I work in a hospital setting and also in an out patient setting. I have found over the years that starting nipple shields in hospital is detrimental to breastfeeding. Babies may be latched and look as if they are nursing well, but they struggle to transfer colostrum through the shield. Mothers go home feeling they are breastfeeding, but they aren't really. The first visit to the family Dr. confirms this, excessive weight loss, mother feels like a failure and formula feeding begins. My other concern is a lack of stimulation to breasts for proper hormonal spiking. When a baby breastfeeds, hormones increase and these hormones drive long term milk supply. If there is a barrier between baby and breast, and the stimulation a breast gets is muted, like in the case of a nipple shield, then the hormones don't spike as high as they should and milk supply is affected. It's like using a cell phone in a poor reception area, your target audience (in this case, moms breasts) only hear ever third of fourth suck.

We have instituted nipple shield policies in our hospital:
1. Nipple shields can only be started by an L.C. 
2. Nipple shields can only be used after secretory activation or lactogenesis II has occurred. 
3. Mothers who use nipple shields must have a test weight done with the first use to determine if milk transfer is adequate or not. 
4. Any mother using a shield will need to pump to augment stimulation to breast tissue (frequency of pumping depends on how well baby transfers   
    milk at breast, if baby needs a top up, mom needs to pump at every feed, if mom does not need a top up, mom needs to pump at every other feed)
5. The nursing dyad must be seen within 24 to 48 hours after starting with a nipple shield to make sure everything is going well. A full feeding 
    assessment including a test weight must be done at this visit. 
6. Dyads using a nipple shield will be followed for as long as needed, for some mothers this is when they are able to wean from a shield, for other 
    mothers it is until they are super comfortable using a shield.

These rules may seem excessive, especially if you work in an area where nipple shields are used to achieve a latch. However, I have seen a baby lose 10% of their weight and a mother all of her milk supply in 24 hours with using a nipple shield. This mother was nursing well, had an excellent supply, but her baby took a few minutes to latch. Baby was 3 weeks old, and her friend suggested she use a nipple shield. Within 24 hours her excellent supply was gone and baby had lost 10% of the previous days weight. It took us 3 weeks of hard work to rescue what damage the nipple shield had done. In my opinion nipple shields should never be used lightly, and never without excellent follow up, and always with the thought that even though a latch has been achieved and it appears as if baby is nursing well, milk transfer may actually be minimal. 

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