Dear all,
I do understand the conflicts that occur in the hospital with moms whose
babies are not latching, everyone is stressed, baby is hungry, and mom
needs a feeding plan at discharge. I work in the outpatient setting and
I also do hospital work and see newborns at the hospital, so this is
something I deal with too.
First of all I know that nurses are using nipple shields even in the
first 24 hours, not only in my institution, but from what I have heard
from several of you who have written privately to me. I think that is
ridiculous and there is no 'excuse' for using a shield at that time. As
far as I am concerned, using a shield in the first 24 hours is
unethical, because the risk of the shield is being taken (possible
change in hormone physiology, changing infant 'target') before the baby
has been given fair chance to gather up his neurologic senses to
effectively latch. To me that makes absolutely no sense.
So what about at a 48-72 hour discharge? Some of you have written to me
about cases where there seemed to be no choice, ie mom has no access to
a pump, she is going to throw in the towel, baby is frantic and needs to
be at the breast to instill confidence, etc. Well, I know that there are
moms who are leaving with a nipple shield, who do absolutely fine with
breastfeeding down the road. However, I know, based on my experiences
that not every health care provider who hands out a shield is giving
proper education on the theoretic risks of the shield. I say theoretic
because we have no *good quality* evidence for or against the shield,
just case reports.
My bottom lines are these:
1. We have no good evidence that using a shield is safe. Someone
mentioned the Chertok study. But like all other nipple shield studies it
is very small (n=54). It is very poorly done...it states that infant
growth is no different between nipple shield users and nonusers, but the
study does not describe how much the mothers were breast vs bottle vs
formula feeding! Clearly the reviewers didn't know how to assess a
breastfeeding article, and not surprisingly the article was not
published in a breastfeeding- knowledgeable journal. Just as I concluded
in my literature review of nipple shield use in 2010, I still conclude
that we have no good evidence.
2. Given that we have no good evidence (other than case reports) for the
*safety* of shields, I feel that families need *informed consent*. IF
they are given shields at time of hospital discharge, they need to
understand that the shield*could* impact milk transfer, the shield
*could* make it harder for the infant to eventually latch on his own,
the shield *could* cause more sore nipples, and the shield *might* be
associated with a lowered milk supply. The reason I put in the 'coulds'
and 'might' is because we have no evidence that the shield does not do
these things, and based on our knowledge of physiology, the shield could
certainly do these things. Yes, there are cases where none of these
things occur, but we cannot make evidence-based clinical decisions on
case reports. These families need to be followed closely to make sure
that mom is maintaining her supply and the baby is growing well, and
that she is taught techniques to discontinue the shield, as well as
proper care of the shield. I don't expect that hospital nurses have the
ability to counsel on all of these things, since they typically are not
following these families longitudinally after discharge.
3. I feel that the nipple shield is the equivalent of breastfeeding
fast-food. All families should be given the confidence that babies have
a *deep, very strong instinctual reflex* to latch and nurse. I feel that
this message is lost, and families are frantic if the baby does not
latch in the first day or 2. Everyone needs to calm down. It is possible
that handing over an nipple shield is like throwing a wrench into the
anxiety rather than calming and reassuring everyone that the baby needs
time, bonding, and some flow of intuition between mom and baby. I find
that I spend a lot of time in my lactation clinic coaching moms that the
baby can and will latch, and how to drum up that reflex, using STS and
infant-led latch, not when the baby is really hungry, but when the baby
is fed, relaxed, but interested in sucking. Yes, that might not happen
in the first few weeks, but it will eventually, and everyone needs
patience. But if the baby is always expecting silicone when he wriggles
down to the breast, it might take longer for that baby to latch without
the shield. Hospital staff are not managing these moms and babies over
the next few years like I am, so they don't see the long-term impact of
handing out these shields.
I could go on and on. Health care providers need to avoid doing harm.
Above all else, health care providers must give evidence-based informed
consent so families can 1) make good decisions and 2) have tools and
resources to preserve breastfeeding upon being handed a nipple shield.
Anne
Anne Eglash MD, FABM, IBCLC
Clinical Professor
Dept of Family Medicine
Medical Director UW Lactation Clinic
University of Wisconsin School of Medicine and Public Health
600 N. 8th St.
Mount Horeb, WI, 53572
608-437-3064 (O)
608-437-4542 (fax)
608-550-3054 (pager)
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