Nipple shields are to me, the perfect example of why I love being a lactation consultant in private practice and why I found being an LC in the hospital so frustrating. When I go in and work with a mom, I have as much time as I want, to evalualte the situation and figure out the solution. It generally takes me about 2 to 2.5 hours. When I see a mom it is generally several days after the birth and she has already been struggling for several days to get things right. So I am there because those measures have failed. One of my my biggest highs as an LC is to walk into a scenario where a baby and mom have given it their best shot, but despite both their efforts, the baby can't hang onto the nipple. I LOVE to provide that woman with a nipple shield, test weigh the baby before and after and prove to this woman that breastfeeding is possible for her and her baby. The joy that unites this frustrated dyad as they achieve their goal is palpable!!!And I have never worked with a woman who couldn't eventually dump the shield and nurse on her own.If the intake is inadequate, and it occasionally is, then we talk about pumping after feedings. 

This scenario is not generally possible in the hospital for multiple reasons. One of the major problems though, is that you can't do test weights on day one or two, it wouldn't make sense, even if it were logistically possible. So if a mother is discharged with a nipple shield, it is on a leap of faith, that the shield will work, that the mother will get the appropriate followup and that if things are not working out with the shield, she will figure it out before her supply is damaged or the baby has lost a dangerous amount of weight. Even seeing milk in the bottom of the shield when it is removed from the breast does not ensure good transfer, I have seen this happen on multiple occasions when milk transfer was less than adequate as measured by the scale.

I can envision scenarios where test weights in the hospital are feasible though. In evaluating whether a nipple shield makes sense for a preemie or is interfering with transfer, why couldn't a test weight be done feeding the baby without the shield and feeding the baby with the shield, assuming that the mother has established a milk supply. That would make studies irrelevant. Again, we would be lookinig at what is best for this particular baby. 

It honestly doesn't matter to me personally, what studies show about transfer with a shield, because in my practice I can figure out whether or not the shield is working for my dyad, which is all that matters. But for those who make policy for hospitals it does matter because in making those policies you are looking at the greater good not on a case by case basis. It does seem that when sending women home with shields, the best advice would be to pump after feedings until proper weight gain through the shield has been demonstrated and that very frequent follow up care should be able to figure who is stuggling and  who is not. But sending a dyad home where no latching has taken place presents its own dangers and also possiblitles for breastfeeding failure. Handing out a shield in the hospital should involve a bit of trepidation that is not called for in private practice.

In my ideal world, every woman discharged stuggling with breastfeeding would get a home visit from a lactation consultant who could help guide her with individualized care, rather than thrown out on her own hoping rather than knowing that the device she is relying on is really working. 

Kathy Lilleskov RN IBCLC 

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