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Lisa Colmillo
Karen Hall
Jane Harman
Tracy Kavanagh

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Roz Webb
Stephanie Westacott
Amanda Wheeler

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Frances Attenborough
Sherry Bevan
Nicola Bradley
Jessica Cather

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Laura Shtaingos
Megan Stephenson
Christine Griffin

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Anna Martin
Karen Miles
Heather Rai
Trina Warman
Sam Robb-King

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If you want to explore the information given on the other topics, please do! The more of the background we all know, the more time we will have for discussions on the day.

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This page contains links for reading for the first exercise we will be doing on Wednesday. It is about five techniques that we feel all bfcs need to have in their toolbox, in case of need.

We have divided you into groups and each group needs to prepare a 5 minute presentation on their topic. There will be time for discussion afterwards.

The group members are listed at the top of each heading.

In your presentation please give a brief description of what this technique is and how to use it practically.  We know you might not wish to use all these techniques, but we think you need to know what they are and how to use them.

Do feel free to coordinate with the whoever else is on your team - we will also allow 5 minutes on the day for you to decide who says what.

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A specific aspect of Gestalt breastfeeding which we will be exploring in more detail on the day

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The original papers (links are on the notes) are written in rather abstruse language - hopefully these notes should make things easier!

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there is so much wrong with this video, but it does show the essentials.

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грудное вскармливание

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правильное прикладывание

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как правильно прикладывать к груди

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лечение трещин

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трещины сосков

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сцеживание молока

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как определить

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хватает ли ребенку молока

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нагрубание груди

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достаточно ли молока у мамы

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восстановление лактации

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правильное прикладывание к груди - в движении

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Правильное прикладывание ребенка к груди, Грудное вскармливание, правильное прикладывание, мультик, как правильно прикладывать к груди, latch, breastfeeding, гв, лактация, лечение трещин, трещины сосков,сцеживание молока, как определить, хватает ли ребенку молока, нагрубание груди, достаточно ли молока у мамы, восстановление лактации

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The Milk Meg's version - scroll down to the video

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*More information on this topic can be found in my NEW BOOK on breastfeeding and tongue ties, "All Tied Up! How To Keep On Boobin' Through A Tongue Tie". Available here.
Most babies will latch on the best when they are supported to self-attach on their own, with the mother in the "laid-back" breastfeeding position, or self-attachment in the "koala" hold. Here is a video to show what this process looks like. It's an amazing thing to see (and experience yourself!)...

But what about the babies who cannot latch on well by themselves? What about the babies with tongue ties or other physical issues going on that inhibit their ability to keep enough of the areola in their mouth while breastfeeding? This is where the "flipple" technique can really help. In the following video I discuss how this little breastfeeding trick can work even better if the mother does this while her baby is in the "koala" position which looks like this:

Step 1. Try to get your knees lower than your hips as this can make it easier for some mothers.

Step 2. Put your baby's mouth right at your nipple.

Step 3. Use the "flipple" technique to get as much of your breast tissue into your baby's mouth as possible. Point your nipple very high towards their nose, try to get as much of the bottom part of your areola into your baby's mouth and use your finger to flip their top lip up after they have latched on.

*You may need to use this "flipple" technique before AND after you get a laser or scissor tongue/lip tie revision done. Some mothers find that they need to use this for quite some time as their baby get's the hang of using their new tongue!

Step 4: Watch this video to see it in action!

And here is another video demonstrating the flipple in an upright position but baby is supported from behind by both a pillow and their mother's arm...

Have you used the flipple and/or the koala hold? Share your experiences below! If you need some help getting your baby to latch on or have questions about tongue ties please CLICK HERE.

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How to get a better latch! The exaggerated latch or "flipple" breastfeeding technique... - The Milk Meg

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And here is another video demonstrating the flipple in an upright position but baby is supported from behind by both a pillow and their mother's arm... Have you used the flipple and/or the koala hold? Share your experiences below! If you need some help getting your baby to latch on or have questions [...]

