note: This article was originally published in the Australian Breastfeeding Association Health Professionals eNewsletter.
Publication: Professional member eNewsletter
Article series: Feature article
Month and year: Sep 2019
Author: Dr Kate Naylor MBBS (Monash), FRACGP, IBCLC, Cert IV Breastfeeding Education
What is a nipple shield?
There is reference to mothers using nipple shields as far back as 1550. The original nipple shields were made of bone, cow skin, pewter, glass or tin. These early shields were conically shaped with several holes in the tip; they provided a physical barrier between the mother’s breast and the baby’s mouth, therefore decreasing pain with latching. By the 1850s they were made of rubber and, in the 1950s, they were made of latex (Powers, 2012).
The original purpose of these shields was to treat sore nipples. A ‘healing’ cream would be placed inside them, placed over the nipples and kept there between feeds. Nipple shields being used as a feeding aide is a relatively modern invention.
Nowadays most modern ultra-thin, silicone nipple shields sold in most chemists are vastly superior. They have a thin layer which covers the areola. In the middle is a conical projection which sits over the nipple with several holes for the milk to pass through. These modern shields provide a thin barrier between baby’s mouth and the sensitive nipple-areola complex.
What's the evidence?
There is actually very little recent, quality published data about the use of nipple shields for breastfeeding problems, which is strange given how often they are recommended to and used by breastfeeding mothers.
There still exists a common misconception that the use of nipple shields causes low milk supply. This stems from several older studies which between them had the following design flaws (Chevalier McKechnie, 2010):
· Using latex shields instead of the newer, ultra-thin silicone shields which may impair the breast stimulation
· Studying the milk transfer only in healthy babies who were previously effectively breastfeeding before the introduction of a shield
· Measuring only one feeding incidence
· Measuring only the amount the mother was able to remove with a pump, with the shield in place under the pump
· Having very small sample sizes
· Retrospective study design which opens up to recall bias
· A study discussing milk transfer for preterm babies using a shield being sponsored by a major corporation that manufactures nipple shields.
A review of the studies available from the last 20 years reveals some important findings:
· A study of 34 preterm babies found that the use of nipple shields can improve milk transfer. Researchers measured the milk transfer during a feed WITHOUT the shields followed by the milk transfer during a feed WITH the shields (Meier, 2000).
· In a longitudinal study of 54 mother-baby dyads followed up to 2 months postpartum, weight gains in these term babies who fed with a nipple shield were similar to term babies who fed without a nipple shield. The majority of study mothers reported that the shield use was ‘useful for breastfeeding’ (Chertok, 2009).
· In a large Danish study of babies with varying gestation, nipple shield use patterns, using a nipple shield for the entire breastfeeding duration was associated with 3-fold increased odds of cessation of exclusive breastfeeding in both primiparae and multiparae (Kronborg, 2017). The study authors commented that they couldn’t draw any definitive causal conclusion concerning the strong association between the use of nipple shield and duration of exclusive breastfeeding, because of the observational design. It is important to remember that often nipple shields are given to mothers who are having trouble with feeding in the first place.
· It has long been recommended that nipple shields are only prescribed by health professionals skilled in supporting and educating mothers about their use. This is often done by experienced lactation professionals eg International Board Certified Lactation Consultants (IBCLCs). Further to this, a large study in Sweden demonstrated that teaching health professionals how to provide breastfeeding counselling to mothers with breastfeeding problems, in addition to a recommendation to use a nipple shield, reveals no statistically difference in duration of total breastfeeding (Ekstrom, 2014).
When are nipple shields used?
The humble nipple shield can be a useful tool to keep the baby feeding at the breast, where it might otherwise be too painful or anatomically difficult. Ideally, the shield would be used only whilst the underlying problem is identified and corrected; but in some cases they may be used for prolonged periods.
Research has shown that nipple shields are used by mothers for the following reasons:
When the mother has cracked or sore nipples but wants to continue to offer milk at the breast (Powers, 2012). A large study of women presenting to a breastfeeding clinic in Perth showed that, frequently, nipple pain was managed by advising the use of a nipple shield (Kent, 2015).
Some mothers with very flat or inverted nipples find a shield helpful as something for the baby to ‘latch to’. The shield is less slippery and stretchy than the nipple and can ‘anchor’ babies when they pause between sucking bursts, instead of slipping off (Powers, 2012)
Some mothers with very flat or inverted nipples find a shield helpful as something for the baby to ‘latch to’. The shield is less slippery and stretchy than the nipple and can ‘anchor’ babies when they pause between sucking bursts, instead of slipping off (Powers, 2012)
When the mother’s breasts are very engorged, the breasts can feel hard and the skin can be stretched so tightly that the nipples become flattened at this time (Chertok, 2009)
When the baby is preterm or low birth weight, and still learning to suck at the breast, use of a nipple shield can help to transfer milk (Meier, 2000)
When the baby has an anatomical issue causing problems with attachment (eg a receding jaw, cleft lip, tongue-tie) (Powers, 2012).
