This is my protocol:  I base the size of the shield I use on the infant's mouth and occasionally the mothers nipple.
I use the largest one possible but generally very small babies <5 lbs need a 16 mm.  These mothers are 
always pumping.  Usually a 6 lb baby can use a 24 mm.  Between 5-6 lbs I usually use a 20 mm.  
I have found that if the shield wrinkles or the baby keeps spitting it out or chomping on it when the baby is latched its an indication it may be too big.
Now having said that a small baby with a big mouth might do fine with 20 mm while a 6 lb baby with a small mouth might still need the 20 mm.
Almost all my moms using a nipple shield are pumping if they are not pumping its because the baby has demonstrated that he or she can 
transfer enough milk for a feeding and can gain adequate weight.  ONce the baby is exclusively breastfed with the shield and gaining an ounce a day for a week.
 I have mom start practicing 1-2 times per day without it.  Usually within 2 weeks the baby is completely weaned from the shield.  
Sometimes I use the shield just to show the mom (especially preemie moms) the kiddo can latch--not expecting much transfer but just so the mom can experience
her baby latching--it keeps them motivated.   
Christine Betzold NP CLC MSN
www.theBFClinic.com




 

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