Nipple Shields - Don't Throw The Baby Out With The Bath Water

Modern Silicone Shield

Nipple shields, the word practically draws a gasp in some circles and to be fair perhaps with good reason.  For years nipple shields were used by many as the "solve all" to breastfeeding problems, rather like sticking a giant plaster over whatever was causing the problem - they either didn't help and feeding was just as painful, or did but mum's supply suffered, and if she got through all that it was often a long and arduous process getting baby to feed without them; techniques recommended ranged from "making baby go cold turkey" to "cut them down gradually" (really not recommended nowadays due to shields being made of silicone which can be very sharp when cut).

Dr Jack Newman himself states there is never a need for nipple shields - and perhaps in a perfect breastfeeding world where everyone can get the help they need instantly, he may be somewhere near the mark.  But at least where I am in the UK, we're simply not there at the moment.

But let's start at the beginning.


Nipple shields have been around since the 16th century, and have been made of lead, silver, wax, wood, pewter, tin, bone, ivory and glass.

Portia Shield

Glass Nipple Shield

More recently plastic, rubber or latex became popular and nowadays the typical shield is a thin piece of silicone worn over mum's nipple and areola - although there are still a few odd contraptions around, like the Portia nipple shield (on the right) endorsed by Claire Byram Cook (or so the packet says). The mum pops the "teat" over the plastic holder, and then puts the plastic holder over her nipple; I'll leave you to make your own minds up about that one, but I'm sure many will note the similarity between this and the image on the left...

Numerous studies demonstrate that shields can affect milk transfer and thus mum's milk supply, however these studies are examining older fashioned thicker shields, that would reduce stimulation to mum's nipples too.

Latex Shield

A 1980's study found latex shields reduced milk intake by a 22%, but had no significant effect on sucking patterns. But shields are now made of thinner silicone, so how applicable is this?

Not very in my opinion.

A 2006 study published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, which examined use of an ultra thin shield found:

"Physiological results demonstrated no significant difference in maternal hormonal levels and infant breast milk intake for breastfeeding sessions with and without nipple shields."

I'm sure many are wondering where I'm going with this - surely we don't want everyone reaching for the shields do we?  Of course not - but we've gone so far the other way that they're seen as a huge cause of breastfeeding problems and something to be avoided at all costs.  They are no longer seen as a useful tool in the bag of someone suitably qualified, but a big no no.

A few months ago I suggested a mum considered the temporary use of shields, with the result being the local NHS Infant Feeding Advisor (midwife) was so upset, you would have thought I had suggested hanging the baby upside down from the washing line whilst mum latched him doing limbo.

I met the mum four days post-partum after what she described as an "horrific" labour and delivery, 48 hours resulting in an emergency section.  There was a long delay between birth and her holding her baby, who had promptly refused to latch - again she filled up as she described the past few days in hospital.  The baby had "screamed" every time she held him, trying to latch, pulling away writhing and twisting, leaving mum in tears.  Biological nurturing (leaning back) which they had suggested in hospital, she had found difficult due to her very large pendulous breasts meaning baby ended up somewhere under her armpit and even with pillows etc mum had felt extremely uncomfortable and the baby had just "pecked and bobbed".

Midwives had offered to take the baby, and as he settled with them (away from his "food source"), mum felt it was her causing the baby to become distressed.  She had managed to get him latched for four feeds the previous day, all of which had followed a 30-50 minute battle, a number of other feeds had resulted in them "giving up" because baby simply wouldn't latch and became either too upset or sleepy to feed.  Mum had been expressing since day one and cup feeding in hospital had been messy, with mum confessing dad had tipped a little in because they were so concerned he wasn't taking any milk (please note this is not recommended and can pose a choking hazard).  Even after the feeds that they managed baby was unsettled and rooting for more.

Lead Shields

Mum didn't hold her baby unless she had no option but to attempt a feed, because otherwise the whole rooting, writing, crying scenario would unfold again.  Mum was utterly miserable - just wanting to feed her baby without him becoming so distressed and frustrated first; she confessed if things couldn't be sorted today she didn't know if she could continue breastfeeding; as it was she was beginning to wonder what she had let herself in for having a baby!  She looked shattered, emotionally drained and desperate.

