Nipple shields: always a bad thing?

drawing of baby on scalesI have spoken to many mothers, including two midwives, who have used shields to ease nipple pain while they are breastfeeding without any apparent problems for their babies. Although they have been described (in the words of one mother) as ‘a godsend – the thing that made breastfeeding bearable for me,’ they are not recommended by the National Health Service.

What’s the problem with using nipple shields? Well, an NHS Primary Care Trust Breastfeeding Policy document cites two studies demonstrating slower milk transfer when using a shield1,2.

The trouble with this research is that it was conducted over 25 years ago, and shields have moved on in that time. A more recent study (published in 2006) test-weighed babies after feeding with or without a thin silicone shield and found that there wasn’t any difference in their milk intake3. The same article reports the results of a survey of mothers’ attitudes to using nipple shields and found evidence that they actually help to prevent early breastfeeding termination, rather than cause it. Another survey of shield use found that 86% of women utilizing them felt that they allowed them to continue breastfeeding when they might otherwise have given up4.

One study investigating the impact of a number of factors on nursing duration initially appeared to link using a nipple shield in hospital with a greater risk of discontinuing breastfeeding5. When other factors known to affect breastfeeding duration (such as the type of delivery the mother had and whether she smoked) were taken into account, however, the relationship between shield use and early weaning declined to the extent it was no longer statistically significant.

It has been suggested that using a shield from very early on could cause nipple confusion, meaning your baby wouldn’t want/be able to feed directly from the breast. An instance of this was reported in a case study more than 20 ago, which described a baby who refused to latch normally onto the breast, having been taught to attach with a rubber bottle teat covering the nipple6. This case study, which doesn’t even really demonstrate the problem – a bottle teat is quite different to a modern shield – appears to be the only recorded evidence for shield related nipple confusion. According to an article recommending shields for feeding premature babies (a situation in which they have been shown to be very useful), ‘the term “nipple/teat” confusion remains a hypothesis,’ i.e. it might be a problem, but there isn’t yet any strong evidence to support it7.

Using a nipple shield won’t necessarily be trouble-free: you have the hassle of cleaning, sterilizing and applying it before each use, not to mention remembering it when you go out. Despite these drawbacks, some mothers undoubtedly find shields very helpful. Women who choose to use them are already experiencing breastfeeding difficulties, such as nipple or latch problems, and are therefore at greater risk of stopping anyway8. When the alternative to a nipple shield is a bottle, perhaps trying one isn’t such a bad idea after all.

  1. Acta Obstet Gynecol Scand. 1987;66(1):47-51.
  2. Early Hum Dev. 1980 Dec;4(4):357-64.
  3. J Obstet Gynecol Neonatal Nurs. 2006 Mar-Apr;35(2):265-72.
  4. J Hum Lact. 1996 Dec;12(4):291-7.
  5. Midwifery. 2008 Mar;24(1):55-61.
  6. J Hum Lact. 1986 ;2(1):28-30.
  7. Infant. 2005 ;1(4):111-115.
  8. J Hum Lact. 2004 Aug;20(3):327-34.

Is lanolin cream a waste of money?

ointments_photoGiven the high incidence of nipple pain (it seems most women experience it when they start breastfeeding1), it would be reassuring to know that something can be done to relieve it. At the breastfeeding antenatal class the midwife told us that there is no evidence for the effectiveness of most nipple creams, although there have been studies showing that Lansinoh (commercially available purified lanolin) helps, and this is the one to go for if you have a problem. This view was echoed by two other midwives (one of whom gave me some sachets) and an NCT breastfeeding counsellor. You can read about my experience of using this preparation in the nipple solutions 1 journal post, but suffice to say that it didn’t work for me.

So, what is the scientific evidence for the effectiveness of lanolin? Probably the first thing to mention is that most of the big brand off-the-shelf nipple creams are simply moisturizers, and as the midwife said, there aren’t any published clinical trials supporting their effectiveness. On top of this, most of them aren’t even safe to go in babies’ mouths, so have you have to clean them off first – not ideal. This isn’t the case for Lansinoh – as it is simply purified lanolin, it isn’t a problem if babies swallow it (although this in itself doesn’t mean it’s worth using, of course).

