What about nipple shields?
The use of nipple shields has become almost epidemic in North America and Europe. Nipple shields are seen as the answer to virtually all breastfeeding problems, from babies not latching on, to nipple soreness, to routine use for premature babies. Even the perception of a mother’s nipples being “flat” often results in the recommendation of a nipple shield sometimes without even an attempt to latch the baby at the breast. We have heard stories from mothers that they were given a nipple shield immediately after the birth of the baby, before they even attempted to put the baby to the breast.
This “epidemic” has occurred without any evidence that nipple shields are safe to use and actually do what they are supposed to do. A quote from a review of the literature on nipples shields says it all: “Introducing nipple shields in the first postpartum week may seem like an easy fix for a frustrated family, but such intervention may preclude a thorough evaluation of the mother–infant dyad to determine why breastfeeding has been problematic and may cause more problems such as lack of effective milk transfer, sore nipples, and loss of milk supply. The pervasive use of nipple shields as an intervention in the very early course of breastfeeding can relay a false message of breastfeeding success and safety to mothers. Widespread retail access to nipple shields might also signal to mothers that nipple shield use is a norm that warrants little concern.” In clinical medicine, it is generally accepted that one must prove the safety and usefulness of an intervention before one can generally recommend it. Nipple shield use has never been proved safe or effective.
The nipple shield is a recommendation without regard to the long term, not only when recommended in the first few days but even in the mother whose baby has started to refuse the breast due to late onset decreased milk supply when there are more effective treatments. But it is particularly pernicious when used to get the baby to take the breast when so many babies who do not latch on during the first few days would easily latch on when the milk supply and milk flow increase on day 3 or 4, especially if the mother is helped by someone skilled at helping with latching on. The questions that are not asked are: “How will a mother whose baby is on a nipple shield continue breastfeeding long term?”, “How will the mother in such a case be able to stop using the nipple shield?”, “What will the effect of the nipple shield be on her milk supply both in the short and longer term?”, “What are other side effects of the use of nipple shields?”. And “What happens to these mothers and babies when they forget the nipple shields on leaving home with the baby who otherwise does not take the breast?”
The most important question is whether something else could have been done instead of introducing a nipple shield. I am convinced, based on 33 years of helping mothers with breastfeeding that there is nothing that can be done with a nipple shield than cannot be done better without one. If a baby can latch on to a nipple shield, the baby should be able to latch on to the breast. The problem is that the more nipple shields are used, the less experience people have applying or searching for alternative solutions, including learning how to help a mother help her baby latch on. The nipple shield solution seems to be an attractive one because it appears to work quickly, indeed, immediately, in most cases. We do love quick solutions.
Unfortunately, patience, skill and experience are necessary to solve some breastfeeding problems; both the mother and the person wanting to help her need to be patient. There is nothing terrible about waiting a few days to get a baby to latch on, if, in the meantime, the mother is given the tools to apply during this time. Even newborn babies can drink from an open cup and or be fed from a small spoon. I would also suggest that a large part of a lactation consultant’s work is to counsel the mother and part of this is to counsel patience and provide a temporary solution that leads to successful breastfeeding long term. Let me propose that for each problem for which a nipple shield is used, there is a real solution which takes into account the long term perspective.
So, what are the problems with the use of nipple shields?
1. Let us be frank: A baby on a nipple shield is not latched on, not at all; it is an illusion to believe he is. Breastfeeding with a nipple shield is not the same as breastfeeding directly. No matter how thin the nipple shield, it’s still not the breast. The question is: if feeding through a nipple shield is “just like breastfeeding”, then why will a baby seemingly “take the breast” with a nipple shield and not take the breast directly? Instead of the baby latching on to the naked breast, the soft, supple, pliable breast, which is an active process, the nipple shield, which is not soft, supple, or pliable, is essentially pushed into the baby’s mouth. The “nipple” of the nipple shield has a much harder texture than the mother’s nipple and is wider and longer. The nipple shield makes the breast into a bottle, essentially. With a nipple shield in his mouth, the baby uses his tongue and cheek muscles just as he does on a bottle or a pacifier and not the way he would when breastfeeding. When a baby is on a nipple shield, in order to get milk, the baby needs to suck hard to get milk out of the breast. This is not what a baby does on the breast. When a baby feeds directly from the breast, he is using a whole different process. He stimulates the breast to release the milk which then flows to the baby. And this is obvious because it is so difficult in most cases to get a baby who is hooked on a nipple shield to then take the breast directly. If they were the same as so many suggest, then why is that so?
2. Some people believe that nipple shields are a tool for teaching a baby how to breastfeed. This is the reason they are used so frequently in the premature baby. But as stated above, this is pure fantasy. A nipple shield teaches a premature baby how to suck from a nipple shield, but not how to breastfeed.
3. A baby on a nipple shield is actually not latched on. A baby on a nipple shield will never do what he is supposed to do on the breast. And delatching a baby from a nipple shield is extremely easy to do, not as it would be if he were directly latched on well to the naked breast.