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After extensive searching, this is the only place where I have found a description of how to attach a baby using nipple shields.

from Chapt 5: They can do it, You can Help: Building breastfeeding skill and confidence in mother and helper, by Rebecca Glover and Diane Wiessinger. IN Supporting Sucking Skills in Breastfeeding Infants, eds CW Genna 2nd edn 2013

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Thoughtful piece from analytical armadillo

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Thoughtful piece from analytical armadillo

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worth reading the comments too

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Nipple shields, the word practically draws a gasp in some circles and to be fair perhaps with good reason. For years nipple shields were used by many as the "solve all" to breastfeeding problems, rather like sticking a giant plaster over whatever was causing the problem - they either didn't help and feeding was just as painful, or did but mum's supply suffered, and if she got through all that it was often a long and arduous process getting baby to feed without them; techniques recommended ranged from "making baby go cold turkey" to "cut them down gradually" (really not recommended nowadays due to shields being made of silicone which can be very sharp when cut).

Dr Jack Newman himself states there is never a need for nipple shields - and perhaps in a perfect breastfeeding world where everyone can get the help they need instantly, he may be somewhere near the mark. But at least where I am in the UK, we're simply not there at the moment.

But let's start at the beginning.

Nipple shields have been around since the 16th century, and have been made of lead, silver, wax, wood, pewter, tin, bone, ivory and glass.

More recently plastic, rubber or latex became popular and nowadays the typical shield is a thin piece of silicone worn over mum's nipple and areola - although there are still a few odd contraptions around, like the Portia nipple shield (on the right) endorsed by Claire Byram Cook (or so the packet says). The mum pops the "teat" over the plastic holder, and then puts the plastic holder over her nipple; I'll leave you to make your own minds up about that one, but I'm sure many will note the similarity between this and the image on the left...

Numerous studies demonstrate that shields can affect milk transfer and thus mum's milk supply, however these studies are examining older fashioned thicker shields, that would reduce stimulation to mum's nipples too.

A 1980's study found latex shields reduced milk intake by a 22%, but had no significant effect on sucking patterns. But shields are now made of thinner silicone, so how applicable is this?

Not very in my opinion.

A 2006 study published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, which examined use of an ultra thin shield found:

"Physiological results demonstrated no significant difference in maternal hormonal levels and infant breast milk intake for breastfeeding sessions with and without nipple shields."

I'm sure many are wondering where I'm going with this - surely we don't want everyone reaching for the shields do we? Of course not - but we've gone so far the other way that they're seen as a huge cause of breastfeeding problems and something to be avoided at all costs. They are no longer seen as a useful tool in the bag of someone suitably qualified, but a big no no.

A few months ago I suggested a mum considered the temporary use of shields, with the result being the local NHS Infant Feeding Advisor (midwife) was so upset, you would have thought I had suggested hanging the baby upside down from the washing line whilst mum latched him doing limbo.

I met the mum four days post-partum after what she described as an "horrific" labour and delivery, 48 hours resulting in an emergency section. There was a long delay between birth and her holding her baby, who had promptly refused to latch - again she filled up as she described the past few days in hospital. The baby had "screamed" every time she held him, trying to latch, pulling away writhing and twisting, leaving mum in tears. Biological nurturing (leaning back) which they had suggested in hospital, she had found difficult due to her very large pendulous breasts meaning baby ended up somewhere under her armpit and even with pillows etc mum had felt extremely uncomfortable and the baby had just "pecked and bobbed".

Midwives had offered to take the baby, and as he settled with them (away from his "food source"), mum felt it was her causing the baby to become distressed. She had managed to get him latched for four feeds the previous day, all of which had followed a 30-50 minute battle, a number of other feeds had resulted in them "giving up" because baby simply wouldn't latch and became either too upset or sleepy to feed. Mum had been expressing since day one and cup feeding in hospital had been messy, with mum confessing dad had tipped a little in because they were so concerned he wasn't taking any milk (please note this is not recommended and can pose a choking hazard). Even after the feeds that they managed baby was unsettled and rooting for more.

Mum didn't hold her baby unless she had no option but to attempt a feed, because otherwise the whole rooting, writing, crying scenario would unfold again. Mum was utterly miserable - just wanting to feed her baby without him becoming so distressed and frustrated first; she confessed if things couldn't be sorted today she didn't know if she could continue breastfeeding; as it was she was beginning to wonder what she had let herself in for having a baby! She looked shattered, emotionally drained and desperate.

