Nipple shields are an individual call, for sure.  In the perfect world I would preside over if I were supreme dictator of all things, no mother would get a shield until she had had the opportunity to spend a few days skin to skin with baby, while skilled help was within arm's reach, and if baby still hadn't figured it out, she would get follow-up from a skilled helper until the baby is thriving and it has been determined that shields are either no longer needed or are needed but not harming anything.  Luckily for me I am not in charge of everything, so we need to have a policy that meets the needs of our real, imperfect world.

Mary Renfrew's 'Enabling Women to Breastfeed' has the best advice I have ever seen about the use of shields, which is, unless you are responsible for following the mother until it is no longer needed, it's better not to introduce them.  In my workplace, this has been interpreted to mean that any mother who is reliant on nipple shields at time of discharge from hospital must be offered early follow-up in the breastfeeding clinic if she lives within reasonable distance. If not, we arrange follow up from her local community health service.  We do not require the person who introduces the shields to follow the mother up personally, only to see to it that she gets follow-up care.

A few years back I would have loved to have locked up the shields and posted a breastfeeding expert to keep the cupboard guarded at all times, only unlocking it if all the hoops had already been jumped through and baby still not at breast.  Since then I have realized that if the breastfeeding specialists in a maternity care setting have this totalitarian view of shield use, the shields don't go away, they just go underground.  This is worse because you don't find the mothers who need your help; they are cowering in the shadows, afraid to reveal the problem for fear of getting a staff member in trouble and it is likely the staff member they are most pleased with because baby is at least in their arms at their breast because of the shield.

Now we focus on documenting when shields are given, why, and what instructions the mothers are given for shield use, including very specific directions for applying them to their breasts.  This has had the added benefit of making staff members justify why they are giving shields; the possibility exists that some women may have been spared their needless use due to this policy.  Staff need to be nurtured to take responsibility for their actions, and they need to be respected rather than criticized when they come up with solutions to problems in the middle of the night which IME is when shields often appear - there are fewer staff so less time available to support mothers in other ways, and everyone wants a quick fix so mother can get some sleep.  Openness around the use of shields makes it easier for staff to get feedback about the cases they have been involved with, so they learn more about distinguishing between appropriate and inappropriate use of shields. 

There are various pitfalls with our approach, and in a setting in which mothers are not able to return for follow-up for whatever reason, it would not work.  It works better for us than anything we have done in the past!

Rachel Myr (midwife/IBCLC in hospital maternity unit)
Kristiansand, Norway

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