The Risk of Nipple Shield Use for Premature Infants
by Anne Eglash MD, IBCLC, FABM
Nipple shields are commonly used for preterm and term infants wherever they are available around the world, for various reasons. My colleagues and I published results from a health professional survey in 2010, finding that more than 75% of lactation specialists recommended nipple shields for some patients, most commonly to assist latch for infants born < 35 weeks gestation. Many fewer, 38%, recommended nipple shields for infants over 35 weeks gestation and < 3 days of age. The main concern among lactation specialists was the lack of follow up for dyads who are recommended nipple shields, because of the risk of milk production loss over time.
Nipple shield use is hotly debated, largely because we have little data on how nipple shield use affects long term breastfeeding success. Lactation specialists have different observations on outcomes, based on the populations they are working with.
The authors of this week’s article performed a Danish national cohort study on the prevalence, motives for use and association of nipple shield use with exclusive breastfeeding. Danish preterm infants are hospitalized until breastfeeding is well established or until exclusive breastfeeding is no longer the goal and mixed feeding or bottle feeding is stable.
The data was collected from a survey of 1221 mothers of 1448 preterm infants with gestational ages of 24-36 weeks. Data on nipple shields was available for 1407 infants, among 21 different NICUs. The incidence of nipple shield use differed between NICUs, from 35%-67% of preterm infants.
- Using a nipple shield for breast engorgement had the largest negative effect on exclusive breastfeeding at discharge.
- Mothers for whom breastfeeding was of very great importance were less likely to use a nipple shield.
- Bottle feeding was introduced significantly more often in infants who used nipple shields.
- Mothers were more likely to use a nipple shield for infant feeding problems, such as falling asleep at the breast, than for maternal problems such as pain.
- Exclusive breastfeeding at NICU discharge was associated with less nipple shield use.
- NICUs with higher nipple shield use had less exclusive breastfeeding at hospital discharge.
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Background and Aim
Prevalence and motives for nipple shield use are not well studied in preterm infants and recommendations of nipple shield use in preterm infants are inconsistent. The aim of this study was to determine the prevalence of nipple shield use, explore the motives for nipple shield use and elucidate the association with exclusive breastfeeding in preterm infants.
The study was part of a prospective survey of a Danish national cohort of preterm infants based on questionnaires answered by the 1221 mothers of 1488 preterm infants with gestational age of 24–36 weeks. Data on nipple shield use was available for 1407 infants.
Nipple shields were used by 54% of the mother-infant dyads for many different motives and was more often related to breastfeeding problems associated with the infant than with the mother. The most common motive for nipple shield use was “infant slipped the nipple” (52%). The lower the gestational age, the more frequently nipple shields were used for motives related to the infant. For those using a nipple shield, only the motive “infant fell asleep at the breast” was associated with a higher risk of not breastfeeding exclusively at discharge (OR 1.90 (95% CI 1.15; 3.13), p = 0.012), and “breast too engorged” with a lower risk of not breastfeeding exclusively (OR 0.32 (0.16; 0.63), p = 0.001), but overall nipple shield use was associated with failure of exclusive breastfeeding.
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.
The authors found that nipple shield use for infant feeding problems had a higher rate of nonexclusive breastfeeding at discharge. Nipple shield use for engorgement was positively associated with exclusive breastfeeding at discharge. The NICUs with higher rates of nipple shield use had lower exclusive breastfeeding rates at discharge, so clearly nipple shield use did not improve breastfeeding rates.
The authors note that the rate of nipple shield use was high in Denmark, as compared to another study done in the UK where only 2% of premature infants received nipple shields. The authors state that the Danish Health Board recommends nipple shield use with a reference to a US study from 2000 involving only 34 premature infants, which was funded by a company that makes nipple shields.
Overall, this study is one of the largest on nipple shields, and its results are concerning. We don’t have good data to support the pervasive use of nipple shields for term and preterm infants in the USA, and we have plenty of data showing nipple shield use being associated with breastfeeding problems.
My soapbox is that nipple shield use interferes with what we know to be absolute truths in breastfeeding science. The nipples MUST feel the infant to increase prolactin at each feeding, and the infant MUST be deeply latched to express milk. The nipple shield likely blunts nipple sensation, risking a drop in baseline prolactin and lack of the rise with feeding. The nipple shield moves the infant further away from the glandular tissue, risking insufficient milk transfer. Lo and behold, these are the exact problems I see in my breastfeeding medicine clinic.
Even though some lactation consultants and mothers swear that the nipple shields save breastfeeding, mothers still need to understand that using a nipple shield is a risky intervention requiring close follow up over time to prevent lactation failure.
There is a myth that the nipple shield is ‘ultrathin’. A nipple shield is much thicker than a condom and I have never heard men say that condoms don’t interfere with sensation. Until we know for sure that nipple shield use sustains the baseline prolactin level over many weeks and allows for consistent prolactin rise with infant feeding over many weeks, I feel strongly that this statement is not evidence-based.