Nipple Shields

It is surprising that the nipple shield, the use of which we had seen decline rapidly from the 1970’s and before, would once again be thought in the 2000’s as an appropriate treatment to cure many breastfeeding problems? It was generally thought to be a mistake to use nipple shields as their use resulted in babies seeming to be stuck on these gadgets. With time, the mother’s milk production would usually decrease if a mother used a nipple shield. Some studies will suggest that there is not a decrease; if one compares milk extraction on a nipple shield to a poorly latched baby, sure, there may be no decrease. The point is to get a baby well latched. We believe a nipple shield does not allow for this. Unfortunately, it is still true in our opinion that it is often not best practise to use a nipple shield and it is the considered opinion of our clinic and institute that nipple shields need hardly ever, if ever, be used.

What are nipple shields?

A nipple shield is different from a breast shield or shell. The breast shell is not used while feeding the baby, but rather in between feedings, and its purpose is to make the nipple more prominent, so that the baby will take the breast better, or, to protect the nipple from contact with the mother’s bra, particularly when the nipple has trauma. Whether the shell actually succeeds in this purpose is debatable, but a breast shell is probably harmless; a nipple shield is not harmless.

Nipple shields are flexible artificial nipples put over the mothers nipple and areola. They are made of silicone nowadays and come in various diameters and sizes. They are used generally for the following reasons:

1. The baby will not take the breast.
2. The mother has sore nipples.
3. The baby is born prematurely.
4. The baby needs to “learn how to suck”.

Nipple shields are not, in fact, the answer to these problems. They give the illusion that the problems have been dealt with, but in fact, the problems have not been dealt with at all. The illusion that things are now going well leads to mothers not getting help early and making fixing the problems more difficult as time goes by. Let’s look at these questions more closely.

1. The baby will not take the breast.

A nipple shield is not usually the answer. In fact, a baby who sucks at the breast through a nipple shield is not latched on to the breast; he is latched on to the nipple shield. Does this matter? Yes, because a poor latch is still a poor latch and baby on a nipple shield has, at best, a poor latch. This means the baby will depend on the mother’s having milk ejection reflexes (letdown reflexes) in order to get milk. If the mother’s milk production is abundant, then the baby actually may gain weight well. Even then, however, we believe that it is problematic to use the nipple shield (see below).

Many mothers have a good milk supply but not what one would call an abundant milk supply. In that case it is very possible that the baby will not gain weight adequately with a nipple shield. Furthermore, as mentioned above, when a baby feeds through a nipple shield, the milk supply can even decrease (see the information sheet Slow weight gain). Even worse, if the milk supply decreases, it becomes more difficult to get the baby to take the breast without using a nipple shield.

Even if some justification can be found for using a nipple shield, starting one before the “milk comes” in is, in our opinion, not best practise. So many babies who do not latch on in the first few days, will latch on without trouble, even easily, when the mother’s milk “comes in”, especially if the mother gets good help. If the mother believes that the nipple shield has dealt with her problem, she may not get help until it is too late. Here is just one email (identifying information deleted) of hundreds we could have included:

“My baby was born on xxx weighing 2.5 kg (5lb 8oz). I started using a breast shield when the baby was a few days old because my baby would not latch on; everything seemed to go okay, but somewhere around 3 weeks I began to notice she didn’t seem to be sucking properly and by her one month check up she’d only gained an ounce.”

So what now? After a month feeding on the nipple shield, it may be extremely difficult to get the baby to take the breast directly especially if the slow weight gain was due to the milk supply decreasing rather than the baby not getting milk well because of the nipple shield (both are, in fact, possible). The mother may have been asked to supplement. The mother needed a lot of support.

We believe it is better that a mother express her milk and give it to the baby by cup (or, if absolutely necessary, by bottle) rather than use a nipple shield. At least expressing milk will usually maintain the milk supply. See the information sheets When baby does not yet latch, Finger & cup feeding and Expressing milk.

