yes--a very interesting discussion!

I personally almost always use a 24mm shield...but I am in an exclusively 
out-patient and usually more than 3 day-old baby setting.  I rarely have 
trouble getting a good amount of nipple into the tip, but I often wonder if 
we see a disproportionate number of large-nippled women.  (Speaking of 
which, I first used the 36mm medela pump flanges yesterday!  Had a mom that 
complained the 30mm were still not comfortable...got out the 36mm, and the 
milk started flowing!  She was one of those women who actually looked like 
she had small nubbins of nipples, but when started pumping they really got 
very wide.)

Anyway, we only have contact shields, so I don't have 20mm.  I have never 
had a situation where I felt the 16mm worked better, but I know one of my 
colleagues has.

Someone mentioned that if the nipple is pulled all of the way into the 
shield it should always be comfortable for mom.  I respectfully disagree.  I 
would say that IF the baby is suckling normally, yes, that should be the 
case.  But I see a LOT of babies who are into "chewing", and continue to do 
this on the shield...which hurts.   I also see a fair amount of babies who 
do not remove milk well with a shield even though mom is more comfortable 
and the breast is pulled into the shield.  Now remember, I see the worst of 
the bad situations...my LCs get to do most of the "easy" ones!!!

Just my 2 cents-

Kathy Leeper, MD, IBCLC
MilkWorks- Lincoln, NE

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