Before long it became clear why this dyad were having problems - baby had a tongue tie which was severely restricting tongue function (probably not helped any by the failure to progress and resulting section), and mum had flattish nipples that inverted with pressure; the combination proving frustrating all round.  Without adequate tongue function baby has cues missing from the feeding sequence he uses to latch, add to that retracting nipples and he can't even get by using a less effective technique.

When a feed was attempted and baby struggled and expressed his frustration, mum quickly became tense and distressed - "you see" she declared, ""we just can't do it".  Despite every trick to improve protrusion, breast sandwiches, deep latch techniques and nipple flips in almost every imaginable position, baby barely latched, he nibbled on the nipple maybe twice but nothing more.  Mum gave a little expressed milk via finger feeding (which both parties loved and the cup hit the bin!) to take the edge off and keep him interested - but just as she had described the cycle of them both ending up upset continued.

At this point mum sobbed, and everything came out from her "failure to birth properly", to her "failure to even hold her baby without him becoming beside himself", to her "failure to feed him".

Mum gave baby some expressed milk so he would settle, I made us a cuppa and we had a long chat, which resulted in me asking if she wanted to consider using a shield until the tongue tie could be further assessed, and so they could both do a little healing from the birth - some breathing time.  After a quick chat about pros and cons, how it may not help or may cause pain, dad popped out to the chemist.

Silver Shield

Mum popped the shield on, hesitantly put her son to the breast and within an instant he was latched and taking full advantage of her now abundant supply!  Mum cried again, this time with tears of joy - "I'm feeding him, I'm actually properly feeding him!!" she declared triumphantly.   She preened and stroked him as he nursed, telling him how clever he was, compressing her breast until before long he popped off satisfied and content.

How do we begin to measure the psychological boost that feeding her baby without distress gave that mum?  The renewed hope that she could breastfeed, that she no longer had to dread picking her baby up and that he only ever cried with her?  Was the latch perfect with the shield?  Nope, but did it actually at that point matter?  Baby got enough to feel satisfied, mum was happy and this was a short term intervention.

With a now beaming mum I called the Infant Feeding Advisor to ask the best route of referral for NHS division.  I was advised to speak to the midwife who as if on cue, knocked on the door.

That's not a tongue tie the midwife declared (after nothing more than a cursory look in baby's mouth) I will refer you but they won't do anything with that.  And what are those shields?  You should be cup feeding, our Infant Feeding Advisor would not be happy with you using those....When she spotted the syringe used for finger feeding, I thought she might actually pop there and then in the kitchen!

At this point mum looked about to cry again and dad quickly intervened to say they had had a lot of trouble cup feeding and this had worked really well.  I will get someone round to show you how to cup feed properly was the midwives reply, he will never breastfeed if you keep using those shields, new guidelines are they're not recommended at all.  Finger feeding shouldn't be used either once the baby needs more than 1 or 2 mls...

After the midwife had gone it was dad who reminded mum of her brilliant feed and that she should follow her instincts, mum decided to stick with the shields and see what panned out.

I received a phone call from her several hours later, telling me the area Infant Feeding Advisor (IFA) had arrived with her less than an hour after the midwife had gone (called in by the midwife) the IFA confirmed it was a tongue tie and referred the baby for division, but also agreed shields were against NHS guidelines and she did not support their use, nor the finger feeding which should not be used as the baby needed to "stretch their tongue attempting to cup feed" and it was not an evidence based method of supplementation (clearly Salisbury NHS disagree and guidelines do actually state cup OR finger feeding is fine).  By this point mum wasn't up for engaging in further discussion and politely told the IFA she intended to continue as was until division.

Long story short the parents waited several weeks for division, during that time they did not receive any information as to when, where or even if the division would take place.  She tried on numerous occasions without the shields, but the result was always the same frustrated crying and so she continued using the shields and feeding her baby!  After 48 hours solid of trying to obtain a date/time for division from the NHS, the parents decided to go private and contacted the IFA on the morning of their appointment to advise her of their plans - within 5 minutes they were advised to drive to a particular hospital where the tongue would be divided....

