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Again this week, I read a comment by a leading breastfeeding expert tutting over the use of nipple shields.

Of course, this person has decades of experience.

Of course, there are plenty of times when nipple shields are used incorrectly and over-enthusiastically .

Of course, when they are used without seeking access to other breastfeeding support they can mean supply issues, continued nipple pain and damage and a situation that can be challenging to unpick.

But can I please just take one moment to say that sometimes they can be bloody marvellous.

I'm not 'supposed' to say that. I've heard lactation consultant colleagues say, "Oooh, I hate nipple shields." I'm meant to be down on them and focus on all the disadvantages.

But sometimes I just feel they need a little bit of defending.

I don't know what's going on with tongue tie at the moment. It seems like every breastfeeding drop-in group I visit has at least a third of babies who are post-frenotomy (tongue tie 'snipping') or they have been diagnosed and are waiting to be seen. Obviously the proportion of babies who come to get breastfeeding support will inevitably include more struggling with tongue dysfunction - however the numbers still seem ludicrous.

I've seen mums who are breastfeeding several months after an initial nightmare month living with tongue-tie and a nipple shield has made all the difference. Tongue tie is often accompanied by a high-arched palate or 'bubble' palate as when a baby is in utero the tongue hasn't been pressing up against the soft bone of the palate due to its restriction and the palate doesn't end up being smoothed into the typical gentle arch. And although babies can feed just fine on flatter nipples and even inverted nipples, they often do like to feel something touching their palate and triggering their sucking reflex. And if that palate is an extra centimetre away, that can be tough. A baby may struggle to get purchase. They may appear to be searching for something and become frustrated. Finding a way to get baby to latch on and stay on may not always be easy.

Babies with tongue tie and high palates can latch on effectively but it's not easy for everyone to find those ways on their own.

There are ways to get babies to latch on beautifully to flat nipples but it's not easy for everyone to find those ways on their own.

In some cases, nipple shields can be a useful tool. The baby receives that palate stimulation and settles into a fabulous rhythm of deep swallows and great chin movements, milk is transferred and it's hard to see what's so evil about that.

Those who demonise nipple shields might have talked about the need to 'work harder' to find a latch that works. That's fine - but when it's 2am and mum is exhausted and baby is exhausted a bottle of formula may well be an appealing choice when your nipples are already sore and feeding has never been easy.

If we make nipple shields the 'bad guy', you may find that less feeding happens at the breast. Not everyone has a breastfeeding specialist sitting in the corner of their bedroom behind the nightlight. Or even access to good quality breastfeeding support throughout the week in the day time.

This morning I worked with a mum who had nipples that looked naturally quite different. One had a wide barrel shape and a length of about 15mm. The other was a slight dome rising no more than 3mm above her areola. She had been feeding successfully on one breast but when it came to the flatter side, baby was confused and frustrated. He had never really latched on for more than a few moments. Several weeks on, she was feeling desperate. She had been supported to try many positions by several breastfeeding counsellors and lactation consultants. She had visited a cranial osteopath. But the reality was that her son was used to the sensation of the longer nipple and the other side was less straight forward and he was struggling to move between the two. Perhaps she could only feed from one side and express the other? Perhaps she could just lactate on one side?

She tried a shield today and, for the first time ever, he moved immediately to deep chin movements, audible swallowing and mum said, "Yay!".

She actually said "Yay!" quite a few times.

I would defy someone who had spent time with that mum and heard her history and worked with her to then say, "I hate nipple shields".

There are certainly times when they don't work well. I've also been to a group and a mum has shown up using shields to help her cope with sore nipples. The low point came a couple of nights ago and she couldn't continue feeding just on the breast. Even in that moment, it's hard to argue it would've been better for her to stop breastfeeding and use a bottle in order to 'rest' completely. The shields allowed her to keep going and avoid the complication of using a bottle. However the shields were not her solution. Thankfully she sensed that and knew to come to a group and get support but I wonder how many women don't. Her positioning and attachment could certainly have done with some improvement. She was leaning forward and 'offering the breast' and then pushing it in baby's mouth without really waiting for a gape or bringing the baby to her. Her nipple was coming out after a feed flattened and compressed and was visibly damaged along the ridge where it was flattened. There were lots of things that could be improved. And the shield didn't help with any of that. But it helped with her psychology and she came to the group. It kept her going.