2. The mother has sore nipples

Using a nipple shield for sore nipples has the same problems as using it for a baby who will not latch on. Milk supply may decrease and the baby may not want to take the breast directly again. Furthermore, a nipple shield is not a good way to treat sore nipples, oftentimes it will make the problem worse and cause more trauma. True, I have heard from some mothers that using the nipple shield helped them get past the pain and they were able to get the baby to take the breast again without pain; this is not always the case and there are better ways of dealing with sore nipples (prevention being the best of all). See the information sheets Sore nipples, All purpose nipple ointment, Candida protocol - Toronto as well as the video clips.

3. The baby is born prematurely.

If the baby is not restricted to starting breastfeeding at 34 weeks gestation (as in most of special care units or neonatal intensive care units in North America and Western Europe), if the mother is helped get the best latch possible and shown how to know a baby is getting milk, then nipple shields will hardly ever be necessary for the premature baby. See the information sheet Breastfeeding the premature baby.

4. The baby needs to learn how to suck

A baby learns to suck and suck well by breastfeeding. If a baby “sucks better” on a nipple shield it’s only because the baby is not latching on to the breast. A baby who latches on and gets milk will suck just fine. The problem is that the baby is not latching on well and using a nipple shield does not teach a baby now to do that.

Nipple Shields © April 2009 
Written by Jack Newman MD, FRPC, and Edith Kernerman IBCLC, © 2009

Sore Nipples

Introduction

The best treatment of sore nipples is prevention. The best prevention is getting the baby to latch on properly from the first day. Mother and baby skin to skin contact immediately after birth for at least the first hour or two will frequently result in a baby latching on all by himself with a good latch. See the information sheets Starting out right and The importance of skin-to-skin contact.

Early onset nipple pain is usually due to one or both of two causes.Either the baby is not positioned and latched properly, or the baby is not suckling properly, or both. However, babies learn to suck properly by getting milk from the breast when they are latched on well. (They learn by doing). Thus, “suck” problems are often caused by poor latching on. Fungal infections of the nipple (due to Candida albicans) may also cause sore nipples. Vasospasm (which is due to irritation of the blood vessels in the nipple from poor latching and/or a fungal infection) may also cause sore nipples (see the information sheet Vasospasm & raynaud’s phenomenon). The soreness caused by poor latching and ineffective suckling hurts most as you latch the baby on and usually improves as the baby breastfeeds. However, if damage is severe, the soreness of a poor latch and/or ineffective suckling may go on throughout the feeding. The pain from the fungal infection often goes on throughout the feed and may continue even after the feed is over. Women describe knifelike pain from the a poor latch or ineffective sucking. The pain of the fungal infection is often described as burning but it does not have to be burning in nature. A new onset of nipple pain when feedings had previously been painless is a tip off that the pain may be due to a Candidal infection, but a Candidal infection may also be superimposed on other causes of nipple pain, so there was never a pain free period. Cracks may be due to a yeast infection. Dermatologic conditions may also cause late onset nipple pain. There are several other causes of sore nipples.

Proper Positioning and Latching

(See information sheet Latching On)

It is not uncommon for women to experience difficulty positioning and latching the baby on. If the mother positions the baby well, she facilitates the baby’s getting a good latch and a good latch not only decreases the risk of the mother becoming sore, but also reduces the baby’s chances of becoming “gassy” because a good latch allows the baby to control the flow of milk better. Thus, poor latching may also result in the baby not gaining adequately, or feeding frequently, or being colicky (see the information sheet Colic in the breastfed baby). See also ibconline.ca for videos that show how to latch a baby on, how to know a baby is getting milk and how to use compression.

Positioning—For the Purposes of Explanation, Let Us Assume That You Are Feeding On the Left Breast

(See information sheet Latching On and the videos at ibconline.ca)

Good positioning facilitates a good latch. A lot of what follows under latching comes automatically if the baby is well positioned in the first place.

