When not to use a nipple shield

Why isn’t the nipple shield helping me breastfeed?

Some babies never learn to use a nipple shield. They may be unable to latch onto it, clamp on to the tip of the cone, or can latch and suck but not get enough milk. Mothers may notice the baby is generally angry or frustrated while breastfeeding with a nipple shield and hungry afterwards. If mothers have strongly inverted nipples, the nipple shield will probably not work. If mothers notice a significant increase in nipple pain while breastfeeding, they should not use a nipple shield until the reason for the pain is fixed.

A) Reasons for not using a nipple shield

This baby could not latch and his mother was breastfeeding with a nipple shield. However, he was unable to take in enough milk while using it, and as a result lost a significant amount of weight. He started to gain once his mother started exclusively pumping and supplementing. She had a full milk supply and the baby was completely breast milk fed.

Nipple shield use has been reported to decrease breastfeeding success (Kronborg 2017; Maastrup 2014; Maastrup 2019). This is likely because mothers with breastfeeding problems resort to using a nipple shield and nipple shields are not always effective in fixing problems.

We estimate that about 60-70% of babies can use a nipple shield. For the remainder, the nipple shield is not effective because:

  • The baby can’t latch or stay latched onto the nipple shield.
  • The baby clamps on the tip of the nipple shield cone.
  • The baby doesn’t get enough milk when breastfeeding with a nipple shield.

If these problems cannot be fixed and this goes unnoticed and you persist in using one, the baby may become underfed and the milk supply will decrease unless you are also expressing. For this reason, a baby should be weighed and examined when starting to use a nipple shield, within a few days, and then again within two weeks.

It is also possible for nipple shield use to cause significant nipple pain. If you cannot fix the problem, stop using one as the pain may increase and even lead to nipple damage.

B) Signs the nipple shield is not working

If the nipple shield is not effective, you may notice:

  • The baby cannot latch or stay latched onto the nipple shield.
  • The baby does not move through the three stages of breastfeeding.
  • The baby is upset during the feed.
  • The baby is hungry after the feed.
  • The baby is never content and breastfeeds too often.
  • The baby is only happy after getting a milk supplement.
  • Your breasts don't feel softer after breastfeeding.
  • You can express similar amounts of milk before the feed as after.

A baby who is generally angry or frustrated while breastfeeding with a nipple shield is telling you the nipple shield is not effective. This should not be confused with the normal behaviour that can make babies mad and let go of the breast.

In addition, you may notice:

  • The baby clamps on the nipple shield cone.
  • Your nipples are very painful while feeding and after.

The guidelines and signs of trouble for nipple shield use by premature babies are somewhat different.

C) The baby can’t latch or stay latched onto the nipple shield

Some babies cannot latch or stay latched onto a nipple shield, just as some cannot latch at the breast. They may be unable to create suction on the nipple shield, or they will pop off and on.

Babies who can’t latch onto a nipple shield:

  • Try to latch or stay latched many times until they get angry or tire out and go to sleep.
  • May clamp on the tip of the nipple shield cone as they try to latch, causing pain.
  • Will act hungry if not supplemented with extra milk.

There may be a reason for this, such as the baby having a cleft palate, but often there is none.

If the baby cannot latch and stay latched onto a nipple shield, mothers need to use other tools to address the baby’s latching problem or the mother's nipple pain and to feed the baby. Mothers in this situation should not use a nipple shield. Furthermore, such babies are unlikely to learn to use one in the future.

D) The baby clamps on the tip of the nipple shield cone

1) Signs the baby is clamping on the nipple shield

Some babies clamp down on the tip of the nipple shield cone with their mouth and pinch the nipple. This is shown in pictures at the bottom of this FAQ.

Such pinching causes pain and prevents the baby from sucking properly and getting milk. You may notice:

  • When breastfeeding:
    • The baby does not take the whole cone into the mouth.
    • The cone is flattened.
  • You feel severe nipple pain as soon as the baby latches, for the whole feed, and for some time after the end of the feed.
  • The baby gets irritated quickly or quickly goes to sleep on the breast because the baby does not get enough milk.
  • A sharp, tender line appears across the nipple face when you remove the nipple. The line can be white or red and there may be nipple damage.