Shields don't help with sore nipples. They can exacerbate issues where babies have insufficient gapes and the baby just then transfers their insufficient gape onto the shield. But if the shield means that mum can cope with breastfeeding until she does manage to get the right support, if they stop her giving up, then that surely is a positive.

Shields are connected to a lower milk supply. Possibly because hormones aren't being stimulated in quite the same way even through the modern thin silicone shields. Possibly because the people who resort to using the shields have issues that are the true cause of milk supply reduction. It can be wise to stimulate your supply using some additional expression if you are using shields and keep a closer on on baby's weight gain. However I've also seen shields get a mum through a difficult couple of days when she had too MUCH milk. After struggling with oversupply and overactive letdown, her baby choking and spluttering with every feed, she found using the shields tided her over until she was able to get proper support and information. The baby was able to come to the breast without being flooded and her alternative would've been expressing and bottlefeeding.

If we demonise nipple shields, we reduce options. Options that actually might help when the next breastfeeding group is in two days time and the breastfeeding helpline isn't open for the next 10 hours. And when the temptation is to pick up a bottle when it's really not want you want to do.

You can use a shield and practice good body positioning and nose to nipple and head tilting and gaping. The baby works at the breast and is held close and does lots and lots of useful and valuable things and transfers milk as it gradually thickens and this is all still breastfeeding.

If you've been a breastfeeding supporter for a gazillion years and you've always managed to get babies to latch on superbly and you've never needed to use a shield - that's dandy. But I will hold my hand up and say that sometimes I've worked with mothers who did use a shield and it made them happy and they felt great and the baby felt great. They went on to reach their breastfeeding goals, often weaning off the use of the shield with very little difficulty.

I think sometimes nipple shields deserve a teeny little 'yay!' They aren't right in MOST situations and good quality breastfeeding information usually means that they are not needed. If they are going to be used, they should be used with support from someone who is qualified in breastfeeding. But in a minority of cases, they can be bloody marvellous.

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Again this week, I read a comment by a leading breastfeeding expert tutting over the use of nipple shields. Of course, this person has decades of experience. Of course, there are plenty of times when nipple shields are used incorrectly and over-enthusiastically .

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From the Australian Breastfeeding Association

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A nipple shield is a flexible silicone nipple that is worn over the mother's own nipple during breastfeeding.
When are they used?
Nipple shields can help establish breastfeeding with some babies who seem to have difficulty achieving and/or maintaining attachment to the breast. However, very few benefit from using a nipple shield. Please consult a breastfeeding counsellor or health professional for one-to-one support before you use a nipple shield. A nipple shield can be a temporary solution but not a permanent fix to an underlying problem. They may affect transfer of milk to the baby which may contribute to poor weight gain and health problems for both mother and baby.
What might cause my baby to have difficulty with attachment?

Events around labour and delivery.

Use of artificial nipples.

Baby's physiology.

Other reasons a shield could be used:

Flat or inverted i.e. non protractile nipples.

Breast refusal.

Sore, cracked, bleeding nipples.

Weaning a baby from bottle to breast.

Re-lactation or induced lactation (adoptive breastfeeding).

Before using a nipple shield, consider:

Accessing skilled breastfeeding support, ideally face-to-face.

Prolonged skin contact, and 'biological nurturing' i.e. laid-back breastfeeding techniques.

Hand expressing drops of milk onto the nipple to tempt the baby to attach.

Regular (2-3 hourly) hand expressing of colostrum to protect milk supply.

Regular (2-3 hourly) feeding of expressed breast milk (EBM) via syringe/cup.

Trying different positions/techniques e.g. cross cradle hold and exaggerated attachment, lying down feeding, underarm hold.

Applying cold to a soft nipple to firm it.

Use of nipple massage, gentle use of breast pump or other suction device to draw nipple out.