After the procedure, mum was again advised to expect difficulty stopping shield use, and so did not attempt it for 3 days whilst the tongue healed.  On day three half way through a feed mum removed the shield and never used it again.


Evidence?

Clinical Use of Silicone Nipple Shields, J Hum Lact. 1996 Dec;12(4):279-85:

"Use of nipple shields is controversial. However, when weaning is imminent, they may enable breast-refusing infants to transfer back to the breast."

Women's experiences using a nipple shield, J Hum Lact. 2004 Aug;20(3):327-34.

"An informal, retrospective telephone survey of 202 breastfeeding women was conducted over an 8-month period of time, assessing patients' perceptions regarding use of a silicone nipple shield. Sixty-seven percent of the women continued to breastfeed after transitioning off the nipple shield."

Now bear in mind we have no idea how many of these 202 mums may have given up breastfeeding entirely without the shield...

Long-term nipple shield use-a positive perspective, J Hum Lact. 1996 Dec;12(4):301-4.

"This report describes ten cases in which silicone nipple shields were used for two weeks or longer. In nine of the cases, shields were used to help babies attach to the breast. These babies had struggled to attach to the areola because of suck problems or the mother's lack of protractility of breast tissue. In the tenth case, the shield was used because of extreme nipple soreness. All babies were off the shield by 3.5 months of age; nine were feeding directly from the breast. All weights were appropriate or above for the age of the infant at three weeks, two months and four months."

Discussion:
Much of the focus surrounding nipple shields is about function - does it impact on milk transfer, mum's hormone levels, milk supply.  What about the psychological impact, did it empower this mum?  Absolutely, and I have no doubt in my mind at all that it preserved breastfeeding where it would otherwise have ceased.  Even if eventually we had managed to get baby latched, what happens at the next feed or at 2am?

I think before anyone even thinks shields, the key is establishing WHY a baby is struggling to feed well - without this it is just a sticking plaster.  They can be hard to stop using if the root cause isn't also addressed,  I think they should only be discussed by a lactation consultant or very experienced, competent breastfeeding counsellor and not as the solve all they used to be.  They're not the answer for all mums, and they're definitely not the answer to all or even most problems - but used wisely, I for one think they're a godsend.

Nine Good Reasons NOT To Use Baby Rice

1.  It's bland and tasteless, yet sweet - which may influence later food choices:  Try it - whilst the texture may be a new experience for baby, there's certainly no flavour enjoyment.  People mix things with it like apple or pear - why?  Why not just give the fruit?

Dr Greene in his paper "Why White Rice Cereal for Babies Must Go" states:

"Some taste preferences are hardwired. And different babies experience taste differently, in part because of hereditable differences in taste bud density.  But careful studies of human twins and of young animals suggest early exposures and social interactions outweigh genetics when it comes to food preferences.(11)"

"Indeed, up to 85 percent of the variability in eating patterns is due to environmental, not genetic factors.(12,13,14,15,16) 

We know in animals that the first bite of solid food can be particularly influential.(14) For human babies the moment of the first bite is laden with positive associations. The child has often been staring at the parents’ food choices, eager to learn what eating is all about. The child is the center of attention at an emotionally charged moment, often with a camera capturing the event.  The processed white rice flour is often mixed with breast milk or formula, giving it an even stronger positive association. 

Conversion of the white rice flour to glucose begins while the cereal is still in the baby’s mouth, lighting up the hard-wired preference for sweets (and the cereal is nearly 100% glucose by the time it is absorbed in the intestines). Given this “perfect storm” of extrinsic and intrinsic factors, both initially and throughout the formative months, it is easy to see how a preference for processed refined grain products could become firmly established, and later in life, challenging to change."

