Karleen sounds like I did before I saw how the nipple shield worked on
premies.  My former supervisors had me scared to death of using them and I
was always admonished that the baby might not transfer enough milk.  We
always used an SNS,which in many cases was inappropriate.  What a nice
surprise I used a nipple shield for a premie and it worked.  I don't use
them  often, but I have a better sense of when and how they work.  Knowing
how to use a tool appropriately is important to avoid overusing it or not
using it at all when it would be helpful.

What helped me learn about appropriate use of the nipple shield was
observation and discussion with my colleagues.

Karleen - if you ever make it here, I would love to have you come to our
support groups to observe and even talk to some of my former clients.
Observation can make a huge difference.  All of your qualms I think come
from the possibility of inappropriate use of the SNS. With careful
management, I have lots of cases where they have gotten off the SNS.  It
happens all the time.

Babies don't HAVE to get used to the SNS. In most cases with a good latch,
I think what babies notice is the flow, not the tube itself.  So, if they
get used to a fast flow from anything (SNS + breast, bottle, fingerfeeding,
cupfeeding) then they are going to continue to expect a fast flow.

YES, I can see how the SNS can work in a way that is similar to the rat
study you described.  If the bottle were placed high - the tube was placed
downward on the breast, or a too rapid flow, the baby would indeed have no
control over flow.  That can be just as harmful as using a bottle
inappropriately.

What I have found happens when a mother has an abundant milk supply and
uses the SNS is that the baby comes off choking, clamps, retracts the
tongue.  I have less often seen that the baby won't take milk.  I alwasy
have women watch for this and call when it happens.  That's when we up the
breast alone time - drop tube sizes - or sometimes even drop the SNS below
waist level, depending on the particular case.  Or, in some cases with a
mom who has a rapid milk ejection reflex - I use other strategies.  For
premies with a mom with a rapid milk ejection reflex, the nipple shield can
sometimes work like a charm.

I find it really helpful to always check for milk transfer from the breast
while using the SNS. So, yes Karleen, I have documented where a baby is
taking next to nothing from the SNS.  I swear it happens, because I've
measured it.

But I want to make it clear, that we do everything to avoid combining a
rapid flow from the mother with a rapid flow from the SNS.  That's not
helpful.

When a baby is capable of sucking effectively initially that then gets
tired on the breast, we start breast alone, use breast compressions, switch
breasts, and then add the supplementer when the baby is still hungry but
can't help the mother release milk anymore.

I have a whole study designed for looking at tube placement and venting and
I think this type of study should really be done.  It would confirm all of
our individual observations about how best to use supplemental devices - or
refute them. We're trying to rebuild our practice after Elizabeth Seton
closed and I have a small son, so I don't have time to do it yet, but I'm
working on my former colleagues at Cornell, and anyone who is interested
and won't forget about this until someone eventually does a well-designed
study.

A separate study should be done on different supplemental devices.  As I
mentioned before, I was amazed when I discovered through the very large
Elizabeth Seton breastfeeding support group that some women were able to
get out of a low supply, inappropraite suck with an Avent bottle (which
seems pretty quick to me) and a pump.  I think patience and diligence will
win out with many different strategies.  What we need to figure out is what
is the fastest strategy for each of the many different situations we
encounter.

The reason why I don't use the Lactaid initially is simply because it is
difficult for women to assemble.  Once they get the assembly, they often do
like it better.  For clients who are just starting to use a supplemental
device at the breast, having to cope with tricky assembly may be just the
thing that causes them to give up.  Even the SNS is tricky.  So, for very
young infants - I often start with a simple syringe and tube that we
provide free.  If the woman can handle that, and the baby needs longer term
assistance, then we switch over to the SNS.  If they can't handle the tube
on the breast, we try other strategies.  If it is an adoptive mom - then I
talk about the Lactaid right away.

The SNS and all the other similar devices are not evils that keeps moms
from bonding with their babies and babies from learning how to breastfeed.
It is simply a tool that can be helpful when used appropriately and
interfere when used inappropriately.

AND finally, I have to pipe up about our visions of the NOBLE SAVAGE!!!
That somewhere or sometime in the past, there was breastfeeding
perfection.  I have lived and worked in many different developing
countries.  I can guarantee that there is no breastfeeding utopia.

They use different tools to solve breastfeeding problems than we use, but
they are not problem free.  Just to give one example, the "pump" that is
used in some cultures is an "older child".  The "supplement" is another
mother that has fully established lacatation.  The older child (pump)
relieves the engorgement, the newborn goes to another fully lactating mom
(supplement) and this is how the problem is fixed.

Also the mortality rates in many of these countries are extremely high - so
there is a lot that is hidden and undetected in those mortality rates.  I
am sure that there are some babies that die because they have significant
problems with their suck and end up underfeeding.  I still remember
conversations with mothers that, in retrospect, suggest to me that there
was something real going on that interfered with their babies driving the
supply.  Someday I also dream of going back to my work in developing
countries and reexamining some of these problems.

Best, Susan Burger

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