If milk is in, deal with any engorgement to soften areola to facilitate attachment.

When breastfeeding is uncomfortable, using a nipple shield can feel like a quick fix, but shields are not a substitute for finding qualified breastfeeding support. If there is an underlying latching problem, adding a shield on top can risk blocked ducts and mastitis, supply reduction, and a baby not getting enough milk. Feeds can end up being long and unsettled and baby may take in more air. When the shield is removed, the underlying problems remain, and may even be worse as the baby has become accustomed to using the shield. Always try and find qualified help if breastfeeding is uncomfortable or challenging.
Care
Wash the shield with hot soapy water, rinse with clean water, dry carefully and store in a clean container.
Choosing a shield
Nipple shields are sized according to the diameter of the base of the mother's nipple. A poorly fitting shield can cause problems including reduced milk transfer and pain.

In the U.K., the standard sizes are 16mm (small), 20mm (medium) and 24mm (large). A larger 28mm size is available online but can be difficult to find.

The size of shield you use is not the same size as the pump funnel you use. Shields are a closer fit. Many shops will only sell one size and you may have to shop online to get a wider selection.

A 'contact' nipple shield has a cut away piece that allows baby's nose or chin to remain close to the breast. This is preferable to a shield where the baby's nose is pressed against plastic.
How to use a nipple shield
It's often helpful to place your baby in skin to skin contact well before you attempt a feed. This will stimulate baby's instinctive feeding behaviours and make attachment to the breast more likely to be successful.

First, try latching the baby without the shield if you feel you can. How long you spend trying to latch effectively without the shield is a very personal decision and will depend on how long ago the baby fed, the support you have, and how breastfeeding has been going in the past.

A warm wet shield sticks to the breast better - run the shield under warm water prior to use.

Roll the wet, warm shield back about halfway down the shank of the shield.

It may adhere to the breast better if you apply a little water or breastmilk around the edge.

Roll the shield back onto the breast so the nipple is drawn into the teat of the shield.

There are some videos online that show you how to apply a shield with this 'slightly inside out' method.

Attachment
Attachment technique is still important with a shield. Don't just poke the shield teat centrally into baby's mouth. Baby should be held close, mouth wide open and chin in contact with the breast. Once attached, you should notice their chin moving deeply to show active swallowing and you will often hear some swallowing at the beginning of a feed.

Towards the end of the feed (when baby's swallowing slows) it is a good idea to use breast compression while baby suckles to increase the milk and fat transfer to the baby. Offering baby both breasts at each feed will mean baby gets more milk.

The nipple shield is a projection of the nipple so, when the baby unlatches, it should look well rounded, just as though baby had a good latch directly at the breast. You should see milk in the shield when baby comes off. As using a shield is often associated with reduced milk transfer, it can be recommended to express in addition, to help protect your supply. Your breastfeeding counsellor or health professional can support you to consider how often this is needed, depending on how things are going.

It's a good idea to keep an especially close eye on baby's bowel movements and urine output while you're using a nipple shield, as these give an indication of milk intake. Baby should have about three tablespoon-sized yellow, grainy stools in 24 hours (after the fifth day) and have at least six wet nappies.

If baby is discharged from hospital using nipple shields, their progress should be closely monitored by the community midwife or health visitor.
Weaning from a shield
Be sure not to make this a battle with your baby, or they will resist more. Don't obsess with weaning off the shield to the point that you are unhappy with breastfeeding. As long as your baby is gaining weight well, there is no need to rush into trying to wean them from the shield. Don't cut down a shield to wean a baby off it - this practice is no longer recommended.

You may be able to remove the shield part way through a feed and continue without. You may only use a shield on one breast, or for the first few minutes. Some babies need only one or two sessions with the nipple shields, while others may need more.

Keep trying as often as you can and give it some time. Your baby might be more receptive to feeding without the shield when they are less hungry or sleepy. Some continue to use a shield for the duration of their breastfeeding experience, but most are able to stop using the shield after only a short time if they wish to.

Be patient while you work through this time of transition. Breastfeeding with a shield is still breastfeeding.