Before long it became clear why this dyad were having problems - baby had a tongue tie which was severely restricting tongue function (probably not helped any by the failure to progress and resulting section), and mum had flattish nipples that inverted with pressure; the combination proving frustrating all round. Without adequate tongue function baby has cues missing from the feeding sequence he uses to latch, add to that retracting nipples and he can't even get by using a less effective technique.

When a feed was attempted and baby struggled and expressed his frustration, mum quickly became tense and distressed - "you see" she declared, ""we just can't do it". Despite every trick to improve protrusion, breast sandwiches, deep latch techniques and nipple flips in almost every imaginable position, baby barely latched, he nibbled on the nipple maybe twice but nothing more. Mum gave a little expressed milk via finger feeding (which both parties loved and the cup hit the bin!) to take the edge off and keep him interested - but just as she had described the cycle of them both ending up upset continued.

At this point mum sobbed, and everything came out from her "failure to birth properly", to her "failure to even hold her baby without him becoming beside himself", to her "failure to feed him".

Mum gave baby some expressed milk so he would settle, I made us a cuppa and we had a long chat, which resulted in me asking if she wanted to consider using a shield until the tongue tie could be further assessed, and so they could both do a little healing from the birth - some breathing time. After a quick chat about pros and cons, how it may not help or may cause pain, dad popped out to the chemist.

Mum popped the shield on, hesitantly put her son to the breast and within an instant he was latched and taking full advantage of her now abundant supply! Mum cried again, this time with tears of joy - "I'm feeding him, I'm actually properly feeding him!!" she declared triumphantly. She preened and stroked him as he nursed, telling him how clever he was, compressing her breast until before long he popped off satisfied and content.

How do we begin to measure the psychological boost that feeding her baby without distress gave that mum? The renewed hope that she could breastfeed, that she no longer had to dread picking her baby up and that he only ever cried with her? Was the latch perfect with the shield? Nope, but did it actually at that point matter? Baby got enough to feel satisfied, mum was happy and this was a short term intervention.

With a now beaming mum I called the Infant Feeding Advisor to ask the best route of referral for NHS division. I was advised to speak to the midwife who as if on cue, knocked on the door.

That's not a tongue tie the midwife declared (after nothing more than a cursory look in baby's mouth) I will refer you but they won't do anything with that. And what are those shields? You should be cup feeding, our Infant Feeding Advisor would not be happy with you using those....When she spotted the syringe used for finger feeding, I thought she might actually pop there and then in the kitchen!

At this point mum looked about to cry again and dad quickly intervened to say they had had a lot of trouble cup feeding and this had worked really well. I will get someone round to show you how to cup feed properly was the midwives reply, he will never breastfeed if you keep using those shields, new guidelines are they're not recommended at all. Finger feeding shouldn't be used either once the baby needs more than 1 or 2 mls...

After the midwife had gone it was dad who reminded mum of her brilliant feed and that she should follow her instincts, mum decided to stick with the shields and see what panned out.

I received a phone call from her several hours later, telling me the area Infant Feeding Advisor (IFA) had arrived with her less than an hour after the midwife had gone (called in by the midwife) the IFA confirmed it was a tongue tie and referred the baby for division, but also agreed shields were against NHS guidelines and she did not support their use, nor the finger feeding which should not be used as the baby needed to "stretch their tongue attempting to cup feed" and it was not an evidence based method of supplementation (clearly Salisbury NHS disagree and guidelines do actually state cup OR finger feeding is fine). By this point mum wasn't up for engaging in further discussion and politely told the IFA she intended to continue as was until division.

Long story short the parents waited several weeks for division, during that time they did not receive any information as to when, where or even if the division would take place. She tried on numerous occasions without the shields, but the result was always the same frustrated crying and so she continued using the shields and feeding her baby! After 48 hours solid of trying to obtain a date/time for division from the NHS, the parents decided to go private and contacted the IFA on the morning of their appointment to advise her of their plans - within 5 minutes they were advised to drive to a particular hospital where the tongue would be divided....

After the procedure, mum was again advised to expect difficulty stopping shield use, and so did not attempt it for 3 days whilst the tongue healed. On day three half way through a feed mum removed the shield and never used it again.

Evidence?

Clinical Use of Silicone Nipple Shields, J Hum Lact. 1996 Dec;12(4):279-85:

"Use of nipple shields is controversial. However, when weaning is imminent, they may enable breast-refusing infants to transfer back to the breast."

