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Nipple Shields . . . Friend or Foe?

Kathy Parkes, IBCLC
From: LEAVEN, Vol. 36 No. 3, June-July 2000, pp. 39-41.

We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.

Nipple shields ... controversial, hated, overused. There was a time when even the thought of their use had Leaders and lactation consultants wringing their hands. But are nipple shields really as terrible as we once thought? Are they always contraindicated? Let's take a look at the research and literature.

To begin, we should define our topic. Nipple shields are artificial nipples worn over the mother's nipple during a feeding. Since the 1500s, devices have been manufactured to provide a means of assisting infants at the breast or to protect a mother's sore or damaged nipples. Initially, nipple shields were made of lead, silver, wax, wood, pewter, tin, bone, ivory, or glass, usually with some sort of gum elastic or rubber teat on which the infant could suck. Interestingly, several of these older versions can still be seen in use today in certain areas of the world. While in Mexico recently, I was able to purchase a glass and rubber nipple shield at the local pharmacy and was told that they are used frequently there.

Currently, though, most nipple shields in use are of the rubber, latex, or silicone variety. They are readily available through lactation counselors and educators, in many hospital newborn nursery and postpartum units, and in chain stores that specialize in baby products. Research evaluating the rubber and latex designs revealed reduced milk transfers of 58 percent and 22 percent respectively. Often, with use of the thick rubber shields, including artificial bottle teats placed over the breast, infants are not able to compress the maternal milk sinuses, which can lead to long-term milk production problems and increased nipple soreness and damage. Since the infant has to rely on suction alone to transfer milk, these types of nipple shields can drastically reduce his milk intake, potentially causing slow or inadequate weight gain. There are reports that even the thin silicone nipple shields cause reduced milk intake and present a potential for reduced maternal milk supply and nipple damage with improper placement.

If there are known and potential problems why are nipple shields used at all? Untrained or inexperienced lactation educators who cannot get an infant to latch on to the breast may introduce them in the hospital to help the infant breastfeed before being discharged. Sometimes concerned friends or family may suggest their use. Common reasons for using a nipple shield include:

  • to improve latch-on when mother has flat nipples.
  • to overcome latch-on problems due to engorgement.
  • to assist infants who are nipple confused, preferring an artificial nipple to the mother's breast.
  • to aid premature infants with tiny mouths, reduced or impaired suck mechanisms, or other physical challenges.
  • to protect sore or damaged nipples.
  • to prevent sore nipples (claimed by manufacturers but not proven).

While nipple shields may permit breastfeeding to continue in some special cases, more often they give the illusion of solving a breastfeeding problem without truly addressing the cause. Most breastfeeding situations involving a healthy, full-term newborn, as well as some more challenging situations involving prematurity, neurological problems, or birth injuries, may respond to interventions that avoid nipple shield use. One-to-one assistance is a must, and experience is an excellent teacher. If a Leader is new to home visits or helping a new mother get started breastfeeding, seeking the expertise of an experienced Leader can be very beneficial. Many Leaders have found that what they thought was good positioning and latch-on over the telephone turned out to be poor positioning or latch-on in person. Being able to show the mother how to gently correct the infant's positioning at the breast may enable her to avoid sore nipples and other breastfeeding problems, without considering the use of a nipple shield. Take time to review the positioning, latch-on, and sore nipple treatment information in the BREASTFEEDING ANSWER BOOK, and share the "hows" and "whys" of good positioning with the mother.

Engorgement can cause a myriad of latching difficulties, and reducing the engorgement is vital to avoid the use of a nipple shield. To reduce fullness in the areola, mothers can use manual expression, a breast pump, and/or the application of cold or warm compresses. Manual expression can be very successful; unfortunately, many mothers are unfamiliar with the process. La Leche League International's tear-off sheet Manual Expression of Breast Milk-Marmet Technique (Publication No. 571-27), shows in detail how to manually express milk. If the mother chooses to pump, encourage the use of a hospital-grade automatic cycling electric pump and pumping only to the point of reducing the areolar engorgement so that the infant can then latch on and breastfeed well.

Although nipple shields are often recommended for mothers with sore nipples, their use does nothing to treat the cause of the soreness. Treatment of sore nipples is discussed in the LEAVEN article, "Nipple Pain: Causes, Treatments, and Remedies", Feb/March 2000, p. 10.

One of the most common rationales for the use of nipple shields is a maternal flat nipple but there are ways to assist the infant to latch on even to flat nipples. The "breast (or nipple) sandwich" technique involves the gentle compression of breast tissue to provide the appropriate filling of the infant's mouth with breast tissue to elicit the sucking reflex. This technique has been likened to an adult who is trying to take a bite out of a large sandwich or hamburger on a bun; the height of the sandwich is too big for the mouth, so the sandwich is compressed to help it fit into the mouth. Page 53 of the BREASTFEEDING ANSWER BOOK details this technique. When using this procedure to assist mothers, be sure to emphasize the following:

  • Compression should not cause the mother pain.
  • The mother's fingers and thumb should be well behind the milk sinuses where the infant's jaws and lips will be.
  • The mother may need to maintain support of the "sandwich" through out the feeding until the infant learns how to achieve this on his own.
  • The shape of the "sandwich" needs to match the position of the infant's mouth.

