OK--I have to "weigh in" on this debate.

I have seen several babies in the past few weeks that clearly benefited
from shield use, but various sources (hospital LCs, friends, books) had
told moms they should not be used because of their effect on milk
supply.

The case that was the most frustrating was of premature twins who are
not exclusively bottle-fed.  If anyone deserves a try at a shield if
they are not able to remove milk without one, it's a preemie, as folks
have already cited.  But several babies can benefit from their use.

Let me preface the rest of my comments by pointing out that I do NOT
work in the inpatient setting, so the absolute youngest babies I see are
36-48 hours of age.  Most are 3 days-3weeks.  And I obviously don't meet
them unless/until they are having trouble.

I find shields can be useful in any situation where the baby is unable
to pull the nipple-areolar complex fully into the mouth.  Causes for
this include short tongue, receding chin, prematurity, low tone (i.e.
Down's), and occasionally mild tongue-tie. (In a situation where parents
are absolutely opposed to clipping, or frenulum is stretchy enough that
I am not sure it needs clipped)   BUT IT IS ESSENTIAL that the shield is
applied properly.  It must be turned half-way inside-out as it is placed
over the nipple, and then it pulls the nipple/areola out into it FOR the
baby.  I explain to parents it takes this job over for the baby, so
he/she has one less thing to do.  It is not helpful to place it over the
nipple if the baby cannot pull the nipple/areola completely into it.
That would be one reason milk removal/supply might be affected
negatively by shield use.

Another reason a shield can be useful is in transitioning a baby from
bottle to breast.  (I also see a fair amount of these)  Babies often
seem to need that more "stiff" stimulus in the roof of their mouths to
initiate suckling on the breast after they have been using bottles, or
even finger-feeding.  Or if mom wants to relactate, she can sometimes
more easily supplement an older baby at the breast with a tube under a
shield at the breast.  (Older babies often refuse the tube or
selectively suck on it...and have been used to the feel of bottle
nipples) Or if a mom has extremely flat, but pliable nipples, and the
baby can't seem to "find" where/how to latch, the shield can help orient
the baby.

In my experience/setting the most common reason I see for nipple shield
"failure", is that the baby has an ineffective suck (no milk removal),
so a shield is placed over the nipple, and the baby continues to (pick
one) continue "chomping" on the tip only, or tongue-thrust against it,
or simply suckle at the nipple only.  All of these cases would proceed
to ineffective milk removal and decreased supply.  So when we try a
nipple shield during a consult, we do pre and post weights to document
good milk removal, and follow closely with weight checks.  I believe
that they are a very useful tool, and do NOT affect milk removal/supply
if used correctly.  But if they do not "solve" the baby's
original/underlying problem, obviously supply will go down.

It is useful to note the latest edition of The BF Answer Book has
included up-dated info on nipple shields, explaining that they no longer
affect milk supply in and of themselves.  Some moms have older editions
of this, and are relieved to hear this "official" sanction.

Kathy Leeper, MD, IBCLC
Medical Director
MilkWorks- Lincoln, NE

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