Dear Jennifer,
 
It sounds as if you did an excellent job with this mother and baby!   
Nothing easy about this, your first consult.  Here's a reference for  applying a 
nipple shield: _www.leron-line.com/updates/Nipple_Shield.pdf_ 
(http://www.leron-line.com/updates/Nipple_Shield.pdf)  
It is not necessary nor recommended to get the nipple all the way to the  
end of shield's teat.  This could cause some of the nipple to be  pulled 
through the shield's holes which can cause damage.  Nipple  shield use should be 
comfortable for mom and baby should be able to attach at  the brim and not 
just the teat.  
 
What you provided this nursing dyad was well thought out despite your  
apparent nervousness about *doing it right.*  Skin-to-skin, biological  
self-attachment, RPS, reading baby's cues of frustration all were helpful  
approaches.  I'd suggest mom and baby just recover for a bit and not stress  about 
whether shield is used or not.  Mom can try removing the shield a few  min 
into the feed, once baby has fed a short time.  Can also try walking  with baby 
and offering the breast in between feeds for ad lib nursing, for  hiccups, 
can't quite settle, etc.  Co-bathing could be helpful to relax  both mom and 
baby and often baby then attaches as well as mom's nipples  protracting 
more.  I would definitely recommend CST or some form of body  work for this 
baby and if that's not feasible, infant massage and whispered  apologies to 
baby for all he went through and his pain, both physical and  emotional.  (This 
often helps mom deal with her pain, as well).  Baby  may not have the 
ability to open widely if there's nerve impingement due to  swelling from 
hematoma at back of skull, or nearer the jaw due to long pushing  stage and 
forceful removal by vacuum.  
 
In time, likely in the not too distant future, baby can latch to bare  
breast and know what to do, that's the reassurance I often give moms.   Looking 
into other possible barriers, as you said about possible tongue-tie  would 
be warranted, too.  Know you did a wonderful job and best to you and  this 
mommy and baby.
 
Barbara Latterner, BSN, RN, IBCLC
 
I just did my first consult and would appreciate your  opinions/feedback.

My appologies for the long post!

Mom had  difficult birth, SROM but no contractions & step b positive, 
therefore she  had a pitocin induction with epidural and antibiotics.  She pushed 
for 3  hours,  the first OB did SIX attempts at a vaccuum extraction, 
before  another OB was called who then performed an episiotomy and then a SEVENTH 
and  successful Vaccuum extraction.  She was hooked up to IVs for more than 
12  hours and consequently exprienced severe edema everywhere, including 
her  breasts, causing nipple distention.

Baby suffered a severe hematoma, had  30 min of skin to skin with mom 
before going to the nursery for  observation.  (This hospital generally does not 
separate moms and babies  and is baby-friendly, but this was an exceptional 
case.)  Baby made no  attempt to latch during the brief s2s.  In nursery, 
baby was fed formula  via bottle teat 7-8 times over his 3 day hospital stay, 
35ml each time.   Paediatrition ordered this because he was afraid of baby 
getting upset and  crying due to the severe hemotoma.  Hemoglobin levels in 
baby were falling  (from 210 to 163), Paediatrition was concerned about 
possible bleeding in baby's  skull.  In hospital, due to the "flat" nipples 
(actually distended nipples  due to excess fluids), nurse gave mom a nipple 
shield at 48 hours because baby  was unable to latch on.  Nurse also suggested 
mom use pump to extract  colostrum and bring out nipples and mom states her 
nipples became much flatter  after.

Mom was released on day 2, baby stayed until day 3.

Mom  called me on day 4, we spoke for 3 hours on the phone.  She reported 
that  her nipples normally protruded but were now flat and her baby could 
still not  latch without the shield.  I suggested RPS before nursing, manual  
extraction, so as to avoid more fluid in the breasts, reverse massage and 
cold  application in between nursing to help reduce edema.  Also LOTS of skin 
to  skin, anti-gravity positioning for all feeds.

I saw mom on day 6.   Observed some assymitry in baby's skull shape, not 
surprising given birth  circumstances.  Parents report that it is greatly 
improved.  No  "banana" posture or cocked chin to indicate torticolis.  Baby 
appears to be  able to turn head equally to both sides.  I instructed parents 
how to  continue to observe for this, since sometimes it takes a while to 
show up.   Baby still has some mild jaudice, but parents say they have noticed 
a reduction  in the yellow colouring.  Oral exam:  baby clamped on my finger 
more  than actually sucking.  very little tongue movement at all.  I did  
possible feel a bit of resistance under the tongue, but I will check again 
when  I see them again soon.  Everywhere is closed for the holidays right now  
anyway, so I would not be able to refer for frenectomy.  I had mom get into 
 a laid-back position and do skin to skin with baby for 30 min while he 
slept and  we filled out the questionnaire.  Finally when he woke, mom first 
tried to  nurse without the shield (after I did RPS), baby got angry and began 
to get  frantic.  So we put the sheild on for breast #1.  Baby nursed 
actively  for 10 minutes with obvious swallowing (gulping!), then fell asleep.   
Remained in s2s while baby slept/rested, roused on his own for breast #2.   
Again I did RPS, then offered baby bare breast (not really and assited 
latch,  but just placed baby in the vicinity).  He latched without the  shield!!! 
 He did not really nurse, but he gummed the nipple for about 3  minutes 
before growing frustrated and we put the shield on.  He then nursed  actively 
with the shield for another 10 minutes.  While he did not really  nurse, he 
did accept the bare nipple in his mouth for the first time, so I  consider 
this a big step in the right direction.

Baby has copious diapers  (mom reports 9 very wet and 5-7 yellow curdy 
stools per 24 hours), from  exclusively nursing with the shield (no 
supplementation since day 3).

My  training did not cover much about how to use or fit nipple shields, 
just when to  use them.  I have learned how to apply them (turn almost inside 
out and  stretch open and let it roll back down over the nipple).  When I 
applied it  this way, mom said it felt like there was a lot more of her nipple 
in it than  the way she had been doing it.  I have not, however found any 
resources as  to how to fit them.  What does a properly fitting shield look 
like?   My client's nipple did not fill the teat of the sheild, despite my 
best  efforts.  Can anyone point me to some info on fitting or photos of how to 
 fit and what it is supposed to look like?

I have suggested to mom that  she continue as much s2s as possible, RPS and 
reverse massage, offer a finger to  baby with light pressure on the palate 
before offering the bare breast in hopes  of stimulating the sucking reflex, 
and to continue to offer the bare breast  using laid-back positioning, but 
not to let baby get frantic or too frustrated,  switching to the shield if 
he won't take the bare breast.

I will go back  soon to do another consult, when I observe for changes to 
the shape of his skull  and apperance of any signs of torticollis and check 
again for  ankyloglossia.

So what do you think?  Anything else I could have  suggested?  Anyone have 
any resources for fit of nipple  shields?



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