How to use a nipple shield

How to choose the right sized nipple shield

If you are needing to use a nipple shield, find an ultra-thin silicone product. You only need one, which you can use on both sides. Some shields have a cut-out piece for the baby’s chin, as well as the nose, but this is not an important consideration.

In some women, it can be quite difficult to know where the base of the nipple ends and the areola begins, which is relevant only when we're trying to fit a nipple shield or pump flange. (It doesn't matter to your baby, who just needs to draw up as much nipple, areola and breast skin with the underlying breast tissue as possible!) It’s important to experiment between nipple shield sizes in this situation, to see which size works most comfortable for you and your baby.

Even if your nipple base is clearly distinguished from the areola, I often recommend that women have two sizes of shields on hand, to experiment between them. The nipple shield is fitted according to the size of the nipple, allowing room for the nipple to expand in the baby’s mouth.

We might make estimates about how much the nipple will expand (some recommend four millimetres in diameter extra to the diameter at the base of your own nipple), but in fact the degree of expansion will vary between women. This is why I often recommend women experiment between sizes - unless you think that it is very obvious in your case that only one size is relevant.

I rarely recommended a a 16 mm shield. Although women regularly come to see me using that size, it’s often too small. Often women are using a 20 mm shield, but need a 24mm one. Or they are using a 24 mm shield, but actually need 28 mm, which (given our world's difficulty in grasping the great variability in our normal female anatomies!) are more difficult to source.

A case when the nipple shield was too small

I once saw a woman whose baby wasn’t gaining weight adequately. She used nipple shields, and I worried even before she fed the baby that they were too small for her. She'd used the same shields to successfully breastfeed her previous baby. She was sure the problem was to do with her supply, not the shields. After she’d had the baby at the breast, I saw how her nipple had expanded to fill and adhere against the silicone walls of the cup. Her ducts would not have been able to expand properly, limiting how much milk could flow out. Of course, if baby is unable to efficiently remove the milk, this impacts on the amount of milk her breast makes, decreasing her supply.

“I’m not here to talk about the shields,” this woman said with annoyance each time I attempted to address this problem. “Every lactation consultant I’ve seen says the shields fit well.” But I felt that to be useful, I needed to talk with her about using a bigger size, and also I needed to address the underlying problems which had resulted in nipple shield use in the first place.

I acknowledged how incredibly disorienting it was when I gave advice that was different to her other health professionals. With her permission, I was finally able to give her my perspective, simply inviting her to experiment and work out what she found worked best.

Avoid nipple shields which are inappropriately shaped for painfree efficient milk transfer

1. I strongly recommend avoiding nipple shields which have complicated shapes to them (instead of a simple single hat or cup for your nipple). These might be promoted as 'orthodontic' or 'triangular'. They transfer milk by exerting a vacuum traction on the nipple without allowing breast tissue to be drawn up deeply into baby’s mouth, and therefore distribute an uneven mechanical load onto your nipple. (Other shields allow an well-defused distribution of mechanical load, even though a silicone layer separates the breast skin from the baby).

   • It's not possible to correct underlying fit and hold problems with these kinds of nipple shields. If they don't actually worsen nipple pain, they may result in a dwindling milk supply over time, due to compromised milk transfer.

2. I also recommend avoiding the nipple shields which have cutouts for both baby's nose and chin, and an oval shape cup.

   • These shields are promoted as better for close skin contact. This consideration is not relevant, because mammalian reflexes are switched on by whole-of-body contact and pressure on the face, not a small extra area of direct skin contact between mother and baby.

   • These shields are also promoted as fitting the nipple better with the oval shaped cup. But the oval shape can actually cause poorer milk transfer, by compressing ducts. The cup should not be fitting up close to the nipple, because a close fit risks occlusion of the ducts which run through the nipple once the nipple expands, as we want it too, during sucking. Whilst nipple shapes are highly variable, most women's nipples are more or less circular at the base. The promotion of an oval shaped cup and extra chin cut-out are marketing techniques to make the shield look innovative and different - but do not correlate with the most common shape of women's nipples, or what we know about mammalian feeding reflexes.

How to put a nipple shield on

Like most other aspects of breastfeeding, nipple shield use is about workability, not perfection.

When you are at home, wet the shield under the tap if you can, then place it over the nipple, with the nipple centred in it. You could give the base of the cup or hat a little stretch as you place it on, which is often recommended – but if that doesn’t seem practical, which it usually isn't, don’t worry. There are four holes in the roof of the cup so it's not that you can create suction by doing this. Certainly don’t try to evert the shield, the way you might sometimes be told!

Often women feel frustrated by nipple shield use because they've been taught they need to go through fiddley and time-consuming processes prior to breastfeeding with it. They might be taught that they need to turn it inside out and bring it on stretched. They might be taught they need to express milk into it to attract the baby. They might be taught to take it off and try again if the areola isn’t partly drawn in.

That’s all too complicated, with no gain. For instance, babies constantly knock nipple shields off. This is normal, and to be expected, especially in those early days when things are still coming together. If your baby is sensitive at the breast, with signs of a conditioned dialling up, everything might seem to get worse if you are feeling you have to stop and fuss with the shield in order to put it on correctly. We can make everything as simple as possible. The main thing is more or less trying to keep your nipple central inside the shield cup.

• Sit in the usual deck-chair position that is part of the gestalt method.

• You’ll need to hold the shield on with your fingers as you bring the baby on in a cross-cradle hold, baby's mouth any old way over the silicone teat (don't wait for wide gapes!).

• Remember not to displace the breast from where it wants to fall as you lightly hold the nipple shield on, or there will be worsened breast tissue drag when you let go.

• Then once baby is on, move directly into the gestalt method – still semi-reclined, baby with a deep face-breast bury – which means that the baby is not going to slip off the shield or the breast.

• Micromovements are still essential, as you experiment to find the place that is zero on the painscale (even with a shield in place) and where the place where the baby can deeply relax and feel stable.

• Don’t worry if the silicone flips up to sit against the baby’s cheeks. This doesn’t affect or bother the baby and is usually hard to prevent.

• Carry the shield in your bra when you’re out and either upend your water bottle to moisten the shield a little before you put it on, or just put it on dry because most babies cope with that perfectly well.

Cleaning your nipple shield

Your shield needs to be washed after use in warm soapy water, much like a breast pump, and stored in a clean dry place. It doesn’t need to be sterilized.

Selected references

1. Chow S, Chow R, Popovic M, et al. The use of nipple shields: a review. Frontiers in Public Health 2015;3:doi:10.3389/fpubh.2015.00236.

2. Geddes DT, Gridneva Z, Perrella SL, et al. 25 years of research in human lactation: from discovery to translation. Nutrients 2021;13:1307.

3. Coentro VS, Perrella SL, Lai CT, et al. Nipple shield use does not impact sucking dynamics in breastfeeding infants of mothers with nipple pain. European Journal of Pediatrics 2021;180:1537-43.

4. Perrella SL, Lai CT, Geddes DT. Case report of nipple shield trauma associated with breastfeeding an infant with high intra-oral vacuum. BMC Pregnancy and Childbirth. 2015;15:155.