Nipple Shields for Breastfeeding/ Chest Feeding: What's the Deal?

Assortment of nipple shield brands and styles.

Nipple shields were invented as a way to breast/chest feed without causing excessive compression directly on the nipple, creating a barrier between the tongue and the nipple. They are mostly used when the nipple becomes too sore. But effective breastfeeding/chest feeding does not involve compression of the nipple! When a baby is latched correctly, breastfeeding/chest feeding works using a combination of compression of the breast/chest by the baby's tongue , negative pressure created when the baby drops their tongue after swallowing, and the lactating parent's milk flow.

Poor positioning and latch technique (the most common cause) or a very tight frenulum (tongue tie) causes nipple compression instead of breast/chest compression. This is a big reason many healthcare professionals and lactation specialists do not recommend the use of nipple shields- the root cause of the nipple compression needs to be fixed. Proper positioning and latch technique cannot be stressed enough! And after several days of monitoring the baby's tongue function, if it is determined that the baby does have a very tight frenulum, a tongue release (frenotomy) is likely warranted.

But did you know there are other reasons not to use a nipple shield?

• Breastfeeding/chest feeding partly works because of the negative pressure (vacuum) created after swallowing, when the tongue releases and drops to the floor of the mouth. But a nipple shield prevents some of this negative pressure from reaching the nipple tip. That means milk won't flow through the breast/chest and out through the nipple as effectively, potentially causing lower milk supply or blocked ducts.

• The hole size and the elasticity of the nipple shield material partially dictate how fast milk flows and how much energy is needed to be expended by the baby. Each brand of nipple shield has slightly different textures, sizes of holes, etc. Unfortunately, there are no good studies showing effectiveness of nipple shields in full-term babies (I will post about nipple shield use in the late preterm gestation at a later time). But there are good studies showing lack of intra-oral pressure (negative pressure or vacuum) and lack of milk transfer when nipple shields are used.

• Nipple shield use involves a symmetrical latch instead of a non- symmetrical latch that is needed when not using a nipple shield. This means that tongue compression will occur closer to the nipple, causing constriction of milk ducts instead of constriction of the milk sacs (alveoli) which are further away from the nipple. One cannot latch a baby asymmetrically with a nipple shield without causing loss of suction of the shield to the breast/chest, thereby causing higher potential for nipple pain and damage and less milk flow.

• Nipple shields are often applied incorrectly, leading to pinching of the nipple and low milk transfer. Watch for a future post about proper application!

Should nipple shields be used for full-term babies?

In my professional opinion, based on scientific facts and research, unless the lactating parent would use a bottle in that instance versus putting the baby to breast/chest, the answer is an emphatic NO!

This means that if a full-term baby (39 weeks or older) needs to supplement, it should be done at the breast/chest. Without a nipple shield. Using a tube and syringe or professional supplemental nursing system. So, the supplemental devices that have a nipple shield attached should not be used until adequate research proves that they are effective at creating adequate negative pressure and that milk transfer is more than or equal to milk transfer without the nipple shield, when effective positioning and latch techniques are used. Unfortunately, most nipple shield companies have not done any research as to the effectiveness of their products.

What about using nipple shields for babies who are not yet term gestation?

• We know that preterm and late preterm infants have a very difficult time creating enough negative pressure (intra-oral vacuum) to effectively breast/chest feed, so that part of the breast/chest feeding equation is not an issue. (Keep following me to get more information about what can be done to significantly balance this part of the equation for less than full-term babies).

• We know that preterm and late preterm infants have reflexes that are not yet mature, making latching and staying latched difficult. A nipple shield improves the latch for these babies. It does not mature the reflex though. Time and adequate nutrition does that.

• We know that preterm and late preterm infants expend excessive energy trying to compress the breast/chest, and that their mouths may not yet be big enough to latch beyond the nipple. A nipple shield, when paired properly with supplemental milk if needed, can decrease the energy expenditure and help them to compress some areola instead of the nipple.

• Medela 24mm nipple shields were studied for the late preterm population and were found to effectively and safely increase milk transfer in this population. However, if the lactating parent does not have a robust milk supply yet, making close to full milk production of at least 720mL/24 hours, using a 24mm Medela nipple shield (medium) paired with a syringe and feeding tube in the dome of the nipple shield helps to increase milk transfer and decrease the amount of vacuum pressure needed to effectively cause adequate milk transfer. Do not use this method of supplementing preterm or late preterm infants without getting full instructions on how to do this properly and safely. You can find more information about this in my book Breastfeeding Challenges Made Easy for Late Preterm Infants: The Go-To Guide for Nurses and Lactation Consultants, available from Springer Publishing or on Amazon. See purchase link on my home page. I will be publishing a new book for parents

  hopefully by the end of 2025, which includes this information as well. Or some of you may have been present for conference talks or webinars I have done on this topic.

So bottom line?

• Nipple shields should only be used for full-term babies if breastfeeding/chest feeding would be given up for bottle feeding at that time, and when used correctly for preterm and late preterm infants.

• Most nipple shields have not been researched for their effectiveness of milk transfer and the amount of needed intra-oral vacuum. We definitely need more research in this area!

• Medela has positive published research on milk transfer, using 24mm (medium) nipple shields for use with late preterm infants. I have no financial interest in Medela. I recommend them solely based on available research.

References:

Coentro VS, Perrella SL, Lai CT, Rea A, Dymock M, Geddes DT. Nipple shield use does not impact sucking dynamics in breastfeeding infants of mothers with nipple pain. Eur J Pediatr. 2021 May;180(5):1537-1543. doi: 10.1007/s00431-020-03901-3. Epub 2021 Jan 14. PMID: 33443588.

VS, Perrella SL, Lai CT, Rea A, Murray K, Geddes DT. Effect of nipple shield use on milk removal: a mechanistic study. BMC Pregnancy Childbirth. 2020 Sep 7;20(1):516. doi: 10.1186/s12884-020-03191-5. PMID: 32894074; PMCID: PMC7487699.

Meier PP, Brown LP, Hurst NM, Spatz DL, Engstrom JL, Borucki LC, Krouse AM. Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding. J Hum Lact. 2000 May;16(2):106-14; quiz 129-31. doi: 10.1177/089033440001600205. PMID: 11153341.

Meier P, Patel AL, Wright K, Engstrom JL. Management of breastfeeding during and after the maternity hospitalization for late preterm infants. Clin Perinatol. 2013 Dec;40(4):689-705. doi: 10.1016/j.clp.2013.07.014. Epub 2013 Sep 21. PMID: 24182956; PMCID: PMC4289642.