2.  It's outdated: back when guidelines suggested 3-4 month weaning (ie before the gut was closed) introducing what is considered to be a low allergen food that is easy to digest (due to the processing) was considered safest, otherwise food proteins can potentially provoke an allergic reaction.  If weaning commences when baby is ready ie they are reaching for food and putting it in their mouth, or at around 6 months as guidelines now suggest; the gut is closed and thus this is not an issue.  Furthermore, in small babies mixing with foods was to try and coax the baby to accept a flavour they may typically reject - a baby ready for solids is ready to enjoy full flavours too.  Those breastfed have already experienced a range of tastes via breastmilk, so why would they need a tasteless food?

3.  It's highly refined: and not in the elegant and cultured in appearance sense - but over processed like white bread which is stripped of nutrients by the processing   It is often then fortified with synthetic vitamins - some just with Thiamin (B1) whilst others are "enriched with 13 vitamins and minerals, like iron and zinc".  However these are less bioavailable to baby than those naturally occurring in foods.

4.  It can cause deficiencies:  consider that when a baby starts solids, the food is shown to displace total milk intake over a 24 hour period.  In a breastfed baby this means they are swapping calorific nutrient rich foods for a poor substitute.  Studies have also shown infants who received iron fortified foods (as some baby rice is) before 7 months, had significantly lower haemoglobin levels at one year than those who had not.  Excess iron also potentially causes harm to the body.

5.  It's high in sugar: Dr. Alan Greene, a paediatrician at Stanford University who started the campaign "white out" says:

"I have been studying nutrition very carefully for more than a decade now and one of the things that I have become convinced of is that white rice cereal can predispose to childhood obesity," said Greene. "In fact I think it is the tap root of the child obesity epidemic." 

Besides its touted digestion benefits, Greene said white rice cereal is also high in calories and made of processed white flour.

"The problem is that it is basically like feeding kids a spoonful of sugar," said Greene.

"The difference between white rice and brown rice is huge," said Greene. "White rice is basically 94 percent starch."

6.  It could be linked to diabetes: A 2010 study published in Arch Intern Med found Those who ate white rice 5 or more times a week had a 17% increased risk of type 2 diabetes compared with those who ate it less than once a month. Those who chose brown rice or another whole grain instead of white rice had up to a 36% reduced risk.

Another study entitled "Carbohydrate Nutrition, Insulin Resistance, and the Prevalence of the Metabolic Syndrome in the Framingham Offspring Cohort", found:

"Whole-grain intake, largely attributed to the cereal fiber, is inversely associated with HOMA-IR and a lower prevalence of the metabolic syndrome. Dietary glycemic index is positively associated with HOMA-IR and prevalence of the metabolic syndrome."

7.  It can contain Arsenic (yes really): From the NHS

"Rice fields are regularly flooded and arsenic is naturally present in the soil. Subsequently the substance is present at a relatively high level in rice. High levels of arsenic are reportedly linked to an increased risk of certain cancers. Researchers in this study tested levels in 17 samples of three unnamed brands of baby rice in British supermarkets and found that 35% of them contained high levels. The Food Standards Agency is reported as saying that there is no danger to infants, but that food regulations should be updated. There are currently EU and US legislations governing inorganic arsenic content allowable in water, but not in foods."

Brown rice is likely to contain more than white, so is not really a viable alternative.  There are currently no EU-wide regulations for arsenic levels in food after the European Food Safety Authority ruled that previous safety limits were inadequate.

8.  It can contain other toxic metals:  A study featured in the journal of Food Chemistry, found feeding infants twice a day on the shop-bought baby foods such as rice porridge can increase their exposure to arsenic by up to fifty times when compared to breast feeding alone.

Exposure to other toxic metals such as cadmium, which is known to cause neurological and kidney damage, increased by up to 150 times in some of the foods tested by Swedish scientists, while lead increased by up to eight times.

Researchers said:

"Alarmingly, these complementary foods may also introduce high amounts of toxic elements such as arsenic, cadmium, lead and uranium, mainly from their raw materials."

Read more 

9.  It's pointless:  Ultimately the question has to be - why use it?  Rather than why not.  There is no research or logic suggesting a baby needs baby rice, and given potential risks what are the benefits?