How often are nipple shields used? There are no current Australian data on this. However, a recent study from Sweden showed that nipple shields may be used by mothers in the first week postpartum. By 3 months this number is down to 10% and, by 9 months, only 1% (Ekstrom, 2014). A large study of 4815 Danish mothers indicated that 22% had used a nipple shield in the beginning of lactation and 7% used it for their entire breastfeeding period. This was more likely in primiparae with breastfeeding problems; or lower gestational age and birthweight babies (Kronborg, 2017). This implies that the need for the shields drops off as lactation progresses. It is also known that breastfeeding rates drop off rapidly after 6 months in nearly every country. What does a shield look like? These days, shields are made of ultra-thin silicone, which stretches enough to create a ‘suction cup’ over the nipple, protecting it from damage by creating a thin barrier between baby’s mouth and mother’s nipple/areola. The mother can still feel the baby’s latch, but the perception of pain may be lessened. It is still important to latch the baby correctly, as even with a shield more damage can be done. Some babies will suck only on the tip of the shield, but this will make vacuum creation more difficult. Ideally, the baby’s chin should be indenting the breast, in order to assist with vacuum creation and thus assist with milk transfer. How does the mother put it on? It is important to handle the shield with clean hands. It can help to warm it up by holding it for a minute or so first. It is stretchy and can be applied to create a degree of suction, helping it to stay in place better. I recommend placing the ‘cut out’ section where the baby’s nose is likely to be whilst feeding. One suggestion is to put baby on your knees in front of you whilst you are applying the shield with two hands. There are two ways to apply the shield: 1. You can ‘invert’ the shield by flipping the sides up; then push it firmly onto the areola around the nipple, and fold the sides down again. 2. You can ‘stretch’ the shield in two hands, applying one side firmly to the skin, whilst stretching the other side ‘up and over’ the nipple, applying it to the other side with some suction then pulling the nipple further into the shield. Be careful not to let the nipple rub on the edge of the conical part of the shield, it should be centred in the middle. One way to help the shield stick is to apply a few drops of breastmilk on the underside of the shield, as moisture will help create suction. How do I recommend the right size shields? Mothers’ nipples can vary greatly in size. Some stick out 1 cm or more, others are quite flat and sit level with the surrounding breast. Some can be 2 cm, some 3 cm wide. Unfortunately, there is not a lot to choose from in terms of sizing. They are generally 16, 20, 24 cm, although one brand markets their 13 mm shield as ‘large’. It is a good idea to measure the nipple from one edge to the other (ie the diameter), measuring at the BASE of the nipple where it meets the areola. It is recommended to buy a shield that fits the nipple rather than one that fits the baby’s mouth. If the shield is too small, it can cause rubbing of the nipple on the inside, which over time may abrade the nipple surface and cause small tears of the skin. Care and cleaning of nipple shields Most shields come with a protective case, which makes them easy for the mother to carry in her handbag or nappy bag. Usually there are two in a pack, so she can keep one in her bag and the other at home near where she feeds her baby. After use, it needs to be washed in hot soapy water, rinsed under running water and air dried on a piece of paper towel. Care should be taken not to leave the shields in direct sunlight for too long as UV damage may cause the silicone to degrade. For how long can the mother use them? As long as she needs to. There is no time limit! As long as the baby is gaining reasonable weight, the mother can be reassured that the shield is doing what it is supposed to do. Further information about how to tell if the baby is getting enough milk can be found here. If there are concerns about adequate milk transfer it is important to get in touch with the ABA Breastfeeding Helpline (1800 686 268) or seek further support from an IBCLC. You can find an IBCLC here. In the case of using shields for nipple damage, it is important to recognise that the latch still needs to be good even with the shield in place. An ABA breastfeeding counsellor or IBCLC can help with positioning and attachment. There are a range of great videos found here. Then once the mother’s nipples heal or the baby becomes stronger, the shields may be slowly weaned off. In the case of using shields for a weak or sick baby, it is helpful to remember that often as the baby grows, their tongue and mouth grows too. As the baby becomes bigger and stronger they may no longer need the nipple shield as an aid to breastfeeding. How can we remove the shields once the baby is growing well? Mothers may want to periodically try removing the shields to see if they are still required. It is best to try this when the baby is calm and attentive, rather than crying and stressed. One trick is to get the baby feeding with the shield in place, then, after the milk ejection reflex (MER) has occurred, breaking their seal, quickly removing the shield, and then offering the breast. The nipple may well have been ‘sucked out’ adequately so that the baby can effortlessly transition to the bare breast. In summary, nipple shields are a great tool to have in your tool box when helping mothers overcome the obstacles mentioned above. They are a great way to enable a mother to keep feeding through some challenges. They may be needed for a very short time, or could be needed indefinitely. The key factor though is that the mother has ongoing support to work through the causative factor and to ensure that the shield is not causing any new problems. More information can be found here. References Chertok, I. (2009). Re-examination of Ultra-thin Nipple Shield Use, Infant Growth, and Maternal Satisfaction. Journal of Clinical Nursing, 2949–2955. Chevalier McKechnie, A. a. (2010). Nipple Shields: A Review of the Literature. Breastfeeding Medicine , 309–314. Ekstrom, A. A. (2014). Women's Use of Nipple Shields - Their Influence on Breastfeeding Duration after a Process-Orientated Education for Health Professionals. Breastfeeding Medicine, 458–466. Kent, J. e. (2015). Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments. International Journal of Environmental Research and Public Health, 12247–12263. Kronborg H, E. F. (2017). Why Do Mothers Use Nipple Shields and How Does This Influence Duration of Exclusive Breastfeeding? Maternal and Child Nutrition, 13, e12251. Meier, P. e. (2000). Nipple Shields for Preterm Infants: Effect oon MIlk Transfer and Duration of Breastfeeding. Journal of Human Lactation, 106–114. Powers, D. T. (2012). Clinical Decision Making - When to Consider Using a Nipple Shield. Clinical Lactation, 3(1).