Amy Wagner BS RN CCES IBCLC writes:  "I'm seeking insight regarding recommendations for pumping with use of a nipple shield. We currently use Medela nipple shields and the product education handout states that pumping is recommended after each use however I have been unable to find any research that supports that recommendation.  Riordan, 2010, in Breastfeeding and Human Lactation, made the same pumping recommendation but I can not find it in 2015 edition of the book.  At the hospital where I work, we recommend pumping after each use followed by a gradual decrease in pumping frequency once infant demonstrates sufficient milk transfer/weight gain with the shield.  I always feel awful giving this pumping recommendation since it is so much work for an already exhausted mother.  What recommendations do you make when using a shield?  Any insights would be helpful."

Amy, as a clinician with a long career in both inpatient and outpatient practice, and as a clinician who has made and will continue to make judicious decisions on initiating nipple shield use, I can understand your sentiments for not wanting to add to a new mother's fatigue by recommending that she express milk for additional breast stimulation during early nipple shield use until the baby shows a stable weight gain pattern.  However, we're educated and trained to do so, and I agree with our formal training in this regard, based upon my observations of infant weight gain in outpatient settings.

The current edition of Wambach & Riordan (2016) on page 250 states, "The newer ultrathin silicone nipple shields are especially helpful for a mother with flat or inverted nipples, for preterm or late preterm infant babies who have trouble latching and maintaining suction, or for babies who have develped a preference for a bottle nipple and thus refuse the breast."  The following paragraph goes on to state the recommendations for the mother to use a multiuser electric breastpump during early nipple shield use, and the baby needs to be weighed twice a week and diaper changes monitored for adequate output, with a gradual decrease in pumping as baby continues with adequate weight gain.  Page 384 in the Wambach & Riordan text also addresses nipple shield use in the Maternal Considerations chapter, stating, "Close follow-up of weight gain and milk supply are imperative until the shield has been discontinued."  In Wambach & Riordan's Chapter 12 on Breastpumps and Other Technologies, pages 449 to 454 are devoted to a review of the literature on nipple shield use as well as lactation management of the dyad using a nipple shield.

It's been my clinical experience in outpatient settings to typically see any one of the following three scenarios regarding early nipple shield use in exclusively breastfed newborns when the new mother has not been pumping:

1) The outpatient dyad is using a nipple shield, the mother is not pumping at all, and the exclusively breastfed newborn is gaining weight appropriately.

2) The outpatient dyad is using a nipple shield, the mother is not pumping at all, and the exclusively breastfed newborn is gaining weight slowly.

3) The outpatient dyad is using a nipple shield, the mother is not pumping at all, and the exclusively breastfed newborn is not gaining weight at all.

If there are experienced outpatient IBCLCs in your community, it would be wonderful for inpatient and outpatient LCs to periodically meet to discuss how inpatient practices might impact outpatient outcomes, such as in regard to early nipple shield use.  Outpatient case studies can provide great insights to inpatient staff re: infant weight gain during early nipple shield use.  Another suggestion is to invite an outpatient IBCLC to speak at an inpatient mother-baby staff meeting on outpatient management of nipple shield use, to help inpatient nurses better appreciate their responsibilities in sending home dyads using a nipple shield (in facilities where mother-baby nurses have access to nipple shields).

In some inpatient settings, only IBCLCs have access to nipple shields.  In other inpatient settings, both nurses and IBCLCs have access to nipple shields, but the nurse's responsibility differs, depending on the setting.  In some inpatient settings, nursing staff is required to refer to the IBCLC for follow-up when a nipple shield has been introduced to a dyad, while in other inpatient settings, nurses are not required to consult the IBCLC for any follow-up of the dyad using a nipple shield.  Regarding the latter scenario, many otherwise experienced nurses are often entirely unaware of the possible risks to the dyad re: poor infant weight gain and a risk to the mother's milk supply.  Inpatient mother-baby nurses are typically focused on supporting the dyad only for the infant's first two to 4 days of life, but their discharge teaching does include guidance to the new parents on matters such as safe infant sleep, monitoring the newborn's intake and output for adequate weight gain and other aspects of newborn care, and thus inpatient nurses who freely provide nipple shields to dyads should be adequately educated and trained in the area of early nipple shield use as well.

To provide greater insight into the heavy prevalence of nipple shield use in a number of inpatient settings, studies can and should be designed to compare the percentage of inpatient dyads using nipple shields from one facility to another, in order to develop standards of care re: percentage of dyads using nipple shields in inpatient settings.  For example, following such a study, the resulting research-based standard of care for early nipple shield use might state that fewer than 5% of all nursing dyads in any facility should be discharged home using a nipple shield (or whatever the percentage is determined to be for such a standard of care).

"Transfer of learning" is a motor learning term, and the transfer can be a positive transfer of learning, a negative transfer of learning, or a zero transfer of learning.  If a nipple shield helps a baby achieve and sustain the oral grasp following the use of an artificial nipple with a bottle or pacifier, this is a positive transfer of learning from the infant's experience in bottle-feeding (or use of a pacifier) to the breast.  If finger-feeding helps the baby learn to associate the smell, touch, and taste of mother's skin with sucking and getting milk, followed by a successful return to the breast, this is also a positive transfer of learning.  Finger-feeding is highly effective toward a positive transfer of learning - - particularly in the first three days of life but not only in the first 3 days of life - - in assisting the infant in transferring their sensory-perceptual-motor learning experiences at the breast with the support of a nipple shield, to no use of a nipple shield for achieving the oral grasp and/or effective suckling at the breast.

Examples of negative transfer of learning to the breast are the breastfed infant's use of an artificial nipple for bottle-feeding, pacifying, or suck training, and the high frequency of observable difficulty in the infant upon returning to the breast.

Interesting examples of zero transfer of learning are cup-feeding and spoon-feeding.  Even though the infant must use an shallow oral grasp to cup-feed or spoon-feed, and even though the reward of milk is immediate and constant in cup-feeding and spoon-feeding as long as the infant is actively sipping from the cup or spoon, the baby's need to suck is not fulfilled at all in cup-feeding or spoon-feeding, and thus cup-feeding and spoon-feeding appear to be frequently protective of the infant's learning experiences at the breast.

If finger-feeding isn't yet being utilized in your practice setting, do consider adding it to help infants transfer their learning from the use of a nipple shield to no use of a nipple shield prior to discharge home.  These successes will lessen the workload for sleep-deprived mothers regarding the recommendations of pumping during early nipple shield use, as well as the maternal workload of more frequent outpatient follow-up for infant weight checks.

With best regards,

Debra Swank, RN BSN IBCLC
Ocala, Florida USA
More Than Reflexes Education
http://www.MoreThanReflexes.org
http://www.MoreThanReflexes.org/on-learning/
http://www.MoreThanReflexes.org/webinars/

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