Laurie Wheeler RN MN IBCLC wrote:  "I was reading Medela's nipple shield handout. It says 'choose a nipple shield that is the correct size for the baby's mouth.'  Long ago, many years ago on lactnet, I think we had a discussion on this.  Some consultants size for the baby's mouth, some size for the nipple. It makes more sense to me to size for the nipple. I know many mothers try various sizes, and sometimes LCs try various sizes.   Opinions? Feedback?"

Am grateful to Ms. Wheeler for bringing up this important topic, given that the above-mentioned nipple shield manufacturer offers a significantly greater range of breast shield sizes in order to accommodate various diameters of nipple anatomy, but limits their nipple shield sizes to only three choices: 16mm, 20mm, and 24mm.  Over the years, I've requested a greater choice in nipple shield sizes from this manufacturer through their customer service department and sales staff, and have received no further response or even discussion from this manufacturer in regard to this clinical need.  I cannot imagine that the potential expense of the design process for additional diameters of nipple shields could even remotely approach the design expense already incurred for their Calma artificial nipple/bottle system.  

Laurie, I very much agree with you in regard to sizing a nipple shield for the maternal nipple, since the nipple must fit into a nipple shield if the nipple shield is to be of any use at all.  Rarely an infant's gag reflex is stimulated by the length of a particular size of nipple shield, and in these few instances, it would be of great benefit to also be able to choose an appropriate nipple shield of somewhat shorter length in support of the infant's needs.  

I am aware of the availability of 28mm nipple shields, but not from Medela as of this date, according to their website.  If an inpatient facility is contracted to provide only Medela products, it may be a challenge in some inpatient settings to obtain larger nipple shields from another manufacturer, depending on the management at a particular facility.  However, the lactation consultant may then provide a Medela breastpump to the mother with appropriately sized breast shields related to the diameter of the mother's nipple anatomy, while the IBCLC endures the experience of cognitive dissonance when explaining to the mother the limitations in size options in nipple shields.  For most mothers and most babies, a 20mm or 24mm nipple shield will suffice, and my education and training has been to choose the larger option whenever possible in healthy, term infants.  For some babies, the 24mm size is too large to accommodate, and the clinician can then select the next smaller size.  At the end of an effective feed with a nipple shield, it's common to see that the maternal nipple anatomy has filled the tip of the nipple shield, when the nipple did not fill the tip of the nipple shield at the beginning of the feed.  I very rarely used a 16mm nipple shield, and this is only in a preterm population when appropriate.  My preference in the preterm population is to use a 20mm nipple shield when appropriate, rather than always initiating the feed in preterm infants with a 16mm, since the clinician can always size down as needed.  Even little preemies open quite wide to yawn, although a 24mm is simply too large for many preemies at the breast.

Having said this much about nipple shield use, I also want to say that a nipple shield is not my first approach for an infant's oral grasp/latch difficulties, but nipple shields are indeed part of my tool kit as an IBCLC.  Sometimes a mother has sustained so much nipple damage that she cannot tolerate the baby's oral grasp without the temporary support of a nipple shield, and in even more severe cases of visible nipple damage, some mothers cannot at all tolerate the baby's oral grasp/latch even with the temporary support of a nipple shield.  Although IBCLCs can certainly observe visible nipple and/or areolar damage in the first three days after birth, the extensive nipple damage seen by outpatient IBCLCs can come as a shock to the clinician who is new to outpatient practice.  Example: multiple and extensive full thickness wounds at two weeks postpartum, with the mother's report that family and friends had been advising her that nipple "soreness" is normal.

I've also experienced a revelation in my career in regard to the use of finger-feeding as a technique for helping infants transfer their learning from the use of a nipple shield for the oral grasp/latch to the successful ability to latch onto the mother's breast without any nipple shield at all.  

I entered the lactation field in 1995 and was not taught or trained in finger-feeding at that time, but eventually heard about the practice of FF.  I did not incorporate FF into my practice for many years, but used cup-feeding as needed as a first choice in alternative methods of infant feeding, as well as tube-feeding at the breast for supplemental feeds.  My initial perception about finger-feeding was that it could be as invasive as placing an artificial nipple in a baby's mouth, and would be teaching the baby a shallow oral grasp similar to using an artificial nipple, so I couldn't appreciate the value of finger-feeding at all.  

