I don't mean to send volumes but have been reading for weeks without time
to type.
    In my private practice I see the majority of my clients after discharge.
I seem to see more babies every day who are not latching prior to discharge
and sent home with a pump and instruction on how to alternative feed
(breastmilk by cup/syringe/fingerfeeding/etc.). I appreciate that these
babies are not just given bottles and realize that hopefully some just figure
breastfeeding out and transition to breast without needing extra help.
Likewise some will give up and move to bottles.
    I have found that many of these clients that come to me are not using
correct breastfeeding techniques!  By simply correcting positioning and
attachment techniques, the majority of the babies do fine. A big concern is
that many are told their baby is sucking incorrectly on day one- and think it
will never change! Another common problem is the tongue up to roof of mouth-
I have found that putting a hand on the back of the baby's head near the top
causes this. You can try it on yourself, as your chin gets closer to chest,
the back of the tongue moves toward the palate ! If a mother is trying to
push her baby on this often happens, especially in the football hold. If a
baby has bruising or a ceplahematoma I think this could make the baby feel
pressure, enough to cause them to hold their tongue up. Supporting the baby
across the shoulders keeps alignment, no chin to chest, and they feed better.
        For the mothers who have moved to bottles after being dischaged as
above and using alternative feeding for a few days, I have successfully used
a silicone nipple shield as a transitional step.  I work with the mother to
first achieve a baby that is happy to be held in a breastfeeding position.
Sometimes the baby crys when it sees the breast if it has been forced into
trying to feed. Those moms just work on bottle feeding at the breast, and
sometimes move right to breastfeeding.
         Guidelines I have set up for my practice include counseling in
attachment/positioning without success, ample milk supply, nipple shield
consent form, and CLOSE monitoring of output continuing until baby has been
at breast only for three days. I have found that the silicone shield with a
firmer nipple seems to work best. I have the mother use the shield for 24-48
hours without trying the baby at breast only. During this time I have the
mother express after feedings and provide the baby with that milk. I think
this gives the mother the confidence in handling her baby and that it will
feed at the breast. The silicone shield has less taste and one mother pointed
out to me that it visually was close to invisable. Using the shield gives the
baby the experience of feeding at the breast - with alternative method
parents often do not hold the baby skin to skin in a breastfeeding position.
After the baby is feeding well ( usually within 1-2 feedings) with the
shield, I like to give the mom a short break(24 hours or so) with no changes.
This really builds their skills and confidence. Then we start feeding with
the shield and remove it after about 5 minutes. I like to have the mother try
this at my office because I can fine tune the attaching. I have only had a
few clients that needed the shield longer that 4-5 days. They continued to
monitor their babies output, had weight checks weekly, and finally lost the
shield (or the dog ate it).
   **** I remember the days when yucky latex shields were handed out like
candy for  "no latch on" & babies were compromised I would not like to see us
move backward!!!  I would not use this method in the first week. My mentor
dies when I tell her I used this method in a case and when she tried it once
it did not work for her! I only do this about 1-2 x per month as a last
resort and FOLLOW UP is critical. I make sure that baby is off  ASAP!****
            Debby Kearney IBCLC who hopes she is still cerified after
admitting to nipple shield use!