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Using a nipple shield with a breastfed baby - ABM

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Nipple shields can help establish breast-feeding with some babies who seem to have difficulty achieving and/or maintaining attachment to the breast.

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From La Leche League

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A nipple shield is a thin, silicone teat that can be placed over a mother's nipple and may help a baby who is having difficulty learning to breastfeed. Holes in the tip allow milk to flow into the baby's mouth. A nipple shield can be used temporarily to help establish breastfeeding or in some cases to help ensure that breastfeeding continues. A shield provides a firm stimulus at the roof of a baby's mouth where the soft and hard palate meet. This can help him suckle more effectively.

If your baby is not nursing at all, or is nursing ineffectively despite improving attachment and increasing milk flow, a nipple shield may help by providing a firmer stimulus in your baby's mouth. A nipple shield may be a useful tool in some situations. When nothing else works, it can be a temporary way to establish and maintain breastfeeding.

A nipple shield may be helpful if

Your baby is struggling to learn how to breastfeed

You have flat or inverted nipples, or very soft breasts as it can help maintain nipple shape

Your baby thrusts his tongue, has a retracted tongue or has neurological problems

Your baby was born prematurely

Your baby needs extra stimulus to prompt sucking

In these situations, a nipple shield can

Give a baby the opportunity to learn to breastfeed

Allow a baby who breastfeeds ineffectively to take more milk directly at the breast. This can be particularly helpful for premature babies

Avoid or reduce the need to express milk and use cups or bottles

Help keep breastfeeding going

Not a magic solution

It is very important to seek skilled help with positioning, attachment and any other problems if you are planning to use nipple shields or are already using them. Helping your baby get a deep latch at the breast is the key to effective and comfortable nursing with or without a nipple shield. A shield cannot correct underlying problems, especially those of sore and damaged nipples or low milk production. And if your baby is not attached well he may compress your nipple, causing damage and intense pain. When your baby latches on deeply at the breast he gets plenty of milk. Also, as you wean from the shield he will be able to adapt to breastfeeding effectively and comfortably without it.

Even with a nipple shield, your baby may still need help to learn to breastfeed well. Sometimes just a small adjustment to the way you hold your baby makes a big difference. You may find the suggestions and pictures in Comfortable Breastfeeding helpful. If you cannot get comfortable or breastfeeds are taking an hour or more, seek help from an LLL Leader who can give you personalised suggestions.

Holding your baby in skin-to-skin contact can make a big difference too. With or without a shield, laid back or 'natural' breastfeeding positions (see above) can be a great help in encouraging your baby to latch on effectively, as well as being comfortable for you. You can either lie down or recline with your baby on top of you and with his whole front against you and his body completely supported by yours. Such positions also leave both your hands free to shape your breast and help him latch.

If your baby won't breastfeed

Don't panic! Some babies take time to learn. However, babies will often latch on and suckle spontaneously if they can snuggle up close to their mother's bare chest for periods of time. Try letting your baby lie on your body as you recline so that both his chest and tummy are against you. This kind of contact, known as Biological Nurturing ™, or laid back breastfeeding usually stimulates a baby's instinct to attach and suckle well at the breast. In such positions, babies can also latch on when sleepy or even asleep. Watch for signs your baby is stirring and gently encourage feeding. If he is not breastfeeding effectively or at all you will need to express your milk for him. This will help maintain your milk production while he learns to breastfeed. An LLL Leader can give you tips for effective milk expression.

Is he getting enough milk?

Offer frequent feeds and monitor wet and dirty nappies for evidence your baby is getting plenty of milk. His weight will need checking regularly-as often as every three days for premature babies. For more information see Is My Baby Getting Enough Milk?

Check your breasts

Areas that aren't being drained well may appear swollen, sore or red. Treat early signs of localised engorgement to avoid a blocked duct or mastitis.

Practicaliti es
Type and fit
Modern nipple shields are made of clear ultra thin silicone. Different makes vary in flexibility. Some shields have a cut out section, but these may not stay in place as well as a full nipple shield. Full nipple shields do not bother babies or affect their breathing. Nipple shields come in different sizes but choice is limited. Both the width of the tip section and the shape of the flat part vary and you may need to experiment to find which size and shape you prefer. A comfortable fit is very important and some mothers need more than one size of nipple shield due to differences between their breasts.