Twelve years after entering the field, I began working as an IBCLC in a very large inpatient facility with 12,000 live births annually, reported then to have the 4th largest birth rate in the U.S.  There were three postpartum floors and a large, 108-bed Level III NICU, and only 8 IBCLCs on staff.  I was one of 3 full-time IBCLCs, and the rest of the IBCLC staff were part-time and prn.  Of the two prn members of our staff, one prn IBCLC worked one to 2 shifts per month at that facility, so we were very, very short-staffed.

By 2007, two years later at this facility, I was willing to try finger-feeding in my practice, although I had not heard my lactation colleagues discussing FF, nor had I read any of their documentation in patient charts re: FF.  The facility was not and is not a Baby-Friendly facility, and many, many newborns experienced skill decay for their breastfeeding skills following the use of an artificial nipple.  The use of artificial nipples in that setting at that time was widespread by otherwise well-meaning night shift nurses, who would often encourage mothers to send their babies to the nursery overnight for just one bottle, "because just one bottle does not cause nipple confusion."  At that time, only the IBCLCs had access to nipple shields there, and a large number of babies were discharged home using nipple shields due to difficulty with the oral grasp at the breast following the use of an artificial nipple.  All IBCLCs on our staff utilized nipple shields as needed in our clinical practice.

Both Medela, the manufacturer that was used by that facility at that time, as well as the Riordan text (Riordan at the time, now Wambach & Riordan) recommended additional breast stimulation via pumping during early nipple shield use until the baby shows a pattern of stable weight gain, although Medela's recommendations in this regard were not included in their product guide, but rather as an optional hand-out available on their website.  In this large inpatient facility with so few IBCLCs, I pondered the concept of finger-feeding if it meant that I could assist more infants in transitioning away from the use of a nipple shield prior to discharge, which would reduce the significant amount of necessary discharge teaching on early nipple shield use, and also would hopefully lessen the time spent in giving mothers referrals to outpatient IBCLCs for routine follow-up related to early nipple shield use, and so on.  If finger-feeding could be successful in helping babies transition away from the nipple shield, the workload for mothers could also be reduced in regard to their efforts spent in purchasing, using, and cleaning nipple shields (and searching for misplaced nipple shields), as well as spending additional time and money in obtaining and using a breastpump.  In outpatient practice, it's possible to meet dyads using a nipple shield where mothers report never pumping at all and where exclusively breastfed infants have appropriate weight gain and are thriving, but it's also possible to meet infants during early nipple shield use who are not gaining well or who are not gaining weight at all, and whose mothers report that they have not been pumping at all during this period of early nipple shield use.  So inpatient IBCLCs and mother-baby nurses bear a certain amount of responsibility when discharging a dyad home with nipple shield use.

Although I did not conduct a formal research study on finger-feeding to help newborns transfer their learning to the breast without the support of a nipple shield, I did keep careful notes on infant outcomes in order to determine how effective finger-feeding would be for this purpose.  This is what I found (and this can and should be formally studied):

Finger-feeding in the first three days of life to assist babies in transitioning from the use of a nipple shield to breastfeeding without the use of a nipple shield:

- 80% of infants using a nipple shield transitioned to no nipple shield use for direct breastfeeding within the first 24 hours of finger-feeding, including one infant who transitioned to the breast without a nipple shield after only 2 minutes of finger-feeding

- 10% of infants using a nipple shield transitioned to no nipple shield use for direct breastfeeding within the second 24 hours of finger-feeding

- 10% of infants using a nipple shield were discharged home breastfeeding with the support of a nipple shield, with the recommended teaching on   nipple shield use.  In this group, maternal nipple anatomy was either very short/nearly flat, flat, inverted, or and/or retracting; and breast engorgement was often present by the day of discharge as well

The term "transfer of learning" is from the field of kinesiology, the study of human movement, motor learning, and motor control.   Transfer of learning may be a positive transfer of learning, a negative transfer, or a zero transfer of learning.  

A positive transfer of learning takes place when the previous learning of one skill facilitates the learning of a new skill.  In our field of infant feeding, it's highly uncommon to observe an infant's display of a prompt and positive transfer of learning from the oral grasp of an artificial nipple to the maternal nipple-areolar complex, and similarly, it is highly unlikely to observe an exclusively bottle-fed infant switch competently back and forth between different styles/shapes/contours of artificial nipples, whether the artificial nipple is a bottle teat or a pacifier/soother/dummy.  Instead, we are far more likely to see the breastfed infant's skill decay for breastfeeding following the use of an artificial nipple, and particularly the early use of an artificial nipple, with skill decay defined as the decrease in speed and accuracy for the task.  Bottle-feeding families as well as hospital nursing staff often report that bottle-fed infants often struggle with one style of artificial nipple, while "doing better" with another style of artificial nipple.  When babies have learned how to breastfeed as well as bottle-feed, it's common to hear parents report that even though the baby "does fine" switching back and forth from breast to bottle, their babies often display greater skill with one style of artificial nipple during bottled feeds, as well as difficulty with other styles of artificial nipples (measurable as delays in reaction time, movement time, and response time).  

