Continuing the thread on nipple shield use and echoing Laurie Wheeler's great response to Michelle's request, I'd like to share my own clinical experience in assisting very young newborns as they transfer their learning from nipple shield use for successful latching, to latching well without the support of the nipple shield.  

From 2005 to 2008, I worked in a large metropolitan hospital with an annual birth rate of 12,000 live births, where I was one of 3 full-time IBCLCs among a total staff of 8 IBCLCs, including part-time and prn staff.  This was not a Baby Friendly facility, and although nipple shields were not available to members of the nursing staff and only IBCLCs had access to nipple shields, there were many nipple shields in use due to the high frequency of bottled supplementation for hyperbilirubinemia, hypoglycemia protocols, as well as bottled night feeds in the nursery, etc., which is to say that following infants' observable skill decay for latch and/or effective suckling after the use of an artificial nipple, nipple shields were often used to support the baby's willingness and ability to successfully respond to the maternal breast re: latch and/or effective suckling. 

In my last year there, I felt a personal and professional drive to gently try harder to get my little patients off nipple shields, and thus I introduced finger-feeding to my practice (by this time, I had been an IBCLC for 10 years, had not observed FF in my clinical practice or others' clinical practice prior to that time, but I was skilled with cup-feeding and tube-feeding at the breast).  My wish to help babies further was born of desperation to avoid the lengthy patient teaching necessary at discharge specific to mothers going home with babies who were latching only with the support of a nipple shield (my quiet desperation was due to the tremendously high volume and short-staffing far below the standards of care, and often-strict limits to the hours in an assigned shift).  

In spite of providing these mothers with verbal teaching and Medela's nipple shield handout as well as a handout for outpatient follow-up with a listing of private practice IBCLCs, I still worried that many new and exhausted mothers would not fully comprehend the need for the recommended nipple shield management, and then have a baby who was at risk for slow weight gain, no gain, or ongoing weight loss, as I had often observed in my previous (and subsequent) private practice.  

I consulted my Riordan & Auerbach text regarding finger-feeding, reviewed the content several times, then tentatively introduced it into my inpatient practice, using a 10 ml syringe with a #5 French infant feeding tube (we did not have formal finger-feeding equipment on hand).  Much to my surprise, I discovered that in this inpatient population consisting primarily of 3-day-old infants and younger who were unable to latch without a nipple shield, 8 out of every 10 of my little baby patients were then latching without the nipple shield within the first 24 hours of finger-feeding.  This included one little baby who latched without the nipple shield within 2 minutes of finger-feeding, and another little one who latched after two separate finger-feeding sessions.  

So that was 8 out of every 10 babies using a nipple shield who then displayed a "positive transfer of learning" for latch after finger-feeding over a 24-hour period.  I was amazed about the entire finger-feeding concept at this point.  

For the remaining 2 out of 10 babies who were 3 days of age and younger and who were also unable to latch without a nipple shield, 1 out of 10 babies displayed a positive transfer of learning to latch without a nipple shield after finger-feeding for a second 24-hour period.  

For the last 1 out of every 10 babies who were 3 days of age and younger who were unable to latch without a nipple shield in spite of one to 2 days of finger-feeding (reflecting a zero transfer of learning), one of 10 babies were discharged home using the nipple shield, and this was almost always associated with shorter nipple anatomy, flat nipple anatomy, retracting nipple anatomy, inverted nipple anatomy, and/or breast engorgement.  

Prior to incorporating finger-feeding into my practice, my perception of finger-feeding was that it was not that much different than bottle-feeding due to the long, firm shape of mother's finger.  After I tentatively introduced finger-feeding into my practice in 2008, I observed one display after another by babies who transferred their learning by finger-feeding re: no longer needing a nipple shield to latch.  To avoid a possible and likely flow preference by the baby for an immediate flow of milk with the first suck, I advised each mother to let the baby suck on her finger without giving milk for approximately 30 seconds to a minute (unless she was a mother with an observable immediate MER when previously pumping).  The other exception to this short delay of milk at the onset of the finger-feeding session (to create similarity for the mother's MER) was when the infant was in advanced hunger and was not calmed by sucking only; in such instances, the baby was then calmed with milk during the early session of finger-feeding.  

