Dear all:

Since I don't work in the hospital, I don't see the really tiny babies.  I fit my nipple shields 
based on milk transfer, not the size of mom or baby. I've only had one little 4 pounder 
transfer an adequate amount of milk from a 16 mm shield.  When I test it out, I find that 
most babies need a 24 mm nipple shield to get the lower jaw in deep enough to release 
milk using the shield.  I've seen some very dramatic differences - once a baby took 30 min 
to get 1 oz from a 16 mm shield and then promptly downed 3 oz in 10 min with the 24 mm 
shield.  I think I've only used 20 mm nipple shields about 3 times.  Again, I'm not the in the 
hospital, so I am sure there are differences in the early days in a hospital setting than what 
I see with older babies out of the hospital.

I do tend to put most women on 30 mm breast shields, but I have seen some downsides. 
Ocassionally I've seen some women who released milk better from the slightly tighter 27 
mm shield.  These are the exceptions, not the rule.  So, I'd watch for both comfort and for 
milk release over time.  Also, for more elastic breasts, I've seen the ocaissional dramatic 
increase in milk release with angled shields.  It doesn't seem to have the same effect with 
less elastic breasts.

Best, Susan Burger

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