We IBCLCs often provide a "nipple-confused" baby with the support of a nipple shield, and ideally this support is only temporary.  When the baby responds much more quickly to the maternal anatomy when a nipple shield is in place, we can state that the baby has had a positive transfer of learning from artificial nipple to the nipple shield at the breast. The infant's sensory-perceptual-motor learning experience of finger-feeding re: learning to associate the smell, touch, and taste of the mother's skin with sucking and receiving milk also supports a positive transfer of learning by the infant.  This can even be measured in the same manner that kinesiologists measure skill acquisition and skill decay, by measuring reaction time to the stimuli, movement time for completing the movement (such as the baby's ability to achieve and sustain the latch prior to beginning rhythmic suckling), and response time as well.  These measurements are measured in units of time re: milliseconds, and even the infant's skill decay at the breast for the oral grasp can be measured in milliseconds,  i.e., we often observe (as millions of mothers have observed) the phenomenon of the delay or impairment in responding to the previously cued (orienting) stimulus, referred to as an Inhibition of Return (IOR) when this inhibition is quantified by at least 500 to 3000 milliseconds.  In response to the infant's measurable skill decay following the use of an artificial nipple, nipple shields are frequently and heavily used in many settings due to the infant's newly displayed success in returning to the breast when the breast has been augmented by the nipple shield, giving the experience of similarity to the infant of the previously used artificial nipple.  

A negative transfer of learning occurs when past experience in one skill obstructs or hinders the performance and learning of a new skill.  An example of a negative transfer of learning in our field of infant feeding is when a breastfed infant is bottle-fed, followed by observable and measurable skill decay at the breast for the oral grasp and/or effective suckling for adequate milk transfer.  Suck-training with an artificial nipple is another example of the subsequent and common negative transfer of learning to the breast.  The use of a nipple shield in helping infants transfer their learning to the breast can be observed as an improved reaction time to the maternal anatomy, which provides the infant with an associative learning experience of similarity to the length and firmness of the previously used artificial nipple.  However, many babies do not then immediately begin sucking in an effective manner with the new support of the nipple shield, but rather spend a number of seconds, or even a minute or more, in exploring the new shape of the teat of the nipple shield, which is similar but different to the previously used artificial nipple, but more similar than the maternal nipple that is not augmented by the nipple shield. 

A zero transfer of learning occurs when the learning of one skill neither contributes to nor interferes with the learning of another skill.  An example from our infant feeding world is cup-feeding, which is often observed to neither contribute to nor interfere with the infant's learning at the breast.  This is interesting, because the baby learns how to use a shallow oral grasp when cup-feeding, and the milk is given with the baby's first sip, although during cup-feeds, the infant's need to suck is not fulfilled at all.  In 20+ years of practice, I've only met one mother who reported that her baby preferred cup-feeding.  She explained that her baby did learn to breastfeed and would breastfeed, but that he had learned how to cup-feed during his long NICU stay.  She said, "I can just tell that he really prefers to cup-feed - - he got so good at it in NICU, and he looks happier when he's cup-feeding than when he's at the breast!"  

Another interesting aspect of infant feeding is that the younger the infant, the faster the learning as well as the forgetting.  Consider the 6-month-old who is learning how to use a sippee-cup, which is a weeks-long process of motor learning, versus the healthy, term one-day-old infant who learns very quickly how to sip from a cup, and furthermore, learns how to cup-feed during one practice session.  This reflects what is termed "the exuberant learning of infancy" - - and forgetting is exuberant in infancy as well, including motor forgetting.

I apologize for the length of this, but nipple shield use does warrant a lengthy discussion.  There's much more to discuss from a motor learning point of view, but will end here.  I do have a gentle and polite sense of humor, and can hear some kind folks murmuring: "Don't mention nipple shields around Deb Swank - - don't get her started!"   

With gratitude for the opportunity to chat in this forum, 

Debra Swank, RN BSN IBCLC
Ocala, Florida USA
More Than Reflexes Education
http://www.MoreThanReflexes.org
http://www.MoreThanReflexes.org/on-learning/ 

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