Intro

All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

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

Modern Silicone Shield
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.
Portia Shield

Glass Nipple Shield

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.
Latex Shield

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.

Lead Shields
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.

Silver Shield
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.

14 comments:

  1. I'm sooo angry reading some of this. Pah to NHS Guidelines. Do they want women to breastfeed for as long as they can or don't they? When every feed is pure exquisite agony, if indeed you can feed at all with a baby who struggles and refuses like the baby described here (and like mine), who are these people to say nipple shields "aren't recommended at all"? They are like CPR for a breastfeeding relationship that is about to be killed stone dead. They buy some time and more than a little sanity. They prevent women having to give up because they can't take it any more. So what's to disapprove of?

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  2. Oh by the way, I posted that while feeding my 18 month old daughter, with whom I used nipple shields for well over three months (having initially resisted temptation to the point of actually giving up b/f for 2 days due to the "guidelines"). My HV didn't have the heart to quote the guidelines at me herself but let me get on with dealing with things my own way, and thank God she did.

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  3. Zoe woodman (pumping mummies)1 January 2012 14:39

    Agree agree agree! We had limited success with Ns's got told to use them by mw's on the ward, then got told off for using them it was ridiculous if anyone had checked her mouth it was due to tt (lip tie didn't help matters too) but it was due to flat nipples we got told thank goodness this mum had great support from her OH and you.
    We were in central London and my OH had to go to 5 boots stores before found them in stock but with some help from a lovely mw in the high dependency ward I was on we had our first feed with them - she told me they probably wont be happy with you using these on postnatal ward... Seriously there is so much wrong with our bf support god help the mw's when I have my next one I'll be more informed than most on bf and tt and will have an ibclc on call to come to hospital or home immediately after birth. So happy for that family.

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  4. I used nipple shields when my milk came in, as my daughter couldn't latch on because my breasts were so full. (I didn't realise how 'wrong' they were until I saw my midwife's expression when I told her.)

    I only used them for a couple of days and off we went. I think they saved my breastfeeding experience. And I'm still feeding her now, and 25 months.

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  5. Entirely agree AA! Ive suggested shields myself on a number of occasions, similar to the one you describe - always with really positive results (both practically and psychologically)and I've never had a problem supporting the mum to transition back to 'bear-back' feeding once ready. My most recent case involved a baby who had never latched without until 6+ weeks. The first time mum tried, babe went on without a quibble!

    One aspect you haven't covered is that sometimes a mum might have deep-seated psychological reasons against a baby latching directly to the breast. This might be for a number of reasons - a woman's relationship with her breasts can be complex, can't it? The rational wish to provide breastmilk and the urge to experience breastfeeding is at odds with a repulsion, fear or deep anxiety at the prospect of the baby's mouth on her breast. I have found shields to be a great tool in our tool kit for situations like this, too.

    On the other side of the coin though...I would SO love to see at least ONE mum come home from our SCBU WITHOUT shields - it seems to be their default option!

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  6. I cried reading that sstory, it was almost identical to mine almost exactly a year ago.
    The midwives eventually suggested them after the tongue tie that shouldn't affect feeding quite obviously was. And after a mini mental breakdown, the shields saved my sanity. It is heartbreaking to have a new tiny baby that you love so much screaming in pain and hunger everytime he is places in your arms because he is so hungry and can't do anything about it.

    Thankfully the midwives referred us to the Rvi in Newcastle and we had the tie snipped on day 13 and the shields went that day, they were necessary, but I hated them.

    We're still very happily feeding and he turns 1 on Thursday

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  7. There is also the less profound psychological aspect of attempting to latch a baby onto shredded nipples, knowing full well how much it will hurt. Especially when you are told to take off and relatch again and again to get the "perfect" latch (advice that I ditched pretty darned quickly I'm afraid). Over time I found it harder and harder to beat the fear and found myself pulling away at the point of latching which made the problem even worse. The nipple shield provides a physical and psychological barrier - the psychological part of that is totally underestimated by the so-called professionals. I tell you, when you're in that dark dark place the potential effect on your supply is absolutely the least of your worries. Nipple shields saved my breastfeeding relationship with my daughter and bought another 4 months of breastmilk for my tongue tied son that he would never have had otherwise.

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  8. Nipple shields kept me feeding when i developed severely cracked nipples 14 days after my 10lbs 14oz daughter was born (after a 19hour syntocin induced induction with four failed epidurals ending in an emcs with a pph). Had I not used shields I would have given up. Instead I continued feeding, ditched the shields after 10 days and had 12 months of happy breastfeeding AND because of that experience I had the confidence and determination to go and feed my next two children without being daunted by problems.

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  9. I agree with everything that has been said so far.the only thing I would add is that "Guidelines" are exactly that,breastfeeding is nature not a science and one size does definatley not fit all.Sadley it is just another case of women and babies not being treated as individuals and rules prevailing rather than common sense.

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  10. As a breastfeeding practitioner who works in a hospital I would like to say that breastfeeding is not perscriptive, one size does not fit all ! supporting a womens informed choice is so important.Guidelines are there for a reason but sometimes using a guideline as the only point of reference lets mums and their infants down. I enjoyed reading the article but was also saddened by some of your experiances with health professionals who think they are being helpful but failing to see a mothers point of view.

