Nipple shields: the first systematic review after (at least) 300 years of use

A modern nipple shield is a very thin, flexible piece of silicone that is placed over a nipple during breastfeeding. They may help babies to "latch on" to the breast to feed and reduce pain for women and people breastfeeding.

Breastfeeding is associated with better health outcomes, especially for babies born prematurely. However, breastfeeding rates in the UK are among the lowest globally, with many people stopping earlier than they’d like.

Despite centuries of use, there’s no consensus as to whether nipple shields are safe or helpful. Current clinical guidelines rely on low quality evidence (2, 3): there is a significant gap in our understanding. While high-quality systematic reviews exist for other breastfeeding support, none include nipple shields, and reviews that do include nipple shields are lower quality, and don’t answer the questions people have (4-6).

But what do the real people who might want to use them say?

We spoke to patient and public contributors about nipple shields, and here’s what they told us:

What they told us

“I had to find the solution for the pain… seeing him come towards me, hungry, would terrify me… It was the lowest I have felt in my life.”

"toe-curlingly painful – I understand what that means now because it really did".

“I didn't know it would be this difficult [to latch].”

“A friend, she said "have you tried nipple shields? – they really worked for me" she said almost, "keep it quiet – you'll get told off for using them”.

Their experiences with nipple shields were mixed:

“I tried it, but I thought it's not going to work, it doesn't fit my breast, it'll come off, it was a tool that wouldn't fit… I exclusively expressed to seven months.”

“Nipple shields were what saved us… a few weeks down the line we didn't need them”

Others avoided using them due to conflicting advice:

“I saw a support worker from the infant feeding team… she said "they're probably gonna kill me for this if I say it - have you tried nipple shields?”

“For a long time, I kept them as an insurance policy... one of the midwives (she wasn't that helpful) said “don't use them. Just sort out your nipples - put gel on or whatever”. I got the message I definitely don't use them.”

Healthcare professionals and breastfeeding supporters expressed great caution about potential risks:

“…it very quickly can be pushed on to a family and that that can be also be tricky because then babies do get a little bit addicted to shields.”

“…it's not something we would educate women on… it's drilled into our education…training is actually that using them long term can reduce your milk supply”

Our research approach

Our team is undertaking a mixed methods systematic review of the evidence.

Since there is no agreed standard for what matters to people when breastfeeding (such as a Core Outcome Set) we’re working with people with personal experience, health and care professionals, and others who support feeding to identify what matters most to them.

Women we spoke to prioritised outcomes like:

• being able to breastfeed at all
• whether the baby was “dropping centiles” (gaining weight more slowly than expected)
• how old the baby would be when they breastfed for the last time
• levels of pain

While research so far has often focused on outcomes like:

• exclusive breastfeeding, and how old the baby would be when they began other milk
• sucking frequency
• nutritive sucking
• milk transfer measured in millilitres
• percentage of available milk removed from the breast
• levels of pain

We will work together to co-produce information about the results of our study for people who are breastfeeding, health care professionals and others who suppport feeding.

This will enable informed conversations and shared decision-making between breast-feeding people, health and care professionals, and others who support feeding. This will empower breastfeeding and women and people to make the right decisions for them and their families.

You can find out more about this project here.

Want to get involved? Whether you're someone who has breastfed a healthcare professional, or someone else who supports feeding, we'd love your input. Email us to learn more – participants receive £25 for each hour of their time.

*Breastfeeding includes chest-feeding. Chest-feeding is a term preferred by some people whose gender is not female, who have had gender-affirming surgery, or who have had a partial mastectomy.

References

1. Drake TGH. Antiques of Medical Interest: Nipple Shields. Journal of the History of Medicine and Allied Sciences. 1946;1(2):316-7.
2. UNICEF. Baby-friendly Hospital Initiative training course for maternity staff: trainer's guide. In: UNICEF, editor. Baby-friendly Hospital Initiative training course for maternity staff: trainer's guide. https://www.who.int/publications/i/item/97892400089152020.
3. Vieira N, Smith A. Clinical Guideline: Using a Nipple Shield. https://eoeneonatalpccsicnetwork.nhs.uk/wp-content/uploads/2023/07/EoE-Nipple-Shield-Guideline.pdf; 2023.
4. Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews. 2014(12).
5. Flint A, New K, Davies MW. Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database of Systematic Reviews. 2016(8).
6. Chow S, Chow R, Popovic M, Lam H, Merrick J, Ventegodt S, et al. The Use of Nipple Shields: A Review. Front Public Health. 2015;3:236.