I find that nipple shields work best if they are sized to both mom and 
baby. I use the 20 mm most often, the 16 very rarely, and the 24 next 
most often. If mom has a narrower nipple, the 24 is too big and will not 
stay on properly. It comes off and on mom's breast as baby comes off and 
on and you can not get the proper "fill" as Jeanette wrote about.

I want to second that the NS needs to be put on properly. Too many just 
plop it on the nipple. It doesn't work right, nor does it stay on. If 
you do as Jeanette said, half way inside out, then applied to the 
nipple, then made to pop back out, the nipple fills the inner cavity and 
it stays on and is positioned right so that it doesn't rub mom 
incorrectly. If you use a too big of size NS, it is very difficult to 
get the nipple tissue to fill the entire width of the tip (not length, 
but width so it makes a good seal and stays on).

There are three or four ways to put on a NS on the LLLI handout but I 
find that only this one really works.

The other thing about nipple shields is we have to make sure baby is 
putting his lips onto the flat base, not any where on the tip. If you 
don't pull back the breast tissue and look, sometimes baby appears to 
have all the NS in his mouth but is really "tip sucking." Sometimes a NS 
works, but I also have babies with oral motor problems that the shield 
does not increase intake.

I work with too too many moms who have the 24 mm NS from the hospital 
and it is too big, flops around on her nipple and the baby can't use it 
correctly but when they manage to achieve some kind of latch using it, 
he only takes in a bit of the tip into his mouth, not lips on the base.

I have also seen baby's who is tongue thrusting and will be put on a NS 
and they do what I call "bobbing" back and forth on the NS. They slide 
to the tip, slide back to the base, back and forth and I don't think 
they transfer milk very well as per test weights. I see a lot of these 
moms and hospital staff have all told her the NS is working perfectly.

If baby has a tiny mouth, he will tip suck on the 24 mm NS. If mom has a 
large or wide nipple and baby has a tiny mouth, putting her into a 16 mm 
NS may give her nipple damage.

The converse is the baby who is a jaw clencher, the smaller NS may just 
allow him to latch with the "fish lip" look but the 24 mm often makes 
him open wider and more appropriately.

One size does not fit all.

Kathy Eng, BSW, IBCLC

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