Ruth Soloman asked for help with a 6 day old baby who would not attach to
her mother's large flat nipples. I have seen a few cases like this also. My
first "line of attack" is similar to what Kathleen Bruce suggested - I use
a periodontal syringe to squirt milk (preferably EBM, but if none
available, then formula, if baby already receiving supplements) into baby's
mouth if she shows attempts at latching. This is the "suckle right or
drown" principle (Kittie Franz's?), if baby swallows the milk she is likely
to follow it with a good suck. With this baby, this may not be sufficient.
The next thing I would try is a nipple shield in conjunction with the extra
milk. (Note that some brands of shields are better than others. The ones I
prefer are made by C----- A---- and T----- T----- - not sure about what you
get in US. The latter good for babies who bottle feed well, but are not
necessarily nipple confused.) This baby Ruth mentioned sucks a finger well,
so I would expect she may suck on the shield. If you can get her sucking
well on the shield, and the mother still has a good milk supply, she should
be rewarded quickly with milk directly from the breast. The follow-up for
this situation would obviously be to wean off the shield, but I think this
is usually easier on the mum than continuing to express and finger-feed. In
my experience, most mums having to do the latter, don't last long before
they wean. I always impress upon the mother that the baby must suck
properly when on the shield (ie not just on the cone section) and I give
her all the warnings about nipple shields - potential reduced supply,
longer feeding times and potential for baby to get "hooked" on shield. Most
I have found are able to wean off the shield by always trying with bare
breast first (once baby is feeding well) and if baby latches, well and
good, but if she doesn't, the shield is there as a back-up. This is
pschologically much better for the mother who doesn't end up with tension
and a potential battle with a crying baby at each feed.

I have also come across babies with small mouths who physically do not seem
to be able to reach the sinuses to get the milk even if they do latch. A
couple of mums with these sort of babies have kept expressing and bottle
feeding the EBM and just keep trying at the breast. The baby may comfort
suck there even if he can't get the milk. I have not found these babies
getting nipple confused, but I warn the mums about this and discuss
alternative feeding methods. Most eventually come good by about 4-6 weeks.
One recently I got on only by using a shield and Supply Line (Aussie
version of SNS), but in the end the mum decided to keep expressing and
bottle feeding. Sometimes the fiddling is all too much.

Good luck with your mum and 6 d.o., Ruth, and let us know what happens.

Joy Anderson IBCLC
Perth, Western Australia