"You hospital based LC's mustn't forget those of us
that are faced with a mother of a 7 or 10 day old using a nipple shield." 

The person that dealt with the mother after delivery was, in Puerto Rico
....Me!  Mom was given my phone number (or she would stop by my office on
discharge) and we would follow up as long as _she_ wanted to .  As there
were two of us in the office, either one of us was able to help her.  We
also were in close contact with dieticians in WIC and La Leche League
Leaders in other ares of the island to offer assistance if the mom was not
from our area.

Previous to that job I was an LLLLeader - coping with all the problems of
moms who were discharged without adequate follow-up (or was it that they
did not want to remember the instructions?).  There's a letter I wrote in
the JHL a long time ago about my evolution in "blame".  The truth is, we
all are trying to do the best we can, and one of the great uses of Lactnet
is learning about the difficulties "on the other side".  
_____

"The exception is when nothing else has worked, I will often start the
nipple
shield when the baby is 2 or 3 weeks of age."

Therein lies the difference with the moms you see and I see.  Most of the
moms I was called in to see in the hospital were not going to continue
trying for 2 to 3 weeks.  It was either do something now or I will give up.
 

Now, I did find that once we did use a nipple shield, they would work more
willingly on things like SNS, pumping or any other interventions that  were
found necessary.  However, I have to say, that IF I got the nipple shield
on right (the tissue was not one of the newly coined "Latch Defying
Nipple"), there was no need to pump after feeds or do any other
interventions to "protect the supply".   We would ask the moms to come in
24 hours after discharge, some did, some didn't.  Those that did,  and we
found weight loss less than 7%, we'd work on positioning and breast
compressions.  Those that had larger weight losses were instructed on
pumping and feeding baby with finger, cup or bottle - whatever she told us
she could cope with.  Those that didn't we would call and follow up as best
we could by telephone.

I want to stress here that the "Latch Defying Nipple" would probably, if
the term includes the description of taut tissue and truly inverted
nipples, NOT be solved with the use of a nipple shield alone (if ever). 
With this situation, the tissue would not enter the nipple shield,
inadequate milk expression would occur and much assistance would be needed
to maintain milk supply.  

Also:  the nipple shield is just a tool - neither good nor bad - and can be
mis-used, over-used or under-utilized.  In my office and in my car, I have
it and pumps (hand and pedal), SNS, gloves, haberman feeders, peridontal
syringes.... you know, I can't use that car for grocery shopping!
_______

Now, I no longer work in a hospital but  make home visits with Public
Health Nurses and am finding much more need for interventions,  - more
pumping, more use of SNS, as we don't get to see the mom until she is 2
weeks postpartum (get referrals very late - we're working on that ), and
the milk supply IS compromised and needs to be worked on.  Problem is, she
has just about given up and has been giving bottles all this time.  Have
had some great successes with babies who go from bottle to breast, (then we
use SNS to supplement until milk supply is up) but have had others who
can't figure out what to do with this soft tissue.  Again, moms are not so
invested in breastfeeding that they will stop bottles to use cup feeding. 
I can get them to try SNS and Nipple shield (rarely).  usually what I need
to do is increase the milk production with a pump and have her bottle feed
this, then go to the nipple shield once her milk is more abundant.  Finally
we go to the breast.  The entire process takes about 2 - 3 weeks IF mom is
willing to keep this up.  

Please remember I have no physician to ask for Reglan, etc. - and no
prescriptive privileges.  These moms go to public clinics most of which are
manned by physicians that can't figure out why all this fuss with
breastfeeding.  I am working with a wonderful group of dedicated nurses,
Lactation educators and nutritionists who have done wonders considering the
medical "culture" they must cope with and work around.  Now, if we could
just get Dr. Jack, Dr. Granger and Dr. Hale here  - AND if we could get
these doctors to come and listen....  ;-)

Jeanette Panchula, BSW, RN, IBCLC
Vacaville, CA
mailto:[log in to unmask]

PS: The process of weaning from the nipple shield has been as varied as
there are moms and babies - some just quit one day, some go to the breast
on one side and not the other, some use the shield to get things started
then take it off, some use the bare breast at first then END with a nipple
shield.  All who have wanted to have quit using the shield, but some have
decided they wanted to keep using it.(??)

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