogether because they can't get their babies to nurse? I too would rather see the baby at breast with the shield than not at the breast at all. We rarely hear about those moms and babies.  I will be following the patients of the above doctor to see the outcomes of her patients who may be in this situation. (Rest assured, I will continue to work as diligently for this doctor's patients because each mom and baby deserves my best.)
     We need to play fair.  For those who see babies after discharge from the hospital, please look carefully at the way baby is nursing before just chalking it up to the shield. And let us know if there is a problem so we can correct it. We owe that to our moms and babies and to each other as professionals.

Jane Lowe RN IBCLC

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