Dear Lactnet Friends:

Debra Swank proposes a discussion on this topic; I'm in!

I've been in private practice for 30 years. I base my opinions on that,
plus all the reading and conference presentations I have done on the topic.

Nipple shields can be an effective tool when used wisely in a clinical
situation with skilled lactation follow-up. One study published a technique
of doing a pre/post feed weight check with the shield in place. What a
lovely idea.


Mothers have come to me for breastfeeding help, having been given nipple
shields in the hospital. Only 1 (one) of them knew why she had been given a
shield. There's something disturbing to me about that; to give someone a
piece of durable medical equipment and for them not to know why.

In my city, I hear stories from doulas and mothers of nurses giving out
nipple shields on the delivery room table!  Whatever else is true, I feel
strongly that a nipple shield should be a tool of last resort, not the
first.

BabyFriendly Hospital policies can put pressure on staff, particularly
lactation service providers, to make breastfeeding happen to reach the 80%
target. Using a nipple shield makes it easy for someone to force the baby
to the breast. Using a nipple shield when a parent is anxious about
breastfeeding may treat the anxiety, and does not help breastfeeding in the
long run. Overworked staff don't have the time to sit at the bedside and
act like doulas for the initiation of breastfeeding; nipple shields can
enable the breastfeeding box in the medical record to be checked, and then
the family goes home to figure it out.

For some parents, use of a nipple shield in the hospital can reduce the
full expression of Lactogenesis II, leading to failure to thrive. There are
case reports (and I have had such a case myself) where the parent was given
a nipple shield in the hospital, went home using, saw milk in the shield
when the baby detached, felt things were okay, only to have her baby
re-admitted for failure to thrive secondary to impaired Lactogenesis II.
The shield reduces the stimulation to the pituitary; this is serious for
some parents. We have no way of knowing which ones.

That leads me to recommend pumping 3-4 times a day in addition to cue-based
breastfeeding for the first 2 weeks (during the time when the prolactin
receptor sites are being primed) to reduce the potential compromise to full
expression of Lactogenesis II. However, this recommendation is not commonly
given at local hospitals.

The new Geddes study found that "......nipple shield use significantly
reduced milk transfer and nutritive suckling in the comparison group."

The study cited by nearly everyone as supporting nipple shield use in NICU
was funded, in part, by Medela, the company who makes and markets nipple
shields.

("This project was supported by National Institutes of Health Grant
NR03881 and a research grant from Medela, Inc. (McHenry, Ill). " 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.)

This study found that 34 preterm infants  transferred MORE milk with the
shield, not sufficient milk. This is a small sample upon which to base
global practice, but had the resources of a large and well-funded company
to spread the word.


I had one mother who used an old Davol nipple shield base with a bottle
teat on it (OMG!) because she didn't have nipples; she had a hole that
leaked milk at a copious rate. Anything can be useful in a particular
situation. (<
https://www.nikkileehealth.com/an-olympic-gold-medal-for-difficult-breastfeeding/
>)

Another challenge in hospitals is that the shields sold in the US and
purchased by hospitals can be too small to fit the population served.  I
have had clients whose nipples are far larger than the largest Ameda or
Medela shields (that go up to 24 mm). . . in my private practice, I have
purchased the Mamivac shields that go up to a 28 and offer different
shapes. We still need larger sizes than that.

One client was shoving her nipple into a 24mm (given by the hospital) and
had pain during breastfeeding as a result. Another client either forgot or
was never taught how to put the shield on correctly, and had a slow gaining
baby as a result. (Baby had a 5 or 6:1 ratio of suckling to swallowing and
was sliding up and down the shaft of the shield.)


Some of the follow-up studies about long-term nipple shield use mention the
lack of exclusive breastfeeding. In a Chertok study showing that babies
breastfeeding with nipple shields gained sufficient weight, half the babies
were being supplemented with formula by 2 weeks.

The Maastrup et all study, looked a cohort of 1221 mothers and concluded
that " The present study does not give justifiable motives for nipple
shield use, except for "breast too engorged". Nipple shields should not be
recommended for infants falling asleep at the breast, instead, staff and
mothers should be patient, allowing the dyad time skin-to-skin. The results
indicate that the use of a nipple shield does not promote exclusive
breastfeeding in preterm infants."

(Maastrup R, Walloee S, Kronborg H. Nipple shield use in preterm infants:
Prevalence, motives for use and association with exclusive
breastfeeding-Results from a national cohort study. PLoS One. 2019 Sep
20;14(9):e0222811. doi: 10.1371/journal.pone.0222811. PMID: 31539900;
PMCID: PMC6754237.)

Cathy Watson Genna suggests reasons for nipple shield use in community: for
the mother ready to quit, for a baby with clefts, for a baby that can not
grasp a flat or inverted nipple, for the baby needing more sensory
stimulation, and for assisting in transition from bottle to breast. I have
found shield use helpful in such situations, after everything else has been
tried.

My protest (and I do protest) is their abuse, being handed out to everyone
regardless of the clinical need, situation, and availability and
utilization of follow-up.

warmly,

Nikki Lee RN, BSN, Mother of 2, MS, IBCLC, CCE, CIMI, ANLC, CKC, RYT
www.nikkileehealth.com
Pronouns: she/her/hers
*Communications are confidential and meant only for whom they are
addressed.*

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