At first, it may be easiest for many mothers to use the cross cradle hold to position your baby for latching on. Hold the baby in your right arm, pushing in the baby’s bottom with the side of your forearm so that your hand turns palm upwards (towards the ceiling). This will help you support his body more easily as the baby’s weight is on your forearm rather than your wrist or hand. Holding the baby like this also will bring the baby in from the correct direction so that he gets a good latch. Your hand will be palm up under the baby’s face (not shoulder or under his neck). The web between your thumb and index finger should be behind the nape of his neck (not behind his head). The baby will be almost horizontal across your body, with his head slight tilted backward, and should be turned so that his chest, belly and thighs are against you with a slight tilt upwards so the baby can look at you. Hold the breast with your left hand, with the thumb on top and the other fingers underneath, fairly far back from the nipple and areola.

The baby should be approaching the breast with the head just slightlytilted backwards. The nipple then automatically points to the roof of the baby’s mouth.

Latching

1. Now, get the baby to open up his mouth wide. The way to do this is to run your nipple, still pointing to the roof of the baby’s mouth, along the baby’s upper lip (not lower), lightly, just a tickle, from one corner of the mouth to the other. Or you can run the baby along your nipple, something some mothers find easier. Wait for the baby to open up as if yawning. As you bring the baby toward the breast, only his chin should touch your breast. Do not scoop him around so that the nipple points to the middle of his mouth. Instead the nipple should still be pointing to the roof of the baby’s mouth.
2. When the baby opens up his mouth, use the arm that is holding him to bring him straight (not scooped around) onto the breast. Don’t worry about the baby’s breathing. If he is properly positioned and latched on, he will breathe without any problem since his nose will be far away from the breast. If he cannot breathe, he will pull away from the breast. If he cannot breathe, he is not latched properly. Don’t be afraid to be quick.
3. If the nipple still hurts, use your index finger to pull down on the baby’s chin; this will bring more of your breast into the baby’s mouth. You may have to do this for the duration of the feed, but not usually. The pain should usually subside. Do not take the baby on and off the breast several times to get the perfect latch. If the baby goes on and off the breast 5 times and it hurts, you will have 5 times more pain, and worse, 5 times more damage, and the baby and you will both be frustrated. Adjust the latch when putting him to the other breast, or at the next feeding.
4. The same principles apply whether you are sitting or lying down with the baby or using the football or cradle hold. Get the baby to open wide; don’t let the baby latch onto the nipple, but get as much of the areola (brown part of breast) into the mouth as possible (not necessarily the whole areola).
5. There is no “normal” length of feeding time. If you have questions, call the clinic.
6. A baby properly latched on will be covering more of the areola with his lower lip than with the upper lip.

See the video clips at the website ibconline.ca

Improving the Baby’s Suck

The baby learns to suckle properly by breastfeeding and by getting milk into his mouth. The baby’s suckle may be made ineffective or not appropriate for breastfeeding by the early use of artificial nipples or from poor latching on from the beginning. Some babies just seem to take their time developing an effective suckle. Suck training and/or finger feeding (See the information sheet Finger & cup feeding) may help, but note, taking the baby off the breast to finger feed instead is not a good idea and should be done as a last resort only.

Vasospasm: “My Nipple Turns White After the Baby Comes Off the Breast”

The pain associated with this blanching of the nipple is frequently described by mothers as “burning”, but generally begins only after the feeding is over. It may last several minutes or more, after which the nipple returns to its normal colour, but then a new pain develops which is usually described by mothers as “throbbing”. The throbbing part of the pain may last for seconds or minutes and then the nipple may turn white again and the process repeats itself. The cause would seem to be a spasm of the blood vessels (often called “vasospasm” or Raynaud’s Phenomenon) in the nipple (when the nipple is white), followed by relaxation of these blood vessels (when the nipple returns to its normal colour). Sometimes this pain continues even after the nipple pain during the feeding no longer is a problem, so that the mother has pain only after the feeding, but not during it.

What can be done?