Women's experiences using a nipple shield, J Hum Lact. 2004 Aug;20(3):327-34.

"An informal, retrospective telephone survey of 202 breastfeeding women was conducted over an 8-month period of time, assessing patients' perceptions regarding use of a silicone nipple shield. Sixty-seven percent of the women continued to breastfeed after transitioning off the nipple shield."

Now bear in mind we have no idea how many of these 202 mums may have given up breastfeeding entirely without the shield...

Long-term nipple shield use-a positive perspective, J Hum Lact. 1996 Dec;12(4):301-4.

"This report describes ten cases in which silicone nipple shields were used for two weeks or longer. In nine of the cases, shields were used to help babies attach to the breast. These babies had struggled to attach to the areola because of suck problems or the mother's lack of protractility of breast tissue. In the tenth case, the shield was used because of extreme nipple soreness. All babies were off the shield by 3.5 months of age; nine were feeding directly from the breast. All weights were appropriate or above for the age of the infant at three weeks, two months and four months."

Discussion:
Much of the focus surrounding nipple shields is about function - does it impact on milk transfer, mum's hormone levels, milk supply. What about the psychological impact, did it empower this mum? Absolutely, and I have no doubt in my mind at all that it preserved breastfeeding where it would otherwise have ceased. Even if eventually we had managed to get baby latched, what happens at the next feed or at 2am?

I think before anyone even thinks shields, the key is establishing WHY a baby is struggling to feed well - without this it is just a sticking plaster. They can be hard to stop using if the root cause isn't also addressed, I think they should only be discussed by a lactation consultant or very experienced, competent breastfeeding counsellor and not as the solve all they used to be. They're not the answer for all mums, and they're definitely not the answer to all or even most problems - but used wisely, I for one think they're a godsend.

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Nipple Shields - Don't Throw The Baby Out With The Bath Water

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Nipple shields, the word practically draws a gasp in some circles and to be fair perhaps with good reason.

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I could not get my daughter to latch on without the nipple shield either. I know all the books discourage the use of one, but I would not have been able to breastfeed without it. I had made attempts to wean her of it, but it never worked. Finally, I just decided that it was working fine using it and I was going to keep on using a nipple shield while breastfeeding. At 5 months my daughter suddenly started eating without it. I would latch her on then remove it. We finally got to the point where she could latch on fine without it. So, don't give up hope. All that really matters is that you are breastfeeding.

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Is it ok to use nipple shields for the duration of breastfeeding? | Mom Answers | BabyCenter

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I could not get my daughter to latch on without the nipple shield either. I know all the books discourage the use of one, but I would not have been able to breastfeed without it. I had made attempts to wean her of it, but it never worked.

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The size and shape of nipples and breasts vary widely between women. These differences have little to do with the ability to breastfeed-though if one or both nipples are flat or inverted some mothers find that establishing breastfeeding takes a little extra time and patience in the early days.

Inverted nipples? Many nipples will protrude when stimulated. If you think yours may be inverted, try placing your thumb and finger on opposite sides of the areola (the darker area of skin surrounding the nipple) and squeezing gently inwards. A nipple that stands out when stimulated is not inverted. Sometimes nipples may be partly inverted, looking dimpled or folded. Severely inverted nipples usually retract deeply when compressed or stimulated.

It's common for nipples to change shape during pregnancy, gradually protruding more. After your baby is born, your nipples may appear flatter but babies often lick the nipple to stimulate it before latching on. Your nipples may also appear flatter if your breasts are very full or engorged.

Causes

Inverted nipples may be caused by:

Tiny bands of connective tissue connecting the nipple to the inner breast tissue

Short milk ducts

Less dense connective tissue beneath the nipple than in women with protruding nipples

Treatment

There is no agreement about whether it is helpful to treat inverted nipples. The Royal College of Midwives believes that a diagnosis of flat or inverted nipples serves only to damage a mother's confidence in her ability to breastfeed. While individual mothers sometimes find one of the treatments suggested overleaf for inverted nipples helpful, no controlled studies have shown any particular treatment to be effective. Whether or not you try the techniques overleaf, do learn how to hand express milk. You may also like to try expressing your colostrum in the last four weeks of pregnancy. Any colostrum you collect can be frozen and given to your baby after the birth if needed. Antenatal Expression of Colostrum provides more information.

