I frequently come across babies who choke,gag, click, and gulp and have 
trouble handling the flow, begining in the second month and usually resolving 
by the end of the third month. If a nipple shield is helping with the pain and 
the baby is able to drain the breast without the shield and the mother is 
comfortable between nursing, then I would not jump to a conclusion of 
oversupply and I would defintely not move to block nursing until I established 
that it was oversupply for sure. I have seen women destroy lovely supplies by  
moving too quickly to block nursing. To diagnose oversupply I usually use a 
combination of test weights and pumping following feeds to determine the 
babies intake and the residual left behind.You could also look for oversupply by 
substituting pumping for a feeding and measuring what you get, but I think 
test weights and pumping give you  better sense of the true picture. I have 
seen babies have trouble with their mother's let down in cases with absolutely 
normal supply.Especially since this baby is also having trouble with the bottle. 
I would also want to make sure that the bottle has a slow flow newborn 
nipple.I have seen parents using the level 2 nipple with newborns because 
they don't even realize that nipples come in different sizes and flow rates.

It seems to me that the mother would be very happy to have pain-free 
nursing and why do we need to get rid of the shield? If she was on the verge 
of quitting and is now comfortable, I would just reassure her that she and the 
baby will use the shield until they can get to painfree nursing together and 
she can try intermittently to remove the shield. Or else someday her dog will 
eat it or she will leave it behiind when she is out of the house and she will 
discover she no longer needs it.Quite probably as this baby grows he or she 
will be able to drink the fast flow milk without needing to compress and lose 
suction so frequently. Then the clicking will probably stop and the baby will 
also not need to clamp down. 

I don't find it helpful to postition a baby struggling with flow deeper on the 
nipple and always point out to the mothers that if liquid were flying into your 
mouth at too fast a rate, would you want the container to go even deeper 
into your mouth - no way...you would want to protect yourself against that 
flow by  staying shallow. I think it would feel like being waterboarded to be 
forced to go deeper onto a nipple that was flying out milk, that you can't stay 
on top of.Also, I am wondering if the clicking has stopped with the use of the 
shield - if is has, then it seems that the baby is able to maintain suction when 
the flow is at a level that the baby can handle and was releasing suction 
voluntarily so that he or she doesn't drown. Or else the baby needed the help 
of the shield to maintain suction and the job is being made easier for the 
baby. Either way, it seem to me that it is all good...I am also wondering if the 
baby was always clicking or if this has started more recently. If the baby was 
able to maintain a latch early on when there was a slower flow, without 
clicking and the clicking is more recent, then that would also point to difficulty 
with a newly forceful MER.

I always try to use gravity to slow the flow and making sure that the baby's 
head is tilted back to enable swallowing, rather than shoving the baby even 
deeper onto the breast and if that doesn't work then move to a nipple shield. 
When I use a nipple shield in any situation, I do like to use a scale and make 
sure that the baby is able to transfer through the shield by doing test 
weights. I have seen babies suck very vigorously for half an hour and transfer 
less than an ounce per breast or sometimes virtually nothing. If a baby is 
losing milk on the bottle then the baby obviously doesn't have the easiest time 
in the world handling flow period, so that is a baby that I would want to be 
especially certain was able to transfer well with the shield.

I find it fascinating to watch older babies and toddlers at the breast, because 
it seems to me that most dyads get to the point where they can effortlessly 
break every postioning rule in the book - forget the stomach to stomach, 
forget lining up belly button to nose, forget tilting head back, forget slowing or 
speeding up flow, forget deep latch. These babies are nursing with their head 
turned in the opposite direction from the mother, stretching her nipple clear 
across the room, shallow latches, even grinning while they nurse etc etc and 
the mother is just chatting away with a friend oblivious to what would have 
been agonizing at the early stages of nursing....But in the begining each pair 
does have to find their way to comfort. And nipple shields have saved more 
that one breastfeeding relationship for me!!!!!

Kathy Lilleskov RN IBCLC (sorry about the length of this post)

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