Shield use requires careful individual assessment to make sure all the
factors are evaluated.  This will generally alert the LC as to whether
pumping is or is not required.  I have a baby I am working with now who was
ultimately delivered emergency c-sect. after a very stressful labor.  The
baby's head was engaged, but turned, preventing delivery.  He aspirated
meconium, delivered by section and transferred to NICU where he needed
aggressive suctioning and C-pap for 24 hrs.  He developed a pneumothorax,
which resolved on its own in a few days.  Baby is thin, with no fat deposits
in the cheeks.  His suck pattern is inefficient, he clenches his jaws, and
his receding chin makes him difficult to pull in close enough to breast to
prevent nipple pinching. Test weights indicated baby took only 48 ml at the
feed and pumped residual was only an additional 7 ml.  This is low vol. for
Day 10 pp.

 Mom's nipples were very damaged once she was able to start bfg.  They
rapidly cracked and blistered and she got mastitis before I ever saw her.
She started using shields to provide some mechanical barrier to protect the
nipples.  I seldom use shields for this purpose -- esp. when the nipples are
well-everted and elastic, but this morning, even after 2 hrs of work yest on
re-positioning baby, mom called to report that her nipples (after not using
the shield) are blistering again.  Mom is still on anti-biotics, breasts are
soft, milk supply is depressed, and she is exhausted.   She is going to have
to pump to protect production and to give her nipples a break from the
baby's unrelenting jaw clench.

So in this case, there are a bunch of issues and one of them is certainly
how best to temporize in order to keep the options open for a good bfg
outcome.  As I see it, we have to acknowledge that baby was/still is
recovering from birth truama and the thin cheeks and receeding chin are
destabilizing factors.  The baby isn't a good sucker with or without the
shield. This should improve with growth and recovery from the birth truama.
Therefore we have to rely on the pump to supply some of the stimulation I
can't trust this baby to provide.  However (just to complicate matters) the
pump is irritating the areolae (which look red).  So we have to manage that
with lubrication of the flanges and other topicals to protect the nipple
skin.  We have to prevent re-colonization of the skin from the mouth of the
baby (who was probably exposed to who-knows-what kind of germs in the
hospt.)  Mom's mastitis sx are still not resolved after 4 days on abx, so
she also needs to check back with OB about the meds and maybe get a diff.
drug.  So basically, this is such a convoluted mess that it will prob.
continue to require two phone calls a day to keep shifting the care plan
around enough to ensure that we end up with a good outcome.

I guess my point is:  no one using a shield has a normal situation, as
shield use is not called for otherwise.  Consequently, careful individual
assessment of ALL issues will tell whether the mom is going to need pumping
in addition to the shield intervention. Very close follow-up allows the plan
to be refined as needed.  Both OB and Peds require report so they can be
kept up to speed.


Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com
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