Regarding a consent form for use of nipple shields:

We do not have a consent form; however, we do have a printed instruction sheet
that we give to each mother using the sheild.  These instructions are printed on
colored paper, 1/2 sheet.   Please credit the source if you use it.

                NIPPLE SHIELD INSTRUCTIONS

1.  The nipple shield is a temporary aid to help your baby learn to nurse.

2.  It must be kept clean like any other artificial nipple.
***Wash the shield in hot, soapy water.  Rinse with clear, hot water.

3.  You may use the shield at every nursing or as often as you need to use it
for the next 2 to 4 days.

4.  After your baby is attaching well and nursing with the shield, begin weaning
from it.
***Offer your breast using the nipple shield.
***When your baby is attached well to your breast and you
hear him gulping, gently and quickly ease your baby off the breast and allow the
shield to drop to your lap.
***Offer your breast without the nipple shield.

5.  If your baby does not attach to your breast without the shield in place, do
not worry.  Simply put the nipple shield back on your breast and finish feeding
your baby.  Repeat this procedure at the next feeding.

6.  If you are still using the nipple shield after 2 weeks, call to arrange an
appointment for assistance in weaning your baby from the shield -- 543-2241.


NOTE:  The nipple shield can be a helpful device.  However, it is cumbersome to
use and long term use may lower your milk supply.

                Mercy Lactation Support Center
                        (704)543-2242