Pat,

You do not mention the baby's age. Shields are not always a negative.
There doesn't necessarily need to be any hurry in "weaning"  the baby
from the shield if it is serving as a useful tool, (i.e., there is
adequate milk transfer and acceptable weight gain), at least for a month
or two. The diameter of the baby's mouth will grow in the meantime.

Here is my $.02 from an anatomical perspective, as I see it in my mind's
eye and try to convey it to yours. (Capitals are for emphasis only, since
I haven't found a better way to do it in e-mail.)

You describe the nipples only as <truly inverted> yet say <The nipples
will evert while baby is feeding through the shield, then as soon as he
eagerly attempts the breast the nipples turn inward and he is
frustrated.>

What you are describing seems to be what has been termed "umbilicated
nipple." The fact that it does appear to protrude after the vacuum occurs
on the surface of the nipple within the shield is a good sign.

An important question in my mind is "Where are the milk sinuses? (I know
this is now a debated question, but bear with me.) In other words, if you
were to try to do fingertip expression, would your fingertips be close
(within 1/2 inch) of the base of the nipple when you get the best squirt?
Or more like 1 inch, or even 1 1/2 inch?

From the info you gave, if there is adequate milk transfer going on, the
fact that the nipples move into the vacuum the baby creates in the shield
makes me guess the sinuses are fairly close to the base of the nipple.

As in the case of premies and better milk transfer WITH than WITHOUT the
shield (a la Paula Meier's article), if the baby is applying mainly
suction and not compression, the negative pressure through the hole in
the shield is acting directly on the surface of the nipple.

Since nature abhors a vacuum, in order to equalize pressures, atmospheric
pressure on the flesh surrounding the shield forces areolar and
subareolar tissues inward far enough that the shallower milk sinuses
compress themselves up against the inner ring of the shield.

This elicits a fairly good milk flow, especially if a good MER has
occurred. This factor alone is of tremendous importance, because
veterinary science has demonstrated it to be THE main force in milk
transfer.

Perhaps making things as simple as possible, helping her understand how
to trigger and use the power of MER is where the attention needs to be
directed at this time, rather than worry about weaning from the shield.
Breast compression will help the transfer even more.

In the case of a term baby, I think the same principle holds till the
diameter of the "gape" of the jaw can grow to match or exceed the
diameter of the nipple and/or the distance of the milk sinuses from it's
base.

I doubt the baby is "latching" on the shield in the best sense of the
word, and therefore, there is probably little or no compression on the
areola while he is using the shield. In this case of nipple inversion, I
think that is good for now, and correctible when the time is ripe.

There is a difference in the reaction of the nipple to mainly negative
(vacuum) pressure applied on the surface near the tip versus mainly
positive compression focused squarely on the sinuses (as in a less than
adequate latch).

The walls of the sinuses are directly attached to the ducts exiting
through the inside of the nipple. If these walls and exiting ducts are
not elastic enough, they will tend to shorten and retract on direct
compression of the sinuses and tug the inside of the nipple inward.
(invert it).

When the baby's jaws are large enough to achieve a deep, off center
latch, the compression of the upper jaw will fall IN FRONT of the main
portion of the sinuses, to provide support against which the lower jaw
and tongue can compress from BEYOND the main portion of the sinuses.

With the compression applied in this manner, the retraction is minimal
when the tongue is undulating forward against the areola toward the base
of the nipple. (Think of getting the last bit of toothpaste out of the
tube: you start compressing near the far end, right?)

I have had good success with several mothers with umbilicated nipples
with the use of the pump for 15 minutes 4x daily prenatally for the last
3 weeks of pregnancy, and possibly through the engorgement phase
postpartum.

This leads me to the impression that 4 weeks is a reasonable time frame
to use the pump to encourage sufficient eversion to prevent the nipple
from being pulled back inward by compression of taut inner attached ducts
in the case of the umbilicated nipple.

Eventually by the process of tissue expansion (like abdominal skin,
muscle, etc. stretch during pregnancy), if sufficient traction is applied
frequently enough, the inner ducts and walls of the sinuses at the base
of the nipple will become somewhat longer and more elastic and  the
nipple will no longer "retire so easily" when the sinuses are compressed.


I would consider letting the shield be used for feedings for the present,
observing milk transfer/weight gain, and using an electric pump as
described above for a month longer, during which time the baby's mouth
will also grow.

If milk transfer is not adequate, I have had mothers supply EBM  under
the shield by fingerfeeder tube (good for intentional "boluses") or
supplementer tube (steady flow determined by height of supplementer).

I might also consider some pleasant, pacification type non-nutritive
"games" after the baby is well fed and the sub-areolar tissues are more
pliable from recent feeding or pumping, just to keep baby acquainted with
bare flesh (even if latch is not the best) and the breast as a delightful
place to hang out. Second choice would be a knuckle.

Above all, it is important IME to avoid "battleground" associations with
the breast, as this often ends up in increasingly aversive behavior.

I hope these ideas are helpful, and I am interested in the reaction of
other Lactnetters.

Jean
************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio, USA

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