Although I kept a private log of my informal observations, a formal research study undertaken today could incorporate motor learning principles.  Kinesiology is the study of human movement, motor learning, and motor control, and kinesiologists often measure movement in ms (milliseconds), such as the reaction time to the stimuli, the response time to the stimuli, and the movement time for the task as well.  These measurements would be so very helpful in further studying and further defining infant feeding confusions and feeding preferences.  For example, the rapid learning and relearning seen during the first three days of life corresponds to precepts from the field of infant cognition, which describes the "exuberant learning of infancy" as the younger the infant, the faster the learning, and forgetting is faster as well.  This is the case in all species studied, including humans.

Some definitions from the field of motor learning:

reaction time (RT):  the interval between the presentation of a stimulus and the initiation of a response (which is often prolonged at the maternal breast after the baby has a learning experience with an artificial nipple).  

response time:  the interval from the presentation of a stimulus to the completion of a movement; the sum of reaction time (RT) and movement time (MT).  Response time is often prolonged at the maternal breast following the infant's learning experience with an artificial nipple.  

movement time (MT):  the interval between the initiation of a movement and its termination.  Following the infant's learning experience with an artificial nipple, and particularly the early use of an artificial nipple, the infant's movement time for latch is often prolonged. 

plateau: occurs when there are periods of no improvement between segments of improvement.  Note that this is often seen in older infants, i.e., older than 3 to 4 days of age who have had many more learning experiences with an artificial nipple and so there is a more robust motor memory for feeding with a bottle nipple or sucking with a pacifier.  For example, a nine-day-old  client of mine in private practice had only bottle-fed since birth, and when I introduced finger-feeding with his mother's finger, he arched away and maintained his arch throughout the finger-feeding.  He did accept his mother's finger when she lightly brushed her finger-tip down the middle of his lips, while still arching his body, and his oral grasp was not immediate, as we might well expect for a baby who did not have a learning experience with an artificial nipple. This warrants a brief mention of inhibition during learning.  The brain must often inhibit a response to the memory for one object or experience in order to respond to the stimuli of another object or experience.  This is often challenging when learning to discern and differentiate things that are similar yet different, and the younger the organism, the greater the challenges in learning to discern similarities and differences.  Think of the difficulties in learning to write in block letters vs. longhand, or even learning to write solely in block letters and the ensuing difficulties in learning how to write a letter in uppercase vs. lowercase.  Consider the difficulty in remembering a new password, due to the robust memory that has been encoded for one's previous password.  

negative transfer:  the loss in capability for one task as a result of practice or experience in some other task.  The learning of a new skill or its performance under novel conditions is negatively influenced by past experience with another skill or skills, as in the baby's observable difficulty with latch or inability to latch following the learning experience with an artificial nipple.

positive transfer:  the gain in capability on one task as a result of practice or experience on some other task.  The learning of a new skill or its performance under novel conditions is positively influenced by past experience with another skill or skills, as in the baby's observable ability to latch following the learning experience with finger-feeding.    

Toward further developed definitions of feeding confusions and feeding preferences and their impact on breastfeeding duration, I often dream of a "dream team" researchers: a PhD person with the ability to create the study's design and analyze the data; a kinesiologist to provide structure and accurate measuring tools; an experienced IBCLC who has worked with youngest newborns as well as older babies of various ages; and whoever else would be needed to provide a lucid study in real-time motor learning, motor forgetting, and motor re-learning after the infant's observable skill decay that often follows the use of an artificial nipple.  The many, many studies that have correlated early cessation of exclusive breastfeeding with the use of an artificial nipple are very important in measuring these risk factors to breastfeeding outcomes.  Also important are the many studies correlating the use of an artificial nipple with early termination of the entire breastfeeding course, and these studies will also continue to be important as the decades roll by.  

But let's find a way to ethically measure, in real time, the observable feeding difficulties/skill decay that follow a learning experience with an artificial nipple, and particularly the early use of an artificial nipple, prior to building a robust motor memory for latch and effective suckling by the infant.  Earlier posts of mine included listings of the many infant learning labs in the U.S. as well as one in New Zealand (the labs are typically headed by PhDs in developmental psychology, and these scientists also measure infant responses in milliseconds).

To begin, surely these difficulties can be readily measured in exclusively bottle-feeding populations.  So many nursery nurses report that bottle-feeding babies often "do better" with one type of bottle nipple (or pacifier) over another, and measurements would easily be obtained for reaction time, response time, and movement time in comparing the onset of rooting and completion of the oral grasp for one type of artificial nipple vs. another.  There's always something new to learn.  
  
Debra Swank, RN BSN IBCLC
Ocala FL USA

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