Hi, Jan.
       You want to know about nipple shields.  First off, you all need to
know that I do not work in a hospital, so rarely see babies before 3 days old.
That affects some of my answers on this topic.
       If  baby acts like he doesn't know the nipple is in his mouth, I will
try a nipple shield.  I believe that how the nipple shield is applied is
*very* important.  I have moms turn the shield about halfway inside out, set it
against base of nipple, and flip it quickly right-side-out, so that there is
suction that will hold the shield in place, but more importantly, so that the
suction draws out the nipple tissue more like the baby *should* be doing.  I think
this helps baby be better able to compress the "milk sinus" (we need a new
name, other than "magic spot").
       If use of the shield allows baby to have perfect breastfeeding form,
and mom's breasts are soft after the feeding and baby is content, I do not have
mom do insurance pumping.  However, if use of the shield allows baby to latch
when he couldn't do it before, but his form still needs some work, then I do
ask her to do 5-10 min/breast, depending on how poor the feeding is.  And I
explain the parameters for "poor" and "better", so mom can decide for herself
whether it needs to be 5 minutes or 10 after any particular pumping session.  I
do this because I know that as babies get better at breastfeeding, they rarely
make a straight bee-line from "where they are" to "where we want them to be."
 Instead, they usually will do a great feeding and get mom all excited, and
then do 3-4 feedings where they act like they never saw a breast before in
their life, and "why does mom want me here?"  Gradually, the good feedings become
more frequent and the poor ones come farther apart, and I want mom to be able
to realize the difference and know how to meet her own pumping needs.  (It
empowers her and makes my life easier!--grin)
       I also have moms pump after each feeding if it is obvious that she
does not currently have enough milk because baby has done a lousy job of giving
mom's body the right signals for building supply.  Since I have moms do
insurance pumping (though I'm not sure you call it "insurance" when you are
reasonably certain the baby did not empty the breast) when baby did not appear to feed
well or when baby is obviously still hungry but won't stay at breast any
longer because he is frustrated, I then also have mom *offer* supplement using my
method of bottle-feeding.  I stress *offer* (not force) and let mom know that
baby will take less if he got more from the breast.  I tell her that any time
the baby appeared to breastfeed well (and we've discussed just what that means)
and the baby is not interested in any supplement, she can skip pumping after
that feeding.  Again, pumping just naturally happens less and less as baby
breastfeeds better more and more often.  This, to me, seems so much better than a
plan that demands "x" amount of pumping for "x" amount of time.  Those "do
exactly this" kind of plans remind me too much of the way physicians used to do
formula in the early 20th century:  make your baby's food this way this month,
then see me again next month and we'll give you a new recipe.  I want mom to
feel she is responding to what her baby is doing, rather than following a
prescriptive sort of plan from me.
       Of course, throughout this, I always have moms carefully watch diaper
counts and I ask for follow-up phone calls every few days (or sooner if they
have questions), to be sure things are progressing the way I expect them to and
to catch it when it doesn't.
       Dee

Dee Kassing, BS, MLS, IBCLC
Collinsville, Illinois, in central USA

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