Nipple Shields are they really so bad?

I get asked a lot about how to use nipple shields correctly, so I thought I'd share a few thoughts with you too.

Nipple shields have acquired a bad reputation of recent years. Some of you may have innocently started using them on advice of a friend, only to see the midwives shocked face of horror when you told her! A common tale in my line of work. I am on occasions one of those midwives, although I try to keep my thoughts and facial expressions to myself!

Nipple Shields have a bad rap

There is much confusion surrounding their use, so I want to clarify the issue a little.

Nipple shields were originally made of thick rubber and were placed over the nipple like a bottle teat. Of course, it's understandable that the research showed that nipple shield use was linked to:

• Poor sucking ability after stopping use and returning to "normal" breastfeeding.
• Poor milk transfer. Babies had to suck really hard to get much out, only those mothers with copious milk flow would not notice.
• Hungry babies; see note above!
• Reduced milk supply
• Poor weight gain in baby

Often resulting in cessation of breastfeeding.

Giving a baby any new device to learn from has a potential to cause problems, if used incorrectly. I believe this is where nipple shield confusion comes from.

New Nipple Shield Designs

Even the new lightweight silicone nipple shields we have today can still pose potential problems if not used correctly:

They come in 2-3 different sizes. Designed to be used in very premature to full term babies. The larger the size the wider a baby gapes. When breastfeeding we want baby to gape wide to take in as much breast tissue as possible. Therefore using a small or wrong sized shield can result in a smaller gape, which can lead to damaged nipples and poor milk transfer on return to non shield breastfeeding.

• They are made of a substance which does not feel, taste or smell like mum. This can lead to some confusion when trying to return to the breast as baby has gotten use to an alternative.
• The flow is different (often slower) than directly from the breast. Even the twenty first century versions we have around today are not as efficient. This can lead to an upset bub.
• The silicone layer obstructs the skin to skin contact between baby's mouth and areola. This area around the areola is very sensitive and needs frequent stimulation to cause an increase in the hormone prolactin; the hormone which makes the milk. Therefore over time it can lead to a decrease in milk supply.

As you can see it appears there are not many good reasons for their use...or is there?

I have used nipple shields on many occasions with excellent outcomes. It is about knowing when to use them and for how long. Below is the list for and against:

Reasons to avoid (unless with support from lactation consultant, maternal child health nurse or midwife):

1. Sore, cracked or damaged nipples ***see below note, to indicate when it is appropriate to use.
2. One person said you've got flat or inverted nipples, "you'll never be able to breastfeed". Only 4% of women have "true" inverted nipples, where even on stimulation the nipple will not become pointy. Most flat or inverted nipples just need a little extra time spent stimulating them to poke out. The other thing to note is that with the help of a good midwife, careful shaping of your breast tissue can enable a good latch for most babies.
3. Mastitis; this is not looking at the root cause and can make the matter worse.
4. Using shields before your milk has come in. When your breasts are only making small amounts of colostrum in the first few days it would be almost impossible for baby to draw this tiny amount out via the shield. Resulting in a very tired and still ravenous baby.

Times when it may be a great idea to use a nipple shield:

True inverted nipples. If you are of the small minority, it is highly likely you will need to use a shield for the whole time you breastfeed. In this instance a good, well sized nipple shield is your friend.

1. Sore or damaged nipples, (told you I'd come back to this)! Sometimes I may see a mother whose nipples are so damaged that even with improvements to the positioning and attachment it still results in the further breakdown of the already eroded nipple tissue. Ideally a mother would rest her nipples for a few days whilst expressing and feeding the baby her expressed breast milk (EBM). This has two issues for me; firstly most mothers who use EBM feed it to baby via a bottle, which may also result in a change to the babies gape and attachment at the breast on return to breastfeeding. It may also lead to a rejection of the breast over long term use if a bottle is used with a fast flow. Baby can get use to this lovely flow and be disappointed when returning to the breast, which is often much slower and demands more work from baby. My second reason is it removes baby from mum. By this I mean mums often feel like a milking machine and lose the connection with baby and the opportunity to keep building a bond. As such bad damage to nipples is most likely in the first few weeks, when mothers are exhausted and emotional it is very important to keep the act of 'breastfeeding' going. I have seen many mothers feel overwhelmed with the work for expressing when resting damaged nipples and choose to not put bub back on the breast. So, I would always offer the use of a shield if it was likely for short term use and caused no further damage to the nipples.
2. Baby not attaching in the early days. Some babies, for whatever reason, just do not show any signs of wanting to or being able to suck from the breast. After trying skin to skin contact, dripping milk on to the nipple, laid back breastfeeding style and topping up with EBM via a syringe or a cup every 3 hours until the milk comes in can result in many tears. Within the hospital confines we still seem frightened to introduce a shield, but in this instance I've seen great success. It seems that some babies need something harder against their palate to initiate the sucking reflex. To send a mum home from hospital still trying to get her baby to latch, can seem an enormous task for most new parents. It has always made sense to get mum and baby connected and feeding confidently, despite using a shield. Then we can work together to wean off the shield. I have found over the years this is the least stressful option and more often than not results in successful breastfeeding.
3. Oversupply or very fast flow. Some babies struggle with their mother's flow. A Lactation Consultant can help with this issue in several ways, but for some women a nipple shield may be a last resort to help bub cope with your flow.
4. Tongue tied babies. Sometimes a baby with a tongue tie may need something to aid their grip throughout the feed, this is especially successful for those tongue ties which cause baby to pop on and off during the feed because they cannot maintain the vacuum. Whilst waiting for a Frenotomy (see post on tongue tie) this may be a great option to get breastfeeding started. Always seek professional breastfeeding help with this as alternatives may work better for your baby.
5. Premature babies. Nipple shields have been accepted for use more so now in special care nursery's. They can work wonders for a baby who may be struggling to hold onto the breast and feed at the same time. This would only be introduced after many attempts to feed without it, but can be a marvellous tool to achieve successful breastfeeding with a smaller bub.

Caveats:

• Nipple shield use over several weeks may reduce your supply.
• A Lactation Consultant will only advise nipple shield use as a tool to eventually achieving successful breastfeeding. See the shield as a stepping stone to your end goal, not a permanent destination.
• If you do start using a shield in the first week, seek help to wean off it as soon as possible. This would ideally be after 24-72 hrs.
• If you do need to use the shield long term (over a few weeks) you will likely need to maintain your milk supply by expressing 1-4 times per day.
• If you are using a nipple shield for any reason, but especially for damaged nipples, ensure you wash it thoroughly and always handle it with clean hands. Store the cleaned shield in a clean sealable box in between feeds.
• If you commence using a shield ensure you have a qualified breastfeeding professional watch and help you achieve an effective attachment. It is a slightly different technique. If baby is just sucking on the end of the shield this can lead to more problems.
• Always seek good professional breastfeeding support to wean off the shield. Once you go back to full breastfeeding you want to make sure your attachment is perfect, get this checked, if only once.

I hope this helps clarify the mysterious world of nipple shields!

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About the author

Katie James, IBCLC has helped thousands of women through their breastfeeding challenges during those early newborn days. Katie's extensive knowledge and experience, coupled with her down to earth, practical approach is reassuring and empowering for new mums.  Find out more about Katie here.