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FLAT
OR INVERTED NIPPLES
During breastfeeding, the baby draws in nipple, a good portion of the
areola, and underlying breast tissue. This drawing in and shaping of the
breast can only be done if this tissue is capable of stretching. About 10
percent of first time mothers have nipples that are described as flat or
inverted. (Alexander,
1992)
These
terms describe the lack of elasticity of the muscle tissue that makes up
the nipple. It is impossible to judge how the nipple will function just by
looking at it. Mothers or care providers can compress the area just behind
the nipple. If the nipple protrudes, it is everted. If it flattens or
retreats, telescoping in like a navel, then some babies will have
difficulty drawing it up to breastfeed. If a baby is premature, small,
weak, or ill, a flat or inverted nipple can be especially challenging. (Neifert,
1996)
The nipple is an important stimulator of sucking behavior in the infant.
The reflex that triggers sucking involves stroking the palate. (Woolridge,
1986) Some parents may notice that the baby will suck strongly on a
finger, pacifier or bottle nipple, but appear apathetic, disinterested or
frustrated by the breast. This may be because the nipple is not elastic or
everted enough to reach back to stroke the palate. When this happens the
baby doesn’t know what to do next. The baby may bob back and forth and
seem unable to “locate” the nipple, may pull away and cry, or may fall
asleep each time the breast is offered. Skilled help from an IBCLC
and close follow-up from the physician will make it easier to overcome
this challenge. Making sure that latch
technique is correct is the first and most important intervention to
try.
Flat and inverting nipples may become even more difficult for the baby to
manage during the engorgement
phase, when swollen breasts further reduce the elasticity of the breast
tissue. Even normally everting nipples temporarily may flatten if
engorgement is severe.
 While
flat and inverted nipples are rather common – especially in first time
mothers – they typically respond and improve over time. Some women will
choose to wear breast
shells during pregnancy to try to draw out the nipples . After the
birth, when the breasts are hormonally primed to undergo dramatic changes,
breast pumping can help increase elasticity, and can make initial
breastfeeding easier.
Nipple shields
are devices that extend the length of the nipple to stimulate the palate,
triggering the reflex to suck. Nipple shields can be used to encourage the
baby to accept the breast. Direct sucking by the baby through the shield
will help pull out the nipples. If you are using a shield, we recommend
frequent pumping with a hospital
grade double pump during the learning period, to protect milk
supply. Pumping and the use of shields usually can be discontinued as
the nipple elasticity improves and the baby gains strength and improved
breastfeeding technique. This process can take varying lengths of time
depending on how severely the nipple tissue is restricted. It is advisable
to obtain frequent weight checks during this time