Frequently in this list I've heard people complain about the resistance to change seen amongst some doctors and nurses when it comes to lactation management. It's very difficult for people to change practice when presented with new information. It brings up a lot of emotions and stress for people. Humans are emotional beings and we tend to react emotionally to new information rather than rationally because we are not robots. Many times what people hear is that we are saying they are bad practitioners, which is not at all true. I understand it's tough. If nothing else, hopefully when we look at issues like this, we can have some measure of empathy for other HCP's who are also doing their best to help mothers. However, the fact remains that there is no research (this was brought up in a prior thread on this list) showing the newborns ability to transfer colostrum across a shield. If you have some other research, please present it. I understand we all work in less than ideal situations, however, if this is not the best soluation to the problem, we should look at that and think about changing practice if necessary to a solution that results in greater success for parents. 

I'm not a hater of nipple shields, I find them useful in certain situations. Although, in my opinion they are greatly overused, used too early, used in the wrong situations mostly, and many parents are not given enough teaching regarding problems associated with their use and ways to maintain their milk supply when using a shield. Very often when I see parents in an outpatient setting, they can't even verbalize to me how to know if the baby is getting enough to eat! If nothing else that's basic safety information especially when they are using a shield. I don't criticize RNs and LC's giving them in the hospital. I'm not going to say - oh you had a terrible nurse! But I do provide information to parents about how milk production works and how the nipple shield can effect milk supply. Failing to do so would be negligence on my part, in my opinion. If we don't provide this information to the parents, they end up blaming themselves and not understanding what went wrong with breastfeeding, and they are at risk of encountering the same problems with the next baby as well. 

It's merely our job to provide information about best practices, it's the parents job to decide what to do with it. If you recommend to them that best practice is to hand express and spoon feed colostrum and they decline, then that's their choice. We can't become emotional or overly-invested in their decisions. We should also keep in mind that we are doing the best we can with the information we currently possess, just like everyone else. But we need to keep in perspective that in 20 years, it's highly likely that at least 25% of what we are saying now will probably be shown to be incorrect. It's just how medicine works. If you traveled back to 1985 or 1995, how many things would we find have changed since then in lactation? We need to really resist having an emotional reaction to new information. No one knows everything and information is always changing. It means that we are great LC's when we DO change our practice, because we are keeping up with current information. I agree with the sample policy guidelines that were presented here. Only an LC can start a shield prior to mature milk production, nipple shields are avoided prior to mature milk production, test weighing must be done, the mother must begin pumping/expression when using a shield, follow up support within 24 to 48 hours, proper teaching is given, and the priority intervention should be hand expression and supplements with colostrum instead of using a shield. I'm going to try to get a similar policy passed in the hospital where I work. I have a feeling that the Pediatricians will be supportive, they are also concerned with large weight losses we see when mothers are using these shields on the first day. This seems to me to be a reasonable and safer method of increasing the chances of successful breastfeeding for the mother and baby. 

I would also disagree with the sentiment that parents are exhausted and don't want to express milk but would rather have the quick fix of a shield. When you present them with the information, the vast majority of parents I meet are very reasonable people who want to do what gives them the best chance of success. When they understand that you can't force a baby to the breast before they are ready, they will be ready eventually (I don't know when), and the priority intervention is to get mom's milk into the baby, I find that 95% of them opt for hand expression. Occasionally I will get a parent that is insistent on pumping, so after I let her know that the pump is not designed for colostrum and she may not get much out with the pump (don't despair), I get her a pump. Because occasionally you get that rare 10% of women that get a lot of colostrum with a pump, but they are the exception rather than the rule. Then we try hand expression and most are amazed at how much more milk they get that way. Pumping is a lot of work and hassle (in my opinion) but using your hands to express out some colostrum is much, much faster and easier than getting a pump, setting it up, using it and then cleaning it up. Also, the vast majority of women will only need to do this for 12 to 24 hours before the baby latches on well. I usually will recommend to the RN's that if the baby hasn't latched on and transferred milk well within 6 to 12 hours after delivery, they should teach the mother to hand express every 2 to 3 hours and keep baby skin to skin as much as possible. I don't think the baby necessarily will starve and could probably go longer without food, however, it relieves the parents and increases milk supply too. So there is no reason not to begin at 6 to 12 hours. And this should be based of course on effective milk transfer, not minutes at the breast. If the baby goes to breast and has a weak suck or does not swallow, they should also hand express and supplement with colostrum. I found our best success by developing two breastfeeding decision trees. One for babies that are transferring milk well and having at least 6 feeds in the first 24 hours and 8 feeds every day after that, and another protocol for identified poor feeding in which hand expression is initiated. We start all of our late preterm babies on the poor feeding protocol prophylactically.
Tricia Shamblin, RN, IBCLC







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