Hi, All:  Interesting to hear that so many of you use a 24mm shield in most 
intstances.  I, on the other hand, in most instances will use a 16mm 
shield, unless mom's nipples are too large to fit comfortably on visual 
exam or they get too large while being milked.  I guess my shield of choice 
is the 16mm, going up to a 20mm, if it is warranted.  I agree with you 
Kathy - why aren't 20mm shields available as a contact?  I don't believe 
I've ever had a mom come back and tell (or show) me that the shield I gave 
her was too small.  I have had, on the other hand, several instances where 
a mother was given a 24mm shield by someone else and after reassessment by 
me, asked to try the 16 or 20 mm shield, and have the mom tell me she has 
much more success with the smaller shield.  My rationale?  With few 
exceptions (and those are usually some kind of syndrome present in the 
baby) even most 32 weekers can get the mouth open wide enough to take in a 
nipple size that falls within the "usual" range, leading me to almost 
always fit the shield to mom's nipple, rather than the baby's mouth.  If 
you use a slightly smaller shield, rather than a slightly larger one, as 
the baby sucks, the nipple is pulled into the shield and formed within the 
shield due to the baby's sucking.  Moms tell me they feel the suck much 
more than if the nipple is flapping around inside a shield that is too 
large to mold the mother's nipple.  Very occasionally I will have to go up 
a size, if the tip of mom's nipple is being jammed into the end of the 
shield.  I also feel that there is a higher risk of the baby's gums closing 
on the tip of mom's nipple inside the shield, leading to nipple 
soreness/damage when using a larger shield because the baby cannot get as 
far back on the larger shield as he can on a smaller.  I believe the 
difference in the shields is the diameter, with the length staying the 
same.  But if the baby's mouth is stretched more in the horizontal 
direction to accomodate the diameter (width) of the shield nipple, then the 
shield nipple will not fit as far back into his mouth as maybe it should, 
thereby increasing the likelyhood of damage to the mother's nipple.  I also 
see better milk transfer due to what I believe better mom's nipple 
stimulation with the smaller shields.
Whew!  I hope this makes sense.

Pam Hirsch, BSN,RN,IBCLC
Clinical Lead, Lactation Services
Advocate Good Shepherd Hospital
Barrington, IL  USA

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