An article looking at various topical treatments for nipple pain reviews several studies testing the effectiveness of lanolin1. When compared with hydrogel dressings (designed to maintain a moist wound healing environment), lanolin does well. In one study, women treated with lanolin reported significantly less nipple pain and were less likely to suffer from infection than those using the dressings. In another, there was no difference in pain relief, but there were still fewer infections in the lanolin group. Evidence that lanolin is a useful treatment? Not necessarily. As neither of these studies had a control group where no treatment was given, all we can tell is that hydrogel dressings are a bad idea. A study looking at the effect of heat treatment (sunshine or heat lamps) suffers from a similar problem. Using lanolin with the heat treatment offered greater pain relief than using the heat treatment alone, but unfortunately there is no way of telling whether this is better than not using any treatment at all.

In fact, the three studies in the review that compared lanolin with a ‘no treatment’ baseline showed it to be no more effective than leaving the nipples alone. There is also evidence that lanolin offers no improvement over rubbing on expressed milk (which is also reported as being pretty useless at reducing pain). The article also reports some preliminary research indicating that glycerin gel is a better treatment for sore nipples than lanolin (although a later study has found no difference between the two2.

Two further studies also deserve a mention. One provides evidence that peppermint gel is better at preventing nipple cracks and pain than lanolin or a placebo gel3. Another shows that in certain circumstances applying lanolin not only offers no improvement, but might actually make things worse4. The study compared using lanolin cream or breast milk with not using a treatment. The results showed that the appearance of nipple wounds (cracks and fissures) was the same in each group. However, the women who applied breast milk or used no topical treatment recovered significantly faster than those using lanolin.

So, it seems you may be better off ignoring the health professionals’ advice to use a lanolin cream. If you want to keep your nipples trauma-free you may want to think about using peppermint gel, or alternatively go for the inexpensive option of not bothering to treat them at all.

  1. J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37.
  2. J Perinat Educ. 2004 Winter;13(1):29-35.
  3. Med Sci Monit. 2007 Sep;13(9):CR406-411
  4. Saudi Med J. 2005 Aug; 26(8):1231-4.

Does pale skin mean problem nipples?

test tubes and tape measureOne of the anecdotes you may have heard (particularly if you are pale) is that women with fair skin are more likely to experience sore or damaged nipples. If you have very light skin and painful nipples (as I did), it may be strangely reassuring to be able to attribute at least some of the difficulties you’re experiencing to your colouring. On the other hand, if you have dark skin and sore nipples, you may simply view this kind of statement as irritating nonsense.

Is there any evidence that skin colour is associated with nipple problems when breastfeeding? There don’t seem to be any studies looking solely at the relationship between the two, but there are some studies that have included it as a factor, and the results they report are mixed. Whilst one study looking at breastfeeding in the first few days after birth found an association between nipple damage and skin colour1, another found that there was no link between the two2.

To confuse matters further, some research looking at the effect of ‘conditioning’ nipples prior to breastfeeding (by rubbing them with a rough towel – ouch!) found that women with fair skin reported significantly more pain when feeding on the unconditioned nipple, and olive skinned women reported significantly more pain when feeding on the conditioned nipple3. (I should mention that this research was carried out in 1979 – actively damaging you nipples whilst pregnant to ‘toughen them up’ for breastfeeding is no longer recommended.)

So, it seems the jury’s still out on this one. I suppose the most important thing to remember is that whilst there may be some link between fair skin and nipple pain or damage when breastfeeding, there certainly isn’t conclusive evidence for this, and there definitely are reports from women of all skin types that breastfeeding can be very painful!

  1. Rev Bras Enferm. 2005 Sep-Oct;58(5):529-34
  2. Birth. 1987 Mar;14(1):41-5.
  3. Nurs Res. 1979 Sep-Oct;28(5):267-71