Good attachment is the key

Whatever breastfeeding specialists think about the different treatment options, they all agree that getting a deep latch is crucial. Babies breastfeed-not nipple feed-so with effective positioning and attachment your baby can learn to nurse well even if you have flat or inverted nipples. When a baby takes in a large enough mouthful of breast he will be able to feed effectively, so the shape of your nipples may not be an issue at all. Reading La Leche League books and leaflets before your baby is born will help you learn about breastfeeding and how to avoid common difficulties. Try to attend an LLL Meeting too-pregnant women are always welcome.

Comfortable breastfeeding

Comfortable positioning and attachment are important for all mothers. You will have time to practice with your baby while your breasts are soft before your milk comes in. Whether or not you have flattish nipples, start as soon as possible by holding your baby in skin-to-skin contact right after the birth. The earlier you start, the easier it is. laid-back or 'natural' positions can be a great help in encouraging your baby to latch on well, as well as being comfortable for you.

If your baby isn't nursing well

Hand express or pump to stimulate your breasts to make milk. Aim to express as often as your baby would be feeding, about 8-12 times in 24 hours. Your expressed milk can be offered by spoon, cup or syringe while you both learn how to breastfeed. Avoid using bottles or dummies as they may cause nipple confusion, making matters worse.

Soften your breast

Breastfeed as often as you can. When your baby bobs his head and licks the nipple, he naturally makes it easier to latch on. If your breast is full and hard, you can use reverse pressure softening to move fluids away from the nipple area so your baby can latch on well. Apply gentle steady pressure with your fingertips on the areola around your nipple for about a minute. You can also press with the sides of your thumbs or fingers. Denting the breast at the edge of the areola with a finger and placing your baby's chin in the dent may also help. Gently hand express a little milk if needed.

Stimulate your nipples

If your baby's head bobbing and licking isn't enough to stimulate your nipples, try:

Rolling your nipple gently between your thumb and finger

Touching your nipple with a cold moist cloth

Try using a breast pump

With some deeply inverted nipples, when a baby tries to breastfeed, he compresses the buried nipple beneath his mother's areola. If simpler techniques of stimulating your nipples before a feed fail, an automatic electric pump may be needed to provide suction to draw the nipple out before a feed. Once may be enough, or you may need to pump before each feed for a few days or perhaps weeks.

Nipple shields

A nipple shield is a thin, silicone teat that can be placed over a mother's nipple and may help a baby who is having difficulty learning to breastfeed. Nipple shields can be used temporarily to help establish breastfeeding. They come in different sizes-a comfortable fit is very important.

It is very important to seek skilled help with positioning, attachment and any other problems if you are already using nipple shields or planning to use them. Whilst a nipple shield can be a useful tool it should be regarded as only a temporary solution-continue to offer your baby some time in skin-to-skin contact every day without a nipple shield so he has the opportunity to latch on if he is able.

Practicalities

First breastfeeds
Breastfeed early and often after your baby's birth to minimize engorgement. Many babies have no difficulty feeding from mothers with inverted nipples, so start off by putting him to the breast and see how he gets on. If he latches on well and you are comfortable he will get plenty of practice and will probably continue to feed well after your milk comes in and your breasts feel fuller.

If your baby won't breastfeed
Don't panic! A baby usually starts to suck spontaneously if he can snuggle up close to his mother's bare chest for periods of time. Try letting your baby lie on your body as you recline so that both his chest and tummy are against you. This kind of contact, sometimes known as Biological Nurturing™, usually stimulates a baby's instinct to attach and suckle well at the breast. In such positions babies can also latch on when sleepy or in light sleep. Watch for signs your baby is stirring and gently encourage feeding.

Practical tips
Getting a deep latch
Help your baby get a deep mouthful of breast using the following tips:

Bring baby to breast, not breast to baby. Relax comfortably with your breast in its natural position

Keep your baby's whole body close against your body

Help your baby approach the breast 'nose to nipple' with his chin on or close to the breast. Keep his body tucked in close as he attaches and feeds but make sure he can tip his head back easily to open his mouth wide

As your breast touches his tongue, it will push his lower jaw open wider. If you are sitting up, as he opens his mouth to take the breast pull his body in firmly against you and give a little push between his shoulder blades

This will help him open his mouth very wide to get his top lip over the nipple area to latch on, resulting in a bigger and better mouthful of breast

His lower jaw will be tucked into your breast well away from the base of your nipple and his nose will be free. Active sucking is triggered when your breast tissue reaches the back of his mouth

Once your baby is attached you can make small adjustments to maximise your own comfort. If you're sitting up to feed, try shifting your weight back onto your tail bone and reclining your body back a little to open up a space for your baby. This allows more of his weight to be supported by your body and less by your arms. Gravity can help him stay attached deeply.

