I certainly agree with all those who have warned about nipple shield
use.  Any transitional tool, as Kathleen Auerbach pointed out quite
recently, can be easily overused.

I stopped hiding nipple shields after the following incident.  A nurse
who is a staunch breastfeeding supporter reported having worked for an
hour during the night trying to get a baby with inverted nipples to
breast.  The infant was small and she felt he needed food, so she had
bottle fed him (no alternative feeding methods had been approved at this
time--still have a number of doctors who won't allow them).  When I
looked at the mother's nipples, they resembled craters.  I don't recall
having seen any before or since that looked like that.  I decided that I
would rather have the baby use a shield (even if we had to supplement)
rather than not breastfeed at all.

When nipple shield use got out of hand a while back, I posted a notice
saying that anyone who used a nipple shield and left it on for an entire
feeding had to be sure the baby was getting enough milk, had to notify
me, had to notify the doctor, and had to start the mother pumping.  So
much for the quick fix.  Nipple shield use plummeted.

When do I use shields?  Usually when the baby has already had bottles
and thinks milk only comes from plastic.  I try to use the shield only
at the beginning of the feeding.  If I have to leave it on for the
entire feeding and I don't think the baby is getting milk through the
shield, he is supplemented, and the mother is taught to hand express
and/or to pump.  I have even used a 3-step approach, which sometimes
works.  Mother holds baby close while I give the baby sips from [don't
tell anyone] a bottle, quickly switch to the nipple shield with formula
sprinkled on it.  If baby does well with the shield, we try removing it.

In our culture, women want a quick fix.  I see mothers all the time who
are ready to quit breastfeeding in the first postpartum day.  If the
mother or doctor is unwilling to consider another transitional feeding
method or the mother can't tolerate dealing with the baby's frustration
with repeated efforts at the breast, the "last resort" is often
necessary very early (in my opinion).

A note about IBCLC hours per # of hospital births--I am the only IBCLC
for 2 hospitals 15 miles apart.  Each hospital has over 150 births a
month and a breastfeeding initiation rate of around 75%.  (We do have 10
staff nurses between the two hospitals who have taken a basic
breastfeeding course.)  I'm sure more breastfeeding education and
lactation staff would make us less dependent on technology.  However, it
is very expensive for hospitals to pay nurses for "non-productive"
hours, so we are trying to figure out how to best use the resources we
have and to educate without putting out any more money than is
necessary..

Bonnie Jones, RN, ICCE, IBCLC
from the sunny S.W. USA