Lisa,
Re: your question about shields:

I am only a little experienced with various size shields what with my volunteer status. I used the old, old-fashioned glass and rubber nipple kind thousands of times decades ago in the hospital, and infant mouth size was not a problem. Frankly, since so many babies get bottles too, I don't think the old, old kind (still available from some code-breaking companies overseas I think) are as bad as hey have been accused of being. A softened areola is very helpful in all cases.

This comes to mind however. I remember from Paula Meier's article about premie babies getting more with a shield than attempting to nurse with the bare nipple. My impression is that even though the baby's jaws are not large enough to bypass some nipples with or without shields, in order to latch,  the vacuum from the baby's suction on the shield alone allows the nipple to push inward to the point that the firm ring is compressing the lactiferous sinuses (yes, I do believe in them because I have palpated them in late pregnant mothers and brand new mothers thousands of times over 5-6 decades), and that it is the compression of the sinuses against the rings that causes the milk to leave the nipple.

That having been said, one can't enlarge the baby's mouth. Only time and growth will do that. However, it is possible to try RPS on the nipple itself by gently applying pressure all different ways (sideways, together, inwards, etc. on the nipple button). This would apply especially in the first 2 week period if the mom had any IV's whatsoever, but also soon after pumping, which can also allow edema to move into the nipple tissues and temporarily enlarge the nipple measurement. (See. BF Atlas, Clay and Hoover). 

After RPS on the nipple, do thorough RPS on the areola at the base of the nipple, triggering MER and making tissue pliable. Then apply the shield as Linda Pohl has suggested, by turning it halfway inside out first. Then put it over the softened nipple and flip the shield back to regular shape. Since there is a hole in the nipple, obviousy, it's not vacuum that does it, but something in the characteristic of the silicone plus the original measurement/shape of the shield "grasps" the softened nipple and moves it forward to fill the shield all the way to the inside end, (providing the nipple and areola are softened and pliable.) 

I don't think there is as much to worry about concerning "pinching" a pliable nipple by a soft silicone shield with a natural level vacuum of a baby as there is by a too-small rigid plastic flange with machine vacuum working.

Just my observations thus far. I hope to learn something from the replies of others.

K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC, Dayton, OH

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