You can als o experiment with different holds to help you find what works best for you. An LLL Leader can help you find the most effective approach. You can find more detailed information by reading our page Positioning & Attachment.

Some women like (or need) to hold their breast when nursing. They flatten their breast as they would a big sandwich they were offering to the baby, matching it to the oval of his mouth. This can help their baby grasp more breast tissue. It doesn't matter if fingers are closer to the upper jaw but try to keep the "lower jaw fingers" out of your baby's way.

Exaggerated latch
To help get an even deeper latch you could try placing your thumb or finger near the base of the nipple where the middle of your baby's upper lip will be, lined up with his nose. As you press, your nipple will tilt away from your baby, presenting him with your breast rather than your nipple. As he opens wide, snuggle him in close and use your thumb or finger to tuck the breast into his mouth. Your nipple will be taken in last and unroll in his mouth. You can then slip your finger out.

Seek Support

Many mothers experience challenges with breastfeeding and find attending LLL meetings supportive. They will give you the chance to see that, whatever challenges you may face, breastfeeding can become a rewarding experience. If there is no LLL group in your area, you can still contact an LLL Leader for support.

Treating inverted nipples

Various techniques can be used to draw out nipples-though research on their effectiveness is inconclusive. If using devices, it is important to follow the manufacturer's instructions.

The Hoffman Technique
This technique is used during pregnancy. With a thumb on each side of the base of the nipple, press in firmly against the breast tissue and at the same time pull your thumbs away from each other. If this feels comfortable, repeat five times each morning, moving your thumbs around the base of the nipple. If you experience pain this technique may not be appropriate for you.

The Nipplette™
The Nipplette™ is a device that uses suction to help a nipple protrude. It consists of a transparent nipple mould from which air is sucked using a small syringe. The device is placed over the nipple area for increasing time each day during the first six months of pregnancy. One device is needed for each inverted nipple. The manufacturers do not recommend use in the last three months of pregnancy. While breastfeeding, limit use to a few minutes to draw out the nipple immediately before breastfeeding.

Breast shells
Sometimes, two-piece breast shells are suggested to apply steady pressure to encourage flat or inverted nipples to protrude. Whilst individual mothers report that using breast shells is a help, research has found them to be ineffective. They can be worn during pregnancy or before breastfeeds. If you decide to try breast shells, wear them for no longer than 30 minutes before feeds to reduce the risk of nipple soreness due to lack of air circulating around the nipple and blocked ducts due to pressure. You may need a bra with a larger cup size than normal. Breast shells need to be washed daily and any milk collected should be discarded because of the risk of bacterial growth.

Other concerns
Sore nipples
You may experience some discomfort in the first couple of weeks of breastfeeding as your baby gradually draws your nipple out. This is temporary and different from nipple damage and soreness caused by a baby who isn't latching on well. Pat your nipples dry after feeds, replace breast pads frequently and change wet bras. Your aim is for comfortable, relaxed feeds for you and your baby. So seek skilled help if you do experience nipple damage.

One breast preference
Differences in your nipples can lead to your baby preferring one breast to the other. You can encourage your baby to breastfeed on the least preferred side by putting your baby to the breast when he is in light sleep, offering it first at feeds and by breastfeeding frequently. Some mothers express from the least preferred breast to maintain milk production. However, some babies are quite determined in their preferences and end up breastfeeding from only one side. If this happens, milk production from the preferred breast will increase to meet your baby's needs as the other breast produces less. Any lop-sidedness will be temporary.

When further help is needed

If you have flat or inverted nipples and then experience additional challenges such as a premature birth or a thrush infection, seek help from your midwife or LLL Leader.

Written by Karen Butler, Sue Upstone & mothers of LLLGB. Photos courtesy Lois Rowlands and Kate Riley.