1. Pay careful attention to getting the baby to latch onto the breast as best possible. This type of pain is almost always associated with and probably caused by whatever is causing your pain during the feeding. The best treatment for this vasospasm is the treatment of the other causes of nipple pain. If the main cause of the nipple pain is fixed, the vasospasm also usually disappears.
2. Heat (hot washcloth, hot water bottle, hair dryer) applied to the nipple immediately after breastfeeding may prevent or decrease the reaction. Dry heat is usually better than wet heat, because wet heat may cause further damage to the nipples.
3. Vitamin B6 multi complex can also be used, as can magnesium with calcium. On occasion, we have had to use an oral medication (nifedipine) to prevent this type of reaction. For more on these treatments see the information sheet Vasospasm & raynaud’s phenomenon)

General Measures for Nipple Soreness

1. Nipples can be warmed for short periods of time after each feeding, using a hair dryer on low setting.
2. Nipples should be exposed to air as much as possible, except when there is vasospasm.
3. When it is not possible to expose nipples to air, plastic dome-shaped breast shells (not nipple shields which are not, in our opinion, a good treatment for sore nipples or any breastfeeding problem for that matter) can be worn to protect your nipples from rubbing by your clothing (use the largest hole available so your nipple is not rubbing against the plastic). Breastfeeding pads keep moisture against the nipple and may cause damage that way. They also tend to stick to damaged nipples. If you leak a lot you can wear the pad over the breast shell.
4. Ointments can sometimes be helpful. If using our ointment, use just a very small amount after breastfeeding and do not wash it off. We use an “all purpose nipple ointment” (APNO) that we find very useful. See the All purpose nipple ointment recipe. Note, once any ointment or cream is applied to the nipples they are no longer air drying.
5. Do not wash your nipples frequently. Daily bathing is more than enough.
6. If your baby is gaining weight well, there is no good reason the baby must be fed on both breasts at each feeding. It may save you pain, and speed healing if you feed your baby on only one breast each feed, but be careful, not all mothers can feed a baby on only one breast at every feeding or even at all. See the video clips at the website ibconline.ca so that you know when the baby is drinking (or not). It will help to compress the breast (see the information sheet Breast compression), once the baby is no longer swallowing on his own in order to continue his getting milk. You may be able to manage this some feedings, but not others. In very difficult situations, a lactation aid (see the information sheet Lactation aids) can be used to supplement (preferably expressed milk), so that the baby will finish the feeding on the first side. Taking the baby off the breast is a last resort.

If you are unable to put the baby to the breast because of pain, in spite of trying all the above measures, it may still be possible to continue breastfeeding after a temporary (3-5 days) cessation to allow the nipples to heal. During this time, it would be better that the baby not be fed with a rubber nipple. Of course it is also best for you and the baby if the baby is fed your expressed milk. Feed the baby with a cup or use the technique called “finger feeding” (see the information sheet Finger & cup feeding). Once again, it should be emphasized that this is a last resort and taking a baby off the breast should not be taken lightly. Furthermore, it often doesn’t work.

We do not recommend nipple shields because, although they sometimes help temporarily, they often do not. In fact, they may often increase the degree of trauma to the nipples. They may also cut down the milk supply dramatically, and the baby may become fussy and/or not gain weight well. Once the baby is used to them, it may be impossible to get the baby back onto the breast. Use as a last resort only but get help first.

Sore Nipples, © 2009 
Written and revised (under other names) by Jack Newman MD, FRCPC, © 1995-2005
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman IBCLC, © 2008, 2009

Treatments for Problems

Lecithin

Lecithin is a food supplement that seems to help some mothers prevent blocked ducts. It may do this by decreasing the viscosity (stickiness) of the milk, by increasing the percentage of polyunsaturated fatty acids in the milk. It is safe, inexpensive, and seems to work in some cases. The dose is 1200 mg four times a day. There is more to preventing blocked ducts than taking lecithin.

For information on "all purpose nipple ointment", gentian violet, grapefruit seed extract, vitamin B6, nifedipine, and nitroglycerin paste, and fluconazole, see the handout Treatments for Sore nipples and sore breasts, or the handouts Gentian violet and Fluconazole (Diflucan).

Handout #24. Miscellaneous treatments. January 2005. 
Written by  Jack Newman, MD, FRCPC © 2005.

This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.