A variety of nipple shield designs still exist and there is a wide range of
shield sizes in terms of length and base diameter.  This fact means that it
can be difficult to generalize about nipple shields, as a mother may have
obtained one of antique design.  For instance, I had the privilege of
meeting Magda Sachs in Paddington Station in London last Winter for a cup of
tea and a lovely visit.  She presented me with a nipple shield she purchased
at a local chemist (drug store).  It looks identical to the design of
shields from the mid 1980's that are pictured in Maureen Minchion's book,
Breastfeeding Matters, and also in Riordan and Auerbach's chapter on bfg.
equipment.  I was stunned that these are still around!  Her gift helped me
realize that my mental image of a shield may be quite different than the
device a mother may have been given. Also, own experience with new thin
silicon shields is that if they are sized to the MOTHER'S NIPPLE rather than
to the BABY'S MOUTH, they may be an impediment rather than a help. The issue
should always be: Can the BABY accommodate the shield?

 With all these caveats in mind, there is clinical evidence that milk
transfer is actually IMPROVED for the weakly feeding infant WHEN:
 1.shields are chosen after a careful clinical assessment and are the right
tool for the problem at hand
 2 they are the right size for the baby
 3 they are thin silicone
 4 when positioning and latch are good.

 This is because infant suction pulls the maternal nipple up under the
shield . Then, even if the baby releases suction (due to lack of stamina,
etc) the negative pressure holds the nipple in an elongated position.  This
compensates for the baby's inability to sustain the forward hold on the
nipple.  That slight negative pressure may also cause the nipple to keep
leaking milk, creating a reservoir of milk to pool under the tip of the
shield cavity.  Then, if the baby makes even a feeble attempt at the next
suck, a quick milk reward inspires the baby to keep trying.  This makes the
shield an impressive bridging device for the "nipple confused" baby, who is
often discouraged at breast compared with the rewards of the bottle.
Finally, for the mom with inverted nipples, the shield extends (artificially
until the mothers own nipple stretches out) the length of the nipple so that
it strokes the palatal junctions and stimulates the sucking reflex.  Without
this stimulation, the baby will be apathetic about taking the breast.  There
is a lot of information in the literature referencing all these statements.
We have a whole chapter elucidating these matters in The Breastfeeding Atlas
(with photos) and the new Breastfeeding Answer Book also reviews these
issues.  Almost any recent bfg book has up-dated info on shields that is
more current than the old studies that are cited describing reduced intake.
The technology of the new, thin silicone shields is different from the old
Mexican hats and antique designs, however it is important to be aware of the
persistence of shields of old design and of the size issue.  All shield
intitiation should be done after in-person assessment, and shield use should
be monitored to assure the baby is gaining appropriately.

Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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