Because we all care so much, and because we want the very best for our moms
and babies, it is easy to get upset with what we perceive may have happened
with a mom and baby before we began to work with them.
However, we were not there.  We did not see or hear what happened, we have
only what the mother remembers or what she tells us to help us reconstruct
what may have happened before. We did not see that baby in the first days
after birth, when it may have been too sleepy to wake up and feed, or when
it was able to root and latch but then was not able to suck.  Days later,we
did not try to teach the mother when she was exhausted from her labor and
birth, sore and overwhelmed with information and visitors.

Twice in my career I've  had situations that really made this clear to me.
The first time I was an IBCLC at a hospital and also was on the LLL phone
line that week as a Leader.  I had worked with a mother extensively, I don't
remember all the details, but I do remember spending hours with her, making
a special feeding plan for her and her baby, and feeling fairly good about
her and her little one when they left the hospital.  That night I got a call
as a LLLL, from this mom, who did not recognize me.  She went on to tell me
all kinds of things that the IBCLC at the hospital had told her to do.  None
of them were things that I had ever come close to saying. I was totally
shocked by what she said I had supposedly told her to do.  Not once did she
mention that she had a written feeding plan and was to follow-up the next
day at the hospital with our department. No, she made it sound like we had
left her high and dry and she was clueless as to how to deal with feeding
her baby.

The next time was dealing with a mom who was severely depressed.  I was very
concerned about her. I could tell she was struggling with breastfeeding and
mothering.  She called and left a message at the end of the day. I couldn't
reach her because her line was busy, so I took her number home and called
her long distance that evening, spoke with her over an hour. I recall mostly
listening and supporting her with whatever she wanted to do.  We discussed
her husband bottle feeding part of the time so that she could get more rest.
I felt that whatever she felt comfortable about was fine. I felt like she
was calm and more in control when we got off the phone.  Imagine my shock
the next day when her physician called me, irate, because she called him and
told him that the LC had told her if she didn't totally breastfeed, she was
a bad mother. I called him back and we had a good talk, I discussed her
depression and what I had really said.

Since then, I have learned that what the mother relates may be what she
thought was said, but may not be what actually took place.  If she is
feeling overwhelmed, tired, depressed, etc., she may read things into what
was said that really was not said.  When I hear something about another
IBCLC, I work hard to try and understand what really happened, and to know
that whatever it was, that IBCLC did the best she could at the time.  It is
important to understand that some are very very busy, that some are feeling
totally frustrated at the number of non-nursing babies they see each day,
that some are doing the work of 3 LCs.

It can happen to all of us.  As a LLLLeader, I would always see the baby
days down the road, when it was a totally different baby than the baby the
LCs saw in the hospital.  It is awake, more alert, hungry, and can actually
suck.  I didn't understand then, but I do now.  I used to be adamant about
not using nipple shields too.
Now I see they have use in limited situations. Their use is to save the
breastfeeding when it would otherwise be lost.  When I suggest a nipple
shield, this is my personal way.
First, I do not ever use them the first day, although it could happen some
day. Never say never.  First, skin to skin, gentle waking techniques,
pumping and dropper feeding. Cheerleading for mom. Lots of encouragement.
Day two, more skin to skin. Working with the baby and helping mom to try and
recognize the wakeful times and be there to help her latch the baby then.
Continue pumping and dropper feeding.  Observe the baby for all kinds of
things, alertness, willingness to root.  Check the baby's suck with a gentle
assessment of the mouth.

Use a nipple shield only if mom is going to quit breastfeeding otherwise,
mom has great colostrum and I know baby will get milk, MD has insisted that
if baby doesn't latch on and nurse by evening, bottles will begin, or if I
get a sense that it will help. Experience is a great teacher in this regard.

My own personal guidelines for using them- (we use them maybe once or twice
a month)-125 to 140 births
Mom is shown how to apply it correctly, first by me and then she must do it
herself.
She is given written information about using it and about using it as a
temporary aid, and she will know that we will be calling her every day.
Nipple Shield is written in large letters on her follow-up sheet to remind
us.
If she is still using it within a week, we will see her again as an
outpatient when the baby is sucking better, both to check the weight and
color, and to help her learn to nurse without it. If we have any doubt that
the baby is not receiving sufficient milk by day four we will have her come
back in for a weight check and assessment.
I cannot remember any mother using them more than two weeks, most have given
them up by the end of the first week.  Except
I also used it once this year for a mom whose baby had a very small mouth
and her left nipple was huge. We only used it on the left. It had been
taking her an hour to try to latch the baby to that side, and it was
bleeding.
We slipped the shield on and it compressed the nipple down to a size that
would fit in the baby's mouth, and voila, the baby could latch instantly to
that side. Mom was very happy, baby was happy, and the last I heard, she was
using it until the baby's mouth grew larger.

I believe it is best to always give our peers the benefit of the doubt.  We
are all in this profession together.
Take everything you hear with a grain of salt, and we will begin having a
kinder gentler LC world.

Ann Calandro, RNC,IBCLC

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