Kay Hoover and I have a whole chapter about the issue of anatomic
variability as an issue in bfg management in the new edition of the
Breastfeeding Atlas, and we address the issue of shield sizes in detail in
the chpt on flat and inverted nipples.  I think it is an incredibly
under-appreciated aspect of management.  To respond to Jaye's questions:
Medela has re-named (inappropriately, in my opinion) their shield sizes.
They formerly used the terms "Newborn Small" and "Newborn Regular".  Now
they call the Newborn Small the "Extra Small" and the old Newborn Regular is
called the "Standard".  Actually, the scant normative data that exists on
nipple sizes would describe the 16 mm diameter of the "Extra Small" as an
average size for a maternal nipple.  The diameter of the "Standard" is 24
mm. This is a quite large maternal nipple diameter.  It is about the
diameter of a US (or Canadian) quarter, (the size of an Australian one
dollar coin, an Irish two pence, or a Dutch one guilder coin -- trying to be
inclusive here:)  This nipple diameter is quite large for a baby to manage.
So how this could qualify as "Standard" I don't know. I would name the
smaller size "Normal" and the larger one "Large".

In terms of how to measure the size of a maternal nipple, in the Atlas we
picture several ways.  One is an expensive plastic engineer's circle
template (available in any office supply store.)  These templates measure in
milimeters and in fractions of an inch.  Even easier are coin comparisons.
They provide a very familiar frame of reference.  In order to allow for the
swelling that appears to occur when pumping, I suggest that if the maternal
nipple base diameter is the size of a US dime or smaller (17.5 mm), it will
fit in the standard Medela or Holister flanges and in the "Extra Small"
shield.  If the nipple diameter is nickle size (22.2 mm) to quarter size
(23.8 mm), then the mother needs a larger flange size and will fit the
"Standard" nipple shield.  If she fits the Standard size shield, a shield
MAY not be much help because part of the problem may be the size of the
maternal nipple diameter.  Those large diameters may be beyond the strength
of the baby to compress or size of the baby's mouth to accomodate.

Part of all craft mastery is sophisticated application of tools.  One size
does not fit all, and the application of a tool such as a shield must take
into account these issues of anatomic variability and how they may impact
breastfeeding.  Just to pick up a shield and expect it to work without
looking closely at the size  issues (i.e. of the nipple, the size of the
baby's mouth, etc.)  is a set-up for disaster (or at least disappointment).


Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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