Applying
Stretching the shield onto the breast can help it stay in place. You can also moisten the shield's edges or warm it with hot water to help prevent it moving. Turn the nipple shield almost inside out before applying it. Smooth it onto the breast, starting well away from the nipple in the area where your baby's lower jaw will latch on. Stretch the shield over your breast, with the tip centred over your nipple. The nipple shield should be tight against your breast with your nipple extending into the tip. If necessary, you can express milk into the tip or drip expressed milk onto the outside to encourage your baby to latch on.

Cleaning
If you and/or your baby are in hospital, wash the nipple shield thoroughly in hot soapy water and sterilise it before each use. If you have a healthy, full-term baby and are at home, cleaning with hot soapy water or washing in a dishwasher on a hot cycle will be sufficient. Shields should be dried thoroughly before use and stored in a clean, sealed container or bag.

A faster flow
Swallowing encourages sucking, which will help keep milk flowing. A baby who has become used to a continuous fast flow from a bottle may need help to persist with breastfeeding. Hand expressing for a few minutes can encourage a good flow of milk before your baby latches on. You can even hand express milk into your baby's mouth to encourage him to latch on or keep him nursing when your milk flows more slowly.

Try breast compression

1. Support your breast with one hand-thumb on one side, fingers on the other.

2. Wait while your baby breastfeeds actively, his jaw moving all the way to his ear. When he stops swallowing, compress your breast firmly. Hold it squeezed until he stops nursing actively and then release your hand.

3. Rotate your hand around your breast and repeat step 2 on different areas of the breast as needed. Go gently-this should not hurt.

Use a shield with a nursing supplementer

If your baby needs extra milk, a nursing supplementer can be used to deliver this through a tube as your baby breastfeeds. This avoids the need to bottle feed. The end of the supplementer tube can be placed either inside or outside the shield. Consult an LLL Leader if you think a nursing supplementer may be helpful.

Giving up the shields

Nipple shields are intended to be a temporary solution until your baby learns to breastfeed without them. When using a shield, help your baby to latch on by himself with a wide open mouth. This will help him to learn to breastfeed without a shield. Offer your baby some time in skin-to-skin contact every day without a nipple shield so he has the opportunity to latch on if he is able. It can take time to wean from shields but do keep gently trying. Try at times when you and your baby are most comfortable and relaxed and there are fewest distractions. You can try different methods to see what suits your baby.

Start with skin-to-skin next to breast without the nipple shield before nursing with the shield.

Start a feed with a shield, removing it part way through nursing from one breast or when switching breasts.

Gradually offer the breast without the shield.

DO NOT CUT a silicone shield as this could leave sharp edges that would hurt you and your baby.

Seek support

Whilst you may be relieved that a nipple shield is enabling your baby to breastfeed, it can be frustrating if he will not feed without it. However, given time and patience, it is usually possible for a baby to learn to breastfeed without the shield. An LLL Leader can be a useful source of support if you need to choose, use and wean from nipple shields.

Written by Karen Butler, Sue Upstone and mothers of La Leche League GB.

Further Reading

The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010

Positioning & attachment
Comfortable breastfeeding
Engorged breasts - avoiding and treating
Hand expression of breastmilk
Inverted nipples?
Is my baby getting enough milk?
My baby needs more milk
My baby won't breastfeed
Nipple confusion?
Nipple pain - why and what to do

References
The Breastfeeding Answer Book. Third edition. Schaumburg IL: LLLI, 2003.
Breastfeeding and Human Lactation. Fourth Edition. Sudbury, MA: Jones and Bartlett, 2010.
Supporting Sucking Skills in Breastfeeding Infants. Watson Genna, C. Sudbury, MA: Jones and Bartlett, 2008.
This information is available in printed form from the LLLGB Shop
Copyright LLLGB 2016

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how an when to use nipple shields to support successful breastfeeding