For example, in the clutch (football) position, the use of a C-hold on the breast could produce the appropriate shaping to match the width of the infant's mouth and thus achieve a good latch-on. But using a C-hold in the cradle position would put the longest portion of the "sandwich" running from the infant's nose to his chin, making latch-on very difficult. In this position, a U-hold might be more effective.

Offering supplemental expressed milk at the breast can act as a reward for infants who need additional encouragement to breastfeed well. The use of an eyedropper, syringe, or spoon to drip milk onto the breast while the infant is sucking can be helpful; care should be used to go slowly and not overwhelm the infant with large amounts of fluids which can cause choking, panic, or aspiration. Some infants may latch on at the breast but need continued encouragement via the use of a tube-feeding device or periodontal syringe. The periodontal syringe is commonly used by lactation consultants for supplementation at the breast and consists of a 10-cc syringe with a curved tip. Caution should be exercised when using the periodontal syringe, as the tip can easily scratch the inside of the infant's mouth if used incorrectly. Leaders desiring to learn more about use of these items can read the BREASTFEEDING ANSWER BOOK, and work with a more experienced Leader who can show them how to use the devices correctly and safely.

Leaders usually find themselves assisting the mother who is already using nipple shields rather than advocating for or against their use. Offering the mother what Leaders excel at, mother-to-mother support, is vital. Suggesting an increase in skin-to-skin contact between feedings can give both mother and infant a sense of enjoyment, better bonding, and decreased pressure to perform. Warm baths taken by mother and infant together can help them to achieve a state of relaxation that may encourage the infant to latch on at the breast without the nipple shield. Sleepy infants are less resistant to the change from shield to breast; encouraging the mother to attempt latching the baby on during early morning, naptime, or nighttime feedings might be helpful. Mothers who are trying to teach their infants how to breastfeed without the nipple shield will need a great deal of support. Stress levels are elevated during this time and many mothers have weaned from breastfeeding completely when faced with the additional challenges of feedings that do not go as anticipated.

If the infant refuses all attempts to latch on without a nipple shield, realize that the weaning process from a shield can be a lengthy one. If the mother is using a thick rubber shield, a bottle teat, or a latex shield, the first transition can be to a thin silicone shield. The silicone shield should be placed onto the breast snugly, literally becoming a "second skin," allowing the mother's nipple to be drawn deeply into the shank of the shield and causing the infant's jaws to compress the milk sinuses. If the shield is merely set on top of the breast, chances are higher that the infant will latch onto the shield but only take the end of the mother's nipple. This can increase maternal pain and nipple damage, decrease milk intake, and cause inadequate breast stimulation for milk production. One very successful technique is for the mother to warm the nipple shield in water or by holding it in her hand for a few minutes. This allows for more pliability in the shield, which can then be turned partially inside out, placed directly over the mother's nipple, and "peeled back" over the breast to create a tight fit. Moistening the inside of the shield with milk or water will help to maintain a seal once the shield is placed well onto the breast. With the infant's sucking, the mother's nipple is drawn more deeply into the shank of the shield, enabling the infant's jaws to compress the milk sinuses and permitting more effective milk transfer.

If a baby will not latch on to the breast without the nipple shield, the following observations can reassure the Leader and the mother that the baby is positioned correctly:

  • The nose and chin are in contact with the breast.
  • Both the top and bottom lip are fully flanged outward.
  • The baby's cheeks are full and rounded; dimpling of the infant's cheeks during sucking can mean there is too much unfilled space inside his mouth.
  • The mother experiences no pain during feeding.
  • The baby is audibly and visibly swallowing.
  • The mother's nipple is elongated and rounded when the infant comes off the breast.

Many infants are more willing to accept the change from nipple shield to breast after the initial milk ejection reflex (let-down) and a pause in the suck pattern occurs. Gently slipping the shield off the breast and encouraging the infant to latch on to the breast is often what the infant needs to successfully make the transition back to the breast. Other infants need a partial feeding at one breast before they might be willing to attempt to breastfeed at the other breast without the shield. Following the infant's cues will help the mother to know when to attempt removal of the nipple shield in her situation. It can be helpful to encourage the mother to attempt breastfeeding without the shield in place at every feeding. Whether this is done at the beginning, middle, or end of the feeding will depend on the individual mother and infant. The Leader needs to stress to the mother that these attempts are learning opportunities for the infant, not intended to pressure either mother or infant to perform.

