So many of the suggestions from this line of discussion have been very
wonderful.  If this has been stated already, I will apologize now.  I don't
always get to read every submission of LACTNET.  The mother could be using the
wrong size breast shield.  My clientele is almost all working women, and
sometimes I run across what I would describe as "deceptive" nipples.  These are
nipples that appear to correctly fit the shield, but over the course of pumping--do
NOT.  It may take more time, but whenever I sell a pump or kit, I ask the mom
to pump for awhile in my presence (if she is willing).  I tell them the
importance of really making sure that the shields are the correct size.  I apologize
immediately for something that may appear to border on voyeurism, but I have
their best interests in mind, particularly in cases where the mother has made
the decision to pump and feed only. (Believe me, I do everything that I can to
professionally help a mom out of this mentality first.  Most of the time, I
am successful, but there are those that don't want the baby at breast.)

    "Deceptive Nipples" look just fine for the the first two or three
minutes, but will then look like their expanding into the tube.  Or some even look
fine throughout the entire pumping time, but if you move the mom to a larger
shield, she fits that shield also.  The wrong shield size wreaks havoc for the
working mother.  I have bumped into many a mom just one month post return to
work who has practically brought her milk supply down to non-existence.  It is
not uncommon for a mother to need two different sizes for the left and right
nipple either.

    This is a particularly notable problem with Black and Asian women.
However, I would also like to note that the largest nipples I ever came across were
on a caucasian woman. Recently, I came across an Indian woman with Day 4
engorgement from her second child.  Over the phone, she states, "I pump and pump,
but I still feel like I have milk when I am done".  Without larger shields,
this mother would have certainly developed mastitis.  Nipples can grow as the
mother becomes mulitpara.

    Also, women that need a smaller shield have the same supply issues.  Some
mothers think that the pump needs to take in the entire areola just like the
baby, so when the entire areola goes into the tube, they think that will work.
 When you ask if the entire nipple goes into the shield over the phone, they
reply "yes".  When doing phone help it is important to be very specific about
what is going into the breastshield and how it looks.  I tell my moms that
only the nipple goes in there with just a perimeter of areolar tissue for
movement.  Lots of areolar tissue=smaller shield.  If it appears like the entire
nipple is going in, but it is taking up almost the entire tube=larger shield.  If
the nipple skin covers the entire circumference of the shield, especially if
it is turning pink or red=larger shield.  Also, we have what I call the
"peek-a-boo" variety.  These nipples poke in and out of the tube, but the base of the
perimeter of the nipple is being "held back" because the hole is too small.
If you change to a larger shield, you finally see the nipple take up more
space in the tube.  Can you imagine how many mothers might fit this category?

    I felt very validated by the article, "Choosing the Right Fit" written by
Meier, Matykowski, and Zuleger in Issue 21.1 2004 edition of the Medela
Messenger.  Over 3/4 of the mothers in their study needed larger shields.  In my
experience, most women out there have not been professionally "sized" with the
correct breastshield.  There are no warning labels on the pumps, saying that
this is not a one size fits all breastshield.  Honestly, it is like a dress
maker send out a size 12 and stating that it is a one size fits all dress.  This
is an area that all LCs need to be more familiar with, because whether the mom
is working or not, she will probably use a pump.  These moms need real help.
Proper size breastshields are a very important part of the process.

Debbie Albert, Ph.D., IBCLC
Tampa Lactation Counseling
Tampa, FL

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