4. One of the most common reasons for milk supply to decrease with time is that the baby’s latch is not as good as it could be. For example, when the baby has a tongue tie. Thus, a baby on a nipple shield is not latched on at all, and so with time, the milk supply may, and often does, decrease. The reason this is controversial is that in a small number of cases, when a mother begins with an abundant milk supply, she and the baby may manage for several months, but if the milk supply decreases enough, the baby will start to refuse to take the nipple-shielded breast and/or become very unhappy at the breast, with the result that the mother introduces bottle supplements. This often occurs within weeks of birth. As an aside, if the mother’s milk supply was so abundant, it should have been easy to get the baby to latch on in the first week of life. In fact, many mothers are able to get the baby to take the breast directly after weeks of the baby drinking through a nipple shield, precisely because the mother started off with an abundant milk supply. Even then, I would suggest that the milk supply had decreased, but luckily still adequate for the baby to receive milk well from the breast.
5. When the flow of milk is diminished due to a poor latch, including due to nipple shield use, the mother may begin to have problems with recurrent blocked ducts, mastitis and even breast abscess. Blocked ducts/mastitis occur at first when the mother has a fairly generous milk supply, but the baby’s latch is not good and the breast does not drain well. The exact situation of a baby sucking on a nipple shield.
6. Even though nipple shields are supposed to treat sore nipples, in fact, some mothers actually develop nipple pain while on nipple shields. And for some, the pain is in fact worse on a nipple shield.
7. To reiterate, once the baby is habituated to the nipple shield, it is difficult for that baby to start to take the breast directly. Mothers intrinsically understand that using a nipple shield is not really what they wanted, but what we may have done is taken true breastfeeding, that is, on the breast away from them. Those of us working with mothers and babies on a nipple shield find it is much more difficult to get the baby breastfeeding directly from the breast than if the baby were on a bottle, which is not to say that the bottle is a solution either. Young babies who are not latching on can be fed by spoon or open cup. The older the baby on a nipple shield is, the more difficult it is to get rid of the nipple shield.
8. A very big problem associated with the use of nipple shields is that the mother believes that the nipple shield has corrected her problems and she may see no need to do anything further, until it’s too late. Typically, a mother coming to us for help, has had a decrease in her milk supply because of the nipple shield and has found that her baby fusses at the nipple-shielded breast, is not satisfied and not getting as much milk as before. And the longer this goes on, the more difficult it is to get the baby to the breast. So, nipple shield + decrease in milk supply due to nipple shield=greater and greater difficulty in latching the baby on. Often, the mother finds she is not only using a nipple shield but also giving the baby bottles to her fussy baby.
Even if some believe that nipple shields do treat certain breastfeeding problems, the risks associated with the use of nipple shields (see above), should give us pause. Any medical treatment or device that causes so many problems, would not be approved for use by any regulatory agency.
Preventing the “need” for nipple shields
The causes of early breastfeeding problems include, modern birthing practices, not allowing the baby to crawl to the breast immediately after birth, no skin to skin contact between mother and baby, separation of mother and baby often for unnecessary reasons, early introduction of artificial nipples, feeding by the clock, and the use of % weight loss to determine the adequacy of breastfeeding.
Babies often will have difficulty latching on after a birth because of the large amounts of intravenous fluids given to the mother during labour, birth and after. Intravenous fluids during labour and birth go to the baby as well as to the mother and so result in the baby being “overhydrated” at birth and thus the baby loses more weight, approaches the dreaded 10% weight loss (for which, incidentally, there is no scientific basis) and panic begins to overtake the staff in hospital, panic which is transmitted to the parents.
In addition, the mother’s nipples are often oedematous due to her being overhydrated and thus the baby has difficulty latching on. The answer to dealing with these issues is to help the mother get the baby well latched on. This may require “reverse pressure softening” of the breast. And it also requires knowing how to know a baby is getting milk from the breast, or not getting milk from the breast. The answer is not a nipple shield.
Nipple “shape” is a frequent excuse for giving the mother a nipple shield. Intravenous fluids are one cause of “flat nipples”. Amazingly the nipples are no longer flat after the mother has had a diuresis (increased urine output), but that happens only several days later, too late if she has started a nipple shield, because she is usually now home, and believing, perhaps, that her problem has been solved. One of our patients had a nipple shield slapped on her breast while she was still on the delivery table, before she even tried to put the baby to the breast the first time. Interestingly, with a little help at our clinic, the baby latched on, though not without considerable difficulty. But latch on he did, and went on to breastfeed exclusively, not nipple shield feed. No shape of nipple – “flat”, “inverted”, “large” – should make it impossible for a baby to latch on and to be a reason for using a nipple shield.
The most common reasons for mothers being advised to use a nipple shield are the following: 1. The baby is not latching on. 2. The mother has sore nipples and 3. The baby is premature.
Some babies just do not latch on from the very beginning, many for reasons that are not obvious. It seems that people always knew this. At the beginning of the 19th century, Goethe remarked on this in his drama Faust where Mephistopheles says to the student:
So nimmt ein Kind der Mutter Brust
Nicht gleich im Anfang willig an,
Doch bald ernährt es sich mit Lust.
