Nipple shields and milk yields: an update

In a previous post I questioned the received wisdom that using nipple shields will have a negative impact on your ability to nurse your baby (see nipple shields: always a bad thing?). The post challenged one of the main criticisms made of shields — that they slow milk transfer and may therefore mean your baby is inadequately nourished — on the grounds that most of the studies demonstrating this were conducted a long time ago, and more recent research indicates that this problem does not exist for modern shields1.

The researchers who conducted the study in question concluded that nipple shields do not affect the amount of milk babies consumed in a feed by weighing before them before and after they nursed: when a mother was using a shield, the amount by which her baby had increased in weight at the end of the feed was roughly the same as when she was breastfeeding directly. Whilst this result looks positive for nipple shields, ‘test-weighing’ babies in this way is not without its critics, so one could argue that concluding nipple shields have no effect on milk consumption based solely on this evidence is a little premature.

Since writing the post, a follow-up study has been published, this time looking at the relationship between shield use and infant weight gain over a much longer period2. 54 mothers who used a nipple shield provided by a nurse or lactation consultant in the period just after the birth of their babies were recruited for the study, and completed interviews when their babies were 2 weeks, 1 month and 2 months old. Over time, the proportion of mothers using shields diminished (at 2 weeks,  69% of the mothers were still doing it, at 1 month 48%, and at 2 months 33%) and at each stage the responses of women who were still using the shields were compared with those who weren’t.

The main aim of the study was to determine whether nipple shields had a negative impact on weight gain — if babies whose mothers were still using shields grew more slowly than those whose mothers had stopped, then this could be taken as an indication that medium to long term use of shields was causing a real problem. Happily, there was no difference between the groups: whether a mother used a shield made no difference to her baby’s pattern of weight gain.

There were a few complaints about nipple shields: 8 women thought they caused nipple soreness; 2 found them messy; 2 found them inconvenient and 3 had problems with them falling off. In spite of this, 90% of the mothers in the study said that using the shield was a positive experience, and 67% felt it helped prevent them from giving up breastfeeding.

If you are a mother who relies on a nipple shield to breastfeed, these results make reassuring reading. Although shields appeared to cause difficulties for a few women, these were generally minor, and crucially they concerned practical issues, not the health of their babies. As most women felt that shields helped to prolong the period that they were able to breastfeed, this study ultimately supports the view they could be an important intervention for mothers who are having problems, rather than something that will make them worse.

  1. J Obstet Gynecol Neonatal Nurs. 2006 Mar-Apr;35(2):265-72.
  2. J Clin Nurs. 2009 Nov;18(21):2949-55.

Nipple solutions 2: shells and shields


Although I’ve criticized the health service for their, ‘breastfeeding is easy as long as you do it right’ line (a criticism that I stand by), the health visitors and midwives I have spoken to have generally been sympathetic. They have also been willing to deviate from the official advice when it’s obvious that it isn’t working.

Faced with my mutilated nipples, two midwives suggested nipple shields.  A shield is a silicon or rubber teat that you hold over the nipple to protect it during a feed. It is shaped like a large nipple, with holes in the end for the milk to come through. Apparently, they can affect milk supply, so do not have NHS approval, although I have since discovered that this recommendation may be rather out of date (see the nipple shields research post). I didn’t have any luck with shields (C looked at me as if I were mad – she was going to put one of those in her mouth?!) but I have spoken to many women who found them useful.

Breast shells, on the other hand, did prove to be a hit. In contrast to shields, you use shells in between feeds, to protect sore nipples or draw flat ones out (they apply a small amount of suction). They consist of a silicon disk with a hole in the middle for your nipple, topped off with a half a clear plastic tennis ball that acts as a protective bubble around your nipple and stops the fabric of your clothes coming into contact with it. The plastic bit also has holes in, to allow air to circulate. The instructions said to always make sure these were facing upwards, an instruction that I initially failed to heed. What difference would the direction of the holes make? I discovered the answer to this when I noticed a substantial wet patch on my t-shirt. A significant amount of milk can collect in them if you have them on for any period of time, and this milk will naturally leak out of any holes it finds. If you can motivate yourself to sterilize the shells regularly, you can store this milk for later use, but it wasn’t really a priority for me at that point. In the end, I put a breast pad in each shell to soak up any rogue milk (making sure the holes pointed upwards, of course.) Although this will have hindered the air flow a little, the shells still proved very effective in preventing discomfort, and seemed to allow my nipples to heal more easily. I say ‘seemed’ because the effect may have been psychological – when using the shell, my nipple looked less mangled, and I thus assumed it was improving.

I should probably mention, however, that I didn’t exactly use the shells as specified on the box. The instructions state that you shouldn’t use them for more than a couple of hours at a time, as they can cause blocked ducts. I weighed up the potential for blocked ducts against the possibility of my nipples healing a bit faster, and decided the chance of the latter made it reasonable to risk the former. This meant, in practice, that I ended up using them all the time, including at night. Fortunately I didn’t suffer any blocked ducts, although I did end up stretching a rather expensive Elle McPherson nursing bra (and looking like Madonna during her pointy cone bra period unless I dressed very carefully).  To date, there has been very little clinical research investigating the effectiveness (or not) of breast shells (see breast shells: preserving your modesty), but they seemed to help me get through a difficult time. If you want to take the pressure off your nipples – and are willing to risk increasing it on your milk ducts – they may be worth a try.

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.