Hi Jane - you've brought up a lot of issues here.   :-)

At 05:54 PM 29/03/03 -0600, JANE HELGESEN wrote:
>Denise,
>   Wouldn't you think that if a shield worked for the preemie who is
>even weaker and more sensitive that is should certainly work for the
>stronger, more developed full term baby?

First we need to ask 'why' it worked for Paula's prems.  My recollection
has it that even Paula only put forward some hypotheses as to why she got
such good results.  She mentioned baby with low tone being unable to form a
teat - with the shield this teat is automatically formed which then
stimulates the sucking reflex on the baby's hard palate.  She also mentions
the negative pressure that occurs in the tip of the teat holding the nipple
in position during pauses when the baby releases the suction.  I don't
accept this part of her hypothesis because as soon as the negative pressure
is released in the mouth, unless there is something covering the holes in
the shield then the negative pressure in the shield will be lost too.

Full term well infants should have normal tone and be able to form a teat
from the mother's breast tissue without assistance and maintain a negative
pressure in their mouth throughout the feed.  Because the reasons it worked
for Paula's cohort are not the same as this cohort you can't extrapolate
her results to them.

Other confounding factors with preterm infants is that in most Western
nurseries they will be very used to sucking on dummies/pacifiers.  So to an
extent they are already pretty well imprinted onto the feel and taste and
texture of a shield.  ie they will accept it more easily than the
breast.  This shouldn't be the case with full term infants, and I have
found that when mothers have flat nipples and a shield is started
inappropriately that it is very difficult to get that baby to accept his
mother's very different anatomy because they now expect a well-shaped firm
nipple to latch to each time.

Paula's study ONLY looked at milk transfer at a feed, comparing with shield
to without shield in this group.  Preterm babies are all prescribed to
ingest X amount of milk per feed - her infant's were all test weighed and
topped-up to their quota if they didn't obtain it at the breast.  Her
mothers were all pumping to excess too, so there was never any concern
about their supply being affected by the shields, and presumably letting
down to their infant at their breast would have been even easier then
letting down to that pump all the time.
We don't want to be test weighing well full term infants for several
reasons, two of which spring to mind are that it is stressful for mothers
(ie not conducive to low cortisol levels and good oxytocin release), and
that well full term infants regulate their own intake anyway - taking lots
some feeds and not much other feeds because that's just how they feel, not
because it's not there or they can't.
If, as the only studies on shields indicate, milk transfer is decreased
then either the baby has to feed longer to get what they want (and I'm sure
some do) or over time they don't get as much as they need to grow and the
milk supply begins to decrease.  As several have pointed out, these studies
which show a decreased milk transfer are done on babies who were feeding
well anyway.  Their value is in the awareness that when our
not-feeding-well baby is to the stage when he can feed well, then we know
that the shield is now limiting his ability.

So the continuum for the not-feeding-well-baby is:  little milk directly at
breast, maybe more milk with shield, but not as much as directly on breast
when he is capable of feeding well.

My comments on Paula's study so far have all been from memory (yes, I read
it very well!) and I don't have the time at the moment to pull it out and
read it again.... but I do *think* I remember that most, if not all, her
prems were off shields before discharge (ie before term corrected age).

I feel the big saving grace for shields for both prems and full term is
when the mother has an abundant supply which flows well (ie no problems
stimulating a milk ejection).  Like Esther I don't use shields before
lactogenesis II.

>In the last 6 months, our
>standing orders in labor have changed so they have added Fentynl to
>their "Nubain cocktail".   What is happening to our babies?

You now have a population of full term, not well, low tone babies.  Big
problems for breastfeeding with and without shields!

>       Paula Meier reassured me that if a baby in the NICU is not
>drawing enough milk from the shield (as happens at times) it is usually
>a technique problem and can most often be corrected with better
>positioning.

To get a good asymmetrical latch with sufficient breast tissue forming the
teat is difficult when a shield is on the breast.

>   I would also have to add what Barbara Wilson Clay has said
>about the sucking mechanism at the breast and some babies cannot
>properly extract milk from a thicker breast/nipple (something like this,
>sorry Barbara if I have misquoted badly).

Perhaps Barbara would like to expand on this....

>Or how many have been scared into
>getting off the shield and now babies can't nurse at all or are now
>having wt gain issues?  We never hear much about these babies.

Jane this is why we need good research.  We do hear about these babies
every time this subject is discussed, just as other LCs will tell us how
the shield was what caused the demise of breastfeeding for babies and
mothers.  Until shields are only in the hands of experts in infant feeding
who know how, when and why to use them, and that this knowledge is
evidence-based then there will be casualties from both not using them when
they are appropriate and from their inappropriate use.

>"Take the baby off the shield ASAP"

Can I re-phrase that to "Take the baby off ANY intervention ASAP"  As
experienced professionals we should know when that is possible - for an SNS
for some mothers it will be a week, for others 12 months.... same with
shields.  I believe that as soon as we introduce an intervention we should
be planning for its removal - get the mother/baby back to normal as fast as
possible for them.

I apologise to those who are sick of hearing my opinions on this subject -
I had felt that I had said as much as I needed to, but as this post was
directed to me I felt I should respond.
Denise


Denise Fisher
mailto:[log in to unmask]
http://www.health-e-learning.com

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html