Further Reading
Antenatal Expression of Colostrum Beginning Breastfeeding Comfortable Breastfeeding
Engorged breasts - avoiding and treating
Hand Expression of Breastmilk
Is My Baby Getting Enough Milk?
My Baby Won't Breastfeed Nipple Confusion Nipple Shields Sleepy Baby - why and what to do

From LLLI
Inverted nipples don't stop breastfeeding

Books
The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010.

References
Breastfeeding Answers Made Simple. Mohrbacher, N. Amarillo, TX: Hale Publishing, 2010.
Biological Nurturing; Laid-back breastfeeding for mothers DVD. Colson, S. et al. 2012.
An Introduction to Biological Nurturing; New angles on breastfeeding, Colson S. Amarillo, TX: Hale Publishing, 2010.
Supporting Sucking Skills Watson Genna,C. Burlington, MA: Jones & Bartlett, 2012.
How to do Biological Nurturing
This information is available to buy in printed form from our Shop.

Copyright LLLGB 2016

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The size and shape of nipples and breasts vary widely between women. These differences have little to do with the ability to breastfeed-though if one or both nipples are flat or inverted some mothers find that establishing breastfeeding takes a little extra time and patience in the early days. Inverted nipples?

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We will also be talking about Gestalt Breastfeeding during the day, so it would be great if you had time to look at these notes and perhaps the original papers . . . .

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The original papers (links are on the notes) are written in rather abstruse language - hopefully these notes should make things easier!

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This is so interesting, especially when read in conjunction with the papers on Gestalt breastfeeding as they contradict what the ultrasound shows!

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A nipple shield, or as some new mothers have called it a " breast shield" or "nipple guard" is used as a breastfeeding tool to help assist some babies with latching difficulties. There are many different reasons why your Lactation Consultant may have recommended the use of a nipple shield. It could be due to a nipple shape such as flat, short, or inverted nipples. Sometimes it is recommend if the baby has a high palate, a tight frenulum or a tongue tie (frenulum is the stringy flap of skin under the tongue) or other oral anomaly making latching difficult. Another reason would be if mom has severely sore damaged nipples, the nipple shield acts as a barrier to allow the nipples to heal without further damage and reduces the pain from already cracked bleeding nipples. Some mothers find the thought of the baby being placed on their nipple uncomfortable, and is more comfortable knowing that there is a "barrier" of sorts between the nipple and the b aby's mouth.

A nipple shield is a small, thin silicone device that fits over the nipple and areola during breastfeeding. It acts as a barrier between the baby's mouth and your breast. It looks very similar to a hat..some mom's call it the "Sombrero" or "Witches' hat". It works by vacuuming the nipple and part of the areola in to create a sort of suction. Contrary to older versions that were much thicker, this product is made of a lighter clear silicone, with 4 holes at the tip for milk to flow. I only recommend using a Medela brand 24mm nipple shield. Other brands and other sizes can cause more discomfort and allow for a decrease in supply. The shields come in various sizes, extra small (16mm), small(20mm), and medium (24mm). Rarely will anyone need a small or extra small size.I can not stress enough the importance of using the correct size. The majority of women will need a 24mm medium size to adequately suction in the nipple and areola into the shield to allow for milk transfer. The suction allows the baby to transfer the milk correctly. The nipple shield is NOT a breast shell which is worn during pregnancy or in-between feeds to elongate the nipple to make it easier for the baby to grasp. Breast shells are contraindicated now, and should not be used in my opinion for sore nipples.

For some women, the only way they will ever be able to breastfeed is with a nipple shield, where for others it is just a temporary solution. There is nothing wrong with using a nipple shield as long as it is placed and used correctly. Several years ago, the way nipple shields were made and used, the device actually lowered milk supply. This is no longer the case. The way the shield is manufactured actually helps maintain milk supply for some mothers, and in several recent studies it is actually recommended to use a nipple shield with premature babies as it will aid in boosting milk supply. However I ONLY recommend using a 24mm, medium sized shield as this is in my opinion the only size that can aid in production and decrease pain of nipple trauma. If the shield is too small it can decrease your supply which aids the old school train of thought that all nipple shields are bad for breastfeeding. My take on the subject has always been if it helps the mother and the baby maintain a good breastfeeding relationship, and it is not affecting the milk supply there is nothing wrong with using one as long as the mother uses it correctly and follows the below guidelines.

