Dear Winnie,
   I have worked quite extensively with shields in the Level ll nursery and have found this very issue to be true.  (We definately use more shields since Paula Meier's research has been published and with GREAT results.) Some of my colleagues have used the size baby IE less that 6# as the criteria.  I find, however, that is not what makes the difference with the preemies.  If a mom has large nipples, you cannot use a small shield.  The exception is the very small preemie.  I follow these babies closely because as soon as they can get around a larger shield, I switch them over. Often when using the small shield they really only get very small amounts.  Once switched, we see the difference on the baby weigh scale.  The baby's transition to the larger shield usually takes a bit of time. Sometimes a few minutes and sometimes a few sessions.  I always tell the moms this so they don't get discouraged and just go back to the small.  I have used the large on some very small babies so never assume they can't at least try.  More than once I have followed a colleague who used a small shield only to have to switch to a large for better draining of the breasts.  I believe most babies have the adaptability for the mothers that have birthed them.  Most people would probably be amazed at the number of large shields I use for preemies. However, I wish M_____ would make an inbetween size.
Jane Lowe, RN, IBCLC
Mpls, MN area where the mold is overgrowing and we have just borken a record for 7 days straight rain.

"Jean C. mentioned that the mom with the large diameter nipples who
was having some trouble with pumping might need to use a shield
briefly when baby can handle the breast.  However, I can't help but
wonder how the large diameter nipples will work in the standard size
shield.  I have found that they are very uncomfortable for moms with
large nipples.  If the entire nipple can't fit in the shield, how
can baby effectively compress the milk sinuses?  I have the same
question in using the small size shields for preemies even when mom
has average or larger nipples.  If a larger pump flange is needed to
effectively and comfortably pump, wouldn't the same apply to a
shield?  Is there something I'm missing here?"

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