Older lactation texts may advise gradually trimming the tip of the nipple shield back with scissors until the infant transitions to the breast without the shield. Using this method with a thin silicone shield leaves sharp edges that can lacerate the infant's mouth or the mother's nipple, increasing the breastfeeding problems and weaning potential. This technique should never be used with a silicone shield.

During the process of weaning from the nipple shield, it is essential for the mother to stay in close contact with the infant's health care provider in order to monitor the infant in terms of weight gain. Ask about adequate wet and soiled diapers, the mother's nipple discomfort and milk supply. Those infants who are healthy, alert, and gaining weight well may transition directly to exclusive breastfeeding. However, infants who are experiencing slow weight gain, weak or ineffective sucking, and/or neurological or physical challenges may need additional supplementation at the breast. The individual infant and family situation will determine what is appropriate.

Long-term use of the thin silicone shield may be the only option if the infant continually refuses the breast without the shield. Some mothers may consider this option preferable to not breastfeeding at all. However, the mother should continue to try offering the breast without the nipple shield at every feeding. Families in this situation will need continued follow-up for infant weight checks and assessment for adequate intake of milk and for maternal milk production. Referrals to knowledgeable health care providers are appropriate in such cases.

Nipple shields can be a useful tool in maintaining breastfeeding when all other techniques and methods have proven ineffective. However, they should always be used with caution, careful monitoring, and ongoing assessment of the infant and mother, and only after thorough instruction and informed consent of the family.

Nipple shields are frequently used (or misused) for:

Sore nipples (protection and/or prevention)
Flat nipples
Engorged breasts
Nipple confusion/nipple preference
Premature infants
Neurological challenges of the infant
Breast refusal

Problems frequently associated with nipple shield use:

Decreased milk transfer
Increased nipple pain and/or damage
Preference by infant to taste or sensation of shield
Reduced milk supply
Interference with proper latch on
Maternal message of failure as a mother

Are nipple shields appropriate?

Has the mother been assisted in common interventions to get the baby to the breast? Or is the nipple shield the "first line of attack"?

Do the benefits outweigh the risks?

Does the use of the nipple shield fit the mother's breastfeeding plan?
Will the mother be able to receive and comply with careful follow-up?
Does the mother understand that nipple shields are a temporary measure?

Common interventions to avoid nipple shields:

One-on-one assistance by a knowledgeable Leader or lactation consultant.
Assessment of positioning and latch-on.
Use of a hospital-grade electric pump to reduce engorgement or to draw out flat or inverted nipples.
Offering milk rewards at the breast via the use of tube feeding device, periodontal syringes, eyedroppers, etc.
Cup, spoon, finger-feeding methods.
Use of the "breastsandwich" technique.
Increased skin-to-skin time.

Precautions for nipple shield use:

Rule #1: Feed the baby.
Rule #2: Maintain mother's milk supply.
Daily: Monitor baby's frequency of feeds, wet and soiled diapers.
Frequently: Monitor baby's weight gain.
Correct the initial problem that prompted the use of the shield.
Encourage weaning from the shield as soon as possible.
NEVER cut a silicone shield to promote transition back to the breast.


References

Auerbach, K. and Riordan, J. Breastfeeding and Human Lactation. Sudbury, MA: Jones and Bartlett Publishers 1999; 287-88, 427-32.

Bodley, V. and Powers, D. Long-term nipple shield use - a positive perspective. J Hum Lact 1996; 12(4): 301-04.

Brigham, M. Mothers' reports of the outcome of nipple shield use. J Hum Lact 1996; 12(4): 291-97.

Clum, D. and Primomo, J. Use of a silicone nipple shield with premature infants. J Hum Lact 1996; 12(4): 287-90.

Elliot, C. Using a silicone nipple shield to assist a baby unable to latch. J Hum Lact 1996; 12(4): 309-13.

Lauwers, J. and Shinskie, D. Counseling the Nursing Mother. Boston, MA: Jones and Bartlett Publishers 2000.

Martin, Jahaan. Nipple pain: Causes, treatments, and remedies. LEAVEN Oct. - Nov. 1999; 10 -11.

Mohrbacher, N. and Stock, J. BREASTFEEDING ANSWER BOOK. Schaumburg, IL: LLLI, 1997; 53, 86, 390, 396, 401, 417, 566.

Searly, C. N. Rethinking the use of nipple shields. J Hum Lact 1996; 12(4): 299-300.

Smith, Mary K. New perspectives on engorgement. LEAVEN Dec 1999-Jan 2000; 134-35.

Wilson-Clay, B. Clinical use of silicone nipple shields. J Hum Lact 1996; 12(4): 279-85.

Woodworth, M. and Frank, E.. Transitioning to the breast at six weeks: Use of a nipple shield. J Hum Lact 1996; 12(4): 305-07.

Woolrich, M.W., Baum, J.D. Drewett, R.F. Effect of a traditional and of a new nipple shield on sucking patterns and milk flow. Early Human Development 1980; 4: 357-64.

Last updated 11/17/06 by jlm.
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