I want to support Pardee Hinson's excellent post about the use of nipple
shields as a clinical intervention.  All professions have "tool boxes" with
specific tools for specific purposes.  Part of the growth from novice to
expert in any trade involves increasing sophistication in the appropriate
choice of the right tool for the job.  I wouldn't ever want anyone to
carelessly toss a mother a shield merely because they couldn't come up with
a better plan.  This would be especially dangerous if they had no plans to
continue to be involved with the mother to monitor the outcome of the
intervention, revising the care plan on an as-needed basis to insure the
safety of the infant.  Nor would I want a practitioner to eschew the use of
a very effective tool merely because it has a suspicious reputation.

In short, it is rather like suggesting to an apprentice carpenter that a job
requires a screw driver without going into the explanation that there are
different size screw heads.  Or making the assumption that a sledge hammer
will get the same results as a ballpeen hammer.  Tool choices can be subtle
and work very well, or they can be inappropriate and result in poor quality
craftmanship.

In the case of shield use, Pardee is correct.  Shields work well when
infants can't "locate" the maternal nipple.  This results from maternal
anatomical issues such as flat, soft, inverting or non-elastic nipple
tissue.  It also results from infants with poor intraoral stability:
prematures, neurologically impaired, and drug affected infants.  The shield
can increase the tactile responses inside the infant's mouth needed to
trigger reflexive sucking.  If the mother has a good milk supply, milk
reward will be quick (which is why she should be augmenting her breast stim.
with pumping).  The baby will then be induced to suck and swallow, and will
begin to trust that feeding at the breast will effectively satisfy hunger.
Once the trust is re-established, the baby's anxiety is reduced.  As the
primary reasons for the initial problem resolve, the baby is weaned off the
shields.  You can't hurry this part, and people need to trust that as the
situation improves it isn't all that hard to switch to the breast.  Weights
are monitored in the interval, and contact maintained until baby is doing
well without the shield.

One last important point.  I think a lot of bad outcomes with shields are
related to the wrong size shield being used.  Babies have small mouths. They
have to be able to position jaw closure over the lactiferous sinuses in the
breasts.  If a shield is too "tall" (ie shield height is longer than the
reach from posterior palate to lip  seal) then the baby will be milking the
shaft of the nipple.  This doesn't produce good intake if you are NOT using
a shield.  I use the smallest size shields available, tho I wish the
manufacturers would consider slightly enlarging the base of the newborn
small size shields to accommodate larger diameter nipples.  I hope they
don't change the present newborn smalls because I like them so well, but to
ADD a slightly larger diameter with the same height teat  (1.9 cm) would be
useful.

Barbara Wilson-Clay, BSEd, IBCLC
Austin Lactation Associates, Austin, Texas
http://www.jump.net/~bwc/lactnews.html

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