So wird’s Euch an der Weisheit Brüsten
Mit jedem Tage mehr gelüsten.
Here is what I’ve been told is not the best of all translations of Goethe:
The child, offered the mother’s breast,
Will not in the beginning grab it;
But soon it clings to it with zest.
And thus at wisdom’s copious breasts
You’ll drink each day with greater zest.
Current hospital practices are geared to instant solutions, but this “gotta fix it now, this very minute, approach” needs to change and an atmosphere should be created in which mothers and babies are not rushed or forced to get the baby to the breast as soon as possible, immediately.
It is frequent that many mothers will have an intravenous during labour, birth and after and this may result in oedema of the nipples and areolas. This oedema will regress, which is important to appreciate and if appreciated, will help us develop the patience that is necessary to avoid jumping in with a nipple shield. It is also frequent that mothers will receive epidural and/or spinal analgesia. The evidence is strong that the drugs used do indeed affect the baby and result in babies being “confused” or too sleepy. Again, patience is important. So what to do?
• The breast crawl, where the baby is skin to skin with the mother immediately after birth and allowed to crawl to the breast and latch on is of supreme importance. It takes precedence over weighing the baby, washing the baby and so many other routine practices that interfere with the breast crawl and latching on of the baby. The breast crawl may take an hour or more and obviously clashes with the current hospital ambiance and practices.
• Even after the initial breast crawl, mothers and babies should be skin to skin as much as possible.
• Every baby should be checked at birth for tongue tie. This should be as routine as checking the baby’s breathing or listening to his heart. However, the majority of health professionals do not know how to decide if a baby has a tongue tie or not, very frequently passing off a very obvious tongue tie as “normal”.
• As soon as there is a concern that the baby is not latching on or does not actually drink from the breast, the mother’s milk should be expressed and fed to the baby by spoon or cup and not by bottle or through a nipple shield.
• Hospital staff, including midwives, nursing staff, physicians and lactation consultants need to know how to help a reluctant baby latch on when he is showing early signs of being ready to feed. There is a real technique to helping babies latch on well and those who use nipple shields from their earliest training never learn this technique. They jump to the nipple shield.
• The mother should be reassured that her baby will eventually latch on and she should start a routine of hand expression of her milk, cup and/or spoon feeding and she should be taught the “technique” of latching on her baby.
• Followupof any baby not latching on should be within a day or two of discharge from hospital by someone who is experienced in helping reluctant babies latch on. Once the milk increases (“comes in”), it is sometimes much easier to help the baby to latch on.
Sore nipples are almost always due to a baby’s less than adequate latch. No matter what the latch looks like from the outside, if the mother has pain, something is wrong with how the baby is latching on to the breast.
An anecdote. About 2 years ago, I was called to see the new grandchild of a good friend of mine. The baby was 36 hours old when I arrived. The mother was starting to have sore nipples and the baby was never satisfied after a feeding and cried constantly. It took me 1 minute to fix the problem by helping the mother latch the baby on differently from what she was doing. I also taught her breast compression and for the first time the baby fed well and was calm. I should say that in many cases, this is very possible and much easier to deal with than if the baby had been 3 weeks old and on a nipple shield.
So, the key to preventing problems such as sore nipples is to make sure the baby has a good latch and that the baby is drinking well from the breast. This means that soon after the baby is born, someone should observe a feeding and if the mother complains of pain, something needs to be done, and that something is not “try a nipple shield”. If examination of the baby reveals a tongue tie, release of the tongue tie should not be deferred. Sore nipples should not be considered “normal”.
Other measures, such as the use of ointments on the nipple can be used as stop gaps. Nipple shields are not the answer.
Nipple shields are not a method of teaching premature or any other babies “how to suck”. Babies learn to breastfeed by breastfeeding and getting milk from the breast.
Based on work particularly from Scandinavia but also in other sites including Columbia, babies can and should be going to the breast by 27 or so weeks gestation. The North American approach of “no breastfeeding until 34 weeks gestation” has been shown to be detrimental to premature babies learning to breastfeed. The idea that they need to learn to bottle feed before they can start breastfeeding is bizarre to say the least, and based on the false notion that breastfeeding is tiring, or “hard work”.
So, what about mothers who say that the nipple shield saved their breastfeeding?
I will repeat it: there is nothing that can be done with a nipple shield that cannot be done better without one. Measures can be taken to help mothers with breastfeeding problems which would have prevented the “need” for the nipple shield in the first place. The reason we hear stories that “the nipple shield saved my breastfeeding” is the same as those stories that “The doctor said that if I didn’t take this antibiotic for my cold, I could have become much sicker” or “a couple of bottles of formula in the first days saved my breastfeeding”. This may be true, but there was still a better way. For each mother who believes that the nipple shield saved her breastfeeding, there are countless mothers whose breastfeeding was marked by decreasing milk supply, breast refusal, painful nipples and premature weaning. The means the methods we use to help mothers with breastfeeding problems are important and should be those means that allow the mother and baby to develop the skills that lead to a happy and long term breastfeeding relationship.
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Copyright: Jack Newman, MD, FRCPC, 2017, 2018