2) Reasons for clamping

 Some babies will clamp on the nipple shield for no reason.

Others are unable to bring the nipple deep enough into the cone because the nipple root is abnormal or the nipple is inverted.

This occurs because the nipple cannot stretch enough to fully enter the cone of the nipple shield. The cone is empty and without the tissue of the nipple to support it, the cone collapses and the baby keeps the nipple at the front of the mouth instead of out of harm’s way, deeper in the mouth. 

3) Stopping clamping

Please examine your nipple root using the pinch test if the baby is clamping on the nipple shield and address any fixable issues.

If the nipple root is normal, you may be able to help the baby latch by stretching the nipple shield to bring the nipple a little deeper into the nipple shield:

  1. Wet the inside of the rim of the nipple shield with a little water.
  2. Position the baby at the breast in the cross-cradle or under-arm hold.
  3. Have the nipple shield horizontal with the cone facing down.
  4. Pinch both sides of the outer rim with your thumb and pointer finger so that both thumbnails are facing you.
  5. To stretch the nipple shield, turn your hands over so that you now see your fingernails and palms.
  6. Place the stretched nipple shield over the nipple.
  7. Relax your hands and use one hand to keep the nipple shield in place.
  8. Latch the baby right away with your other hand.

If you cannot stop the baby from clamping, do not use a nipple shield. The baby will not get enough milk and you will develop nipple pain and even damage.

E) The baby doesn’t get enough milk when breastfeeding with a nipple shield

1) Describing babies who cannot take in enough milk when using a nipple shield

Some full-term babies can latch and suck well on a nipple shield but cannot get enough milk, even when the mother has a full milk supply.

The reason for this disconnect is unknown. It is possible that some mothers have a weaker let-down when using a nipple shield. Nipple shields have been reported to decrease levels of a mother’s oxytocin, the let-down hormone (Amatayakul 1987; Chertok 2006).

It is also possible that: 

  • The baby is a premature, sleepy newborn, or weak, sick baby, as all may prevent the baby from breastfeeding well both with a nipple shield or without one.
  • The mother has a low milk supply.

2) How to help the baby get more milk when using a nipple shield

If the baby is not latching or getting enough milk, you can try the following:

  • If you are using a 16- or 20-millimetre nipple shield size, your baby may do better with a 24-mm nipple shield.
  • If you have very large nipples, you may require a 28-mm nipple shield.
  • On rare occasions, babies get more milk when using a smaller nipple shield.
  • Ensure that the baby is not clamping down on the end of the nipple.

3)  Using a nipple shield along with supplementing 

You have three choices if your baby can latch and breastfeed with a nipple shield but does not get enough milk:

They are, in order of our patients’ preference:

  1. Express milk and supplement to feed the baby. Once the baby is done feeding, you can breastfeed with the nipple shield to settle the baby or breastfeed the baby to sleep.
  2. Express and supplement exclusively without breastfeeding.
  3. Breastfeed with a nipple shield for some, most, or all of the feeds and then express and supplement to “top up” the baby’s milk intake.

The first approach will provide your baby with breast milk and give you a tool to settle your baby. Both of these benefits are lost with the second approach.

We generally discourage the third approach, as it is time consuming for mothers and can be stressful for the baby. Also a premature, sleepy newborn, or weak, sick baby may waste precious energy breastfeeding ineffectively using a nipple shield.

References

Amatayakul K, Vutyavanich T, Tanthayaphinant O, et al. Serum prolactin and cortisol levels after suckling for varying periods of time and the effect of a nipple shield. Acta Obstet Gynecol Scand. 1987;66(1):47-51
 
Chertok IR, Schneider J, Blackburn S. A pilot study of maternal and term infant outcomes associated with ultrathin nipple shield use. J Obstet Gynecol Neonatal Nurs. 2006 Mar-Apr;35(2):265-72
 
Kronborg H, Foverskov E, Nilsson I, et al. Why do mothers use nipple shields and how does this influence duration of exclusive breastfeeding? Matern Child Nutr. 2017 Jan;13(1).
 
Maastrup R, Hansen BM, Kronborg H, et al. Factors associated with exclusive breastfeeding of preterm infants. Results from a prospective national cohort study. PLoS One. 2014 Feb 19;9(2):e89077
 
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