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  11. Thank you for this aticle, I had to use nipple sheilds with my daughter for 24 week, I have no idea why still, she does not have tongue tie but looks like she may have a lip tie? I am not sure and do not know where to turn to get help.
    I ended up with a long and traumatic birth, failed epidural 2nd degree tears and a ruptured uterous (fun eh, it was meant to be a natural home waterbirth haha) Baby would not latch on, fed once in the first 12 hours but would not latch after that, I had some midwives try to help with positioning but to be honest they were brutal throwing my baby about and making us both stressed. They told me to express I did not know how to and could only get about 10ml after around 14 hours postpartum they threatened me with giving dd a cup of formula if I did not get her to feed soon (!!!! I was horrified, a single mother on my own in tears and they were threatening me with formula !!!!) Eventually a kindly midwife presented me with some nipple sheilds, a smile and told me not to use them long term. I was over the moon when she fed & fed & fed no one looked at dd's tongue until recently and no one offered to help, my health visitor just shrugged when I told her! With the help of local peer support & bf groups & sheer determination, not to mention many tears. I eventualy ditched the sheilds 7 weeks ago, I am thankful to the kind midwife at the hospital for giving me shelids, angry that I got no real help from the hospital and was threatened with formula! (Everywhere in the hospital there are posters promoting unicef baby friendly & bf and they threatened me with formula?)Most of all I am happy that we can now feed sheild free and my 21 week old is thriving.
    This really touched a nerve and bought tears to my eyes when I read it, I feel that mothers pain as I was there myself. Luckily I suffered no supply issues, I was aware of the risks though, my experience has inspired me to do peer support training. Sorry for the long comment.

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  12. My preemie used a shield. She was my sixth bf baby, and the first to use anything but the breast, including a pump and a shield.

    She was born at 29 wks and went for non-nutritive sucking the earliest they "allow" at the hospital. The first week when suck-swallow-breathe can be coordinated, she was taking milk from my breast, but my nipple was bigger than her mouth, and thus, we had the shield. According to my LC, in addition to getting it so she could get her mouth on me, it created more pressure/suction than her tiny little 3 lb self could. Since her mouth could barely get around the nipple, this shield supposedly put pressure on the aereola, needed since the nipple alone is not enough to bring out the milk. At any rate, they timed her feeds, and if she stayed awake for 15 min of suckling, gave her no food via tube. She struggled to gain weight, but gained every day except one, so I guess it worked. I can't imagine her getting any milk w/o it since, as I said, her mouth could only, and hardly, wrap around the nipple alone.

    I also pumped to bring in my milk, on the other side with each feed, but for us, getting off the shield was not hard at all. Of course, she had been directly on the nipple first, then we added the shield when she was allowed to actually feed. My LC had warned that it can inhibit transfer so we would have to watch her weight gain, and I was beginning to suspect that was happening, so that is why I decided to try without. I could tell immediately she had a better feed. However, I also feel strongly that we would not have been directly feeding at the breast when she came home without the shield so I'm glad I had one and I am also glad I was warned about the issues they can cause.

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    1. *She was under 3 lbs at birth--lowest weight was 2#3oz, but I estimate around 3 lbs when she began to feed.

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  13. Your story is a very good example of how book learning can work against us!
    My daughter, Julia, was 6 months old when I got her, and weighed 9 lbs. She was born at term, with a congenital diaphragmatic hernia. She was only feeding a little by mouth and had a gastrostomy. She was antisocial, angry, and developmentally delayed. She needed the comfort of the breast more than my newborns had! To start with, she would freak out before I even got her cradled in my arms.
    The first thing I had to do was get her bottle feeding well. I threw away the preemie nipples as well as the nasty, slimey formula they had her on. I incorporated as much breastfeeding behavior as possible into her bottle feeds. I always fed her myself, held her close, switched arms, etc. She quickly learned to take a comfort from sucking.
    After a little while, I tried offering her my breast again but she still resisted and got upset if I kept trying. I realized that I was going to have to consider everything about the experience of bottle feeding and try to make small, cautious, changes toward breastfeeding.
    I switched her to a wide-based, Nuk nipple. After a while, I took the tube of a supplementer and threaded it through the nipple hole, so that it just barely stuck out. That way, she could suck on the nipple and still feel like she was bottle feeding, but without a bottle attached to it. I first held her like for a bottle feed, and then slowly turned her toward my body, until she was beginning the feed in a true breastfeeding position. It was a wonderful feeling just to have her let me hold her in that position! When she was settled in, mostly fed and half asleep, I would remove the nipple and see if she would take my breast. She would open her mouth, but then close it as soon as her tongue touched my skin, every time.
    This is where we got to a nipple shield. It was obvious that the taste of my skin was throwing her off. I got the nipple shield back out (which I had tried earlier, without success). With that, when I moved the bottle nipple and she opened her mouth, she would take my breast and the shield. After a few times, she would start out on my breast with the shield. That experience made me wonder how moms could use latex shield to help with nipple soreness, because that darn thing hurt! I fed her that way for about a week, though, afraid of losing our progress if I tried to hurry things too much. Since she had always closed her mouth when her tongue touched my breast, I also started washing my breasts with warm water and air drying right before feeding, so there would be less that she could taste there. One day, when she still refused to latched on to my breast without the shield, I just sat there for a minute or so, with her fussing, trying to think of something else to try. All of a sudden, she latched on to my breast and we were at the end of our journey! She nursed until she was a little over 2 years old.

    It was nice being able to tell those who had said it wouldn't work that we had succeeded, but I really only told them so that they would be able to tell others who were struggling to get an older baby to take the breast that it could be done, and without traumatizing the child, with lots of patience and creativity.

    Julia is a beautiful, very healthy, talented, 22 year old woman, now. She has told me many times that she remembers how comforted and safe she felt when she nursed. She has thanked me for going to extra effort so that she could nurse, like her adopted siblings, who came to me at four weeks or younger.

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