Winnie,
I agree with the indications you are presenting, but I still question if
milk transfer is actually taking place in the early days pp.  I prefer hand
expression and feeding these babies with a tiny spoon until milk is flowing
more freely.  In cases where I can hardly express enough colostrum to form a
small puddle in the middle of the spoon, I wonder how the baby can remove it
himself with the shield in the way.
Of course it would be temporary, and I have used shields on moms of preemies
who have been pumping for weeks, and have Niagara Falls milk supplies which
the baby actually handles much better with the shield.  But that mom with
the flat nipples who we can hardly squeeze out a few drops of colostrum may
not be served well by the shields, and my have a false sense of security
that she is breastfeeding.
Esther G

-----Original Message-----
From: Jim & Winnie Mading [mailto:[log in to unmask]]
Sent: Friday, March 28, 2003 3:56 PM
To: EDG; [log in to unmask]
Subject: Re: Nipple shield use in the first 3 days pp


Esther,
I have used them on occasion during the postpartum staty (which here
is generally from 24 to 72 hours depending on type of delivery).
This is done only after nothing else has worked and always after
telling mom it must be considered a "temporary crutch".  We
recommend she always try nursing without the shield first, try
removing after a few minutes if baby needs it to start and give lots
of skin-to-skin cuddling in addition to feeding time.  She is
reminded to keep close watch on baby's output and if baby's doc
isn't planning to see baby within a couple days, we plan at the
least a phone call, and if there are any concerns at that time, an
in-person weight and assessment with an LC.  Depending on
circumstances we will ofter recommend she also pump for additional
stimulation.  We suggest some nipple stimulation before applying the
shield just as we do with pumping  so the nerve endings in the
nipple get good stimulation and help with the release of oxytocin
and prolactin.
And, yes, moisture in the shield after baby finishes is not the same
as obvious milk in the shield.

When might we use a shield with a term baby?
1-Baby is obviously looking for firmer stimulation at the back of
the palate immediately.  This is frequently the flat or inverted
nipple, although many with these are able to latch just fine
"naked".  We will have tried everything we can to get a better latch
before considering the shield.
2- (very akin to number 1) Baby has for one reason or another
already gotten "imprinted" on the artificial nipple-bottle or
pacifier) and will not go directly to breast - shield can be a
bridge back to direct nursing.
3-Mom used one with her previous child and is adamant about using
one now in spite of anything we may say to encourage her to try
without.  She states she will either use a shield or bottle feed!
(These are so frustrating, but we do get one or two a year.)
4-Baby is slow to learn to nurse and mom has reached a point where
she is so frustrated that, in spite of our reassurances and help,
she is ready to throw in the towel if she doesn't see some degree of
"success" in the next 5 minutes.

We always document the reasons for shield use, instruction to mom
and follow-up plan.  When the LCs are available, nurses are not to
initiate shield use without first consulting with the LC.  On off
shifts, they must follow the Policy and Procedure which includes
notification of the LC as to when, why and instruction given mom so
the mom/baby can be followed up ASAP.

Most moms get baby nursing directly within the first week.  Often
this happens "out of the blue" when for whatever reason, baby
decides enough is enough and latches like a pro.  Other times, we
have to keep coaxing baby until he/she is able to nurse directly.
In my 15 years at this hospital I know of 2 who nursed successfully
for months with a shield, but that's 2 out of thousands.  Those moms
who quit before getting baby off shield seem to be quitting for the
same "reasons" as moms who quit and are not using a shield, although
this is from recollection, not recorded statistics.  It would make a
great research project which we may do when we are done with our
current projects.

Winnie

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