In most cases the Nipple Shield is a temporary solution, and will only be used for 1 week to 10 days. However, if you have used one for longer then 2 weeks your baby may have become accustomed to the texture and shape and it may take some time to wean off of the shield. In most cases I have seen, the baby at some point in their breastfeeding journey, wean themselves off the shield. One moment they will be nursing beautifully with it, and then the next moment they knock it off. Every baby is different, and every mother's nipples are different. Being flexible is key, and of course lots of patience when it comes to breastfeeding. If you decide to continue using the Nipple Shield here is a list of recommended guidelines:

1. BEFORE USE: Always be sure to wash the shield in between uses with warm, soapy water. Rinse and dry. Prior to attaching, use some hand expression to help stimulate milk flow and evert your nipple as much as possible

2. HOW TO APPLY: Make sure the shield is dry prior to applying. Invert the shield slightly before placing on breast. Do NOT completely turn it inside out. Make sure the cut out notch is facing the direction that the baby's nose will turn. With the shield slightly inverted, place at the base of your nipple and stretch it over your nipple. This should allow for a good amount of suction, and your nipple should pull out on it's own. If needed use your finger to help pop out the nipple. It is normal for there to be a gap between the end of your nipple and the end of the shield.

3. HOW TO USE: Once the shield is on correctly, with one hand grasp your breast in a "C' hold while the other hand is supporting the baby's head and neck. Gently stoke your nipple against the baby's nose, lips and chin signalling to the baby to open wide. Once the baby has a wide gaping mouth bring the baby directly onto the shield and onto your breast. Never go to your baby, bring the baby to you. We have a saying: "Nose to chin...and hug them in"! Once latched observe that the baby's mouth is open wide and the lips are flanged like a fish. The lips and cheeks should be touching the breast rather then sliding back and forth on the shield.
-Listen for audible swallowing
-The baby's mouth should remain open and wide and the lower jaw should be gliding in a rhythmic motion, not sliding back and forth on the shield
-Watch your baby's cues for signs that the breast has emptied. The baby will either de-latch on their own, or the audible swallowing and jaw glides will stop. Breast compressions while baby is nursing is extremely important as this will encourage your baby to suck vigorously while also effectively empty the breast while stimulation the breast to also produce more milk for the next feed. For instructions on how to hand express clickhere
-If the baby's latch is correct, milk transfer should be adequate. To ensure that your baby is getting enough follow the guidelines in this post:Signs your baby is well fed

4. AFTER FEEDING: Observe if your baby is content and if your breasts feel softer, and that milk is present in the shield. These are all signs of good milk transfer. If you have concerns that the nipple shield is hindering your milk supply, or you are unsure if your baby is getting enough consider a visit with your Lactation Consultant who can weigh the baby before and after a feed to see just how much of that precious milk he drank. Remember if you baby is gaining weight, and has adequate amounts of pees and poops you are doing a great job feeding your little one! Weight checks at a breastfeeding support group or at your pediatrician may be recommended periodically to make sure your baby is maintaining and growing well.

5. If ever you feel ready to get rid of the shield, gradually begin to remove the shield with each feeding session. A great way to do this would be to start a feed with the nipple shield, and then half way through or when it is time to switch to the next breast, remove the shield and attempt to latch. Sometimes if you try to remove the shield at the beginning of a feed when the baby is most hungry, they baby will not be willing to cooperate. It's best to wait till their little belly is slightly full before attempting something new. If it doesn't work the first time, be patient. Place the baby on your chest skin to skin. Eventually your baby will re-orient and before you know it he/she will be feeding just as well without the shield as she/he did with it. Contact your local Lactation Consultant if you need help with this.
Below are examples of a good latch and a bad latch.

6. GOOD Latch

BAD LatchCopyright© 2011 Danielle Gauss - JustBreastFeeding.com. All Rights Reserved.

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A nipple shield, or as some new mothers have called it a " breast shield" or "nipple guard" is used as a breastfeeding tool to help assist some babies with latching difficulties. There are many different reasons why your Lactation Consultant may have recommended the use of a nipple shield.

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We all know that laid back feeding positions support babies to use their inborn reflexes, but what exactly is a reflex. That nice MedLife doc explains. Warning - contains cute baby video!