Dear Amy,
I believe this recommendation comes from the fear that the baby will not 
transfer enough breastmilk with the nipple shield which is sometimes true.

This is where our work begins. In my opinion, based upon research and my 
clinical experience, we have to do careful pre and post weights to see 
what does the baby actually transfer with and without the nipple shield. 
Sometimes I have to try many different sizes, do several pre and post 
weights, so this can be quite a process.

I have found that either the baby transfers plenty of breastmilk with 
the shield and in that case I have the mother pump or hand express twice 
a day right after a feed to help protect her breastmilk supply (I don't 
know if this is necessary but I don't want to jeopardize her milk 
supply)  but to come back for a weight check in 3 days and if the weight 
gain is good, I would usually suggest she stop pumping or hand expressing.

In case two, the baby takes in half a meal or so, not a full feed. In 
this case, yes the mother needs to pump or hand express, BUT what is 
missing from the Medela handout, is you have to then supplement the baby 
appropriately!

Finally, (and there are many other possible variations on this) if I 
have a non latching baby and the baby finally goes to the breast with a 
nipple shield but doesn't transfer much at all, the mother needs to 
supplement for most of the calories and then pump or hand express as if 
she were exclusively pumping or hand expressing. I explain to the mother 
(these mothers are usually so, so relieved and thrilled that the baby is 
AT the breast at all), that they should think of breastfeeding with the 
shield as a fun and comfort activity, more like a little snack, but the 
baby still needs to be fed.
I view nipple shields like training wheels for a bike. Training wheels 
keep you from falling over so you can focus on peddling, stopping, and 
steering. Nipple shields, in some cases, seem to help the baby stay on 
the breast so they can work on milk transfer.

However, then this is crucial. We also have to figure out why they need 
training wheels in the first place! This should be evaluated during your 
exam of the baby at the first visit. Honestly, again in my clinical 
experience, most babies who need shields have the need for some body 
work or an undiagnosed tongue tie. The baby should either just out grow 
the nipple shield quickly (in a few days or a week) like training wheels 
on a bike if they just needed a little help to get started. If they do 
not, in my opinion, there is an underlying physical cause they need the 
nipple shield and another action is required so the baby doesn't need 
the nipple shield anymore.

Sorry for the long post! Some of our profession are not fans of nipple 
shields, but I think using them sparingly as transitional tools while 
you work on resolving the underlying causes can be very effective and 
satisfying to parents.

Thank you!

-- 

Barbara Robertson, MA, IBCLC, RLC
The Breastfeeding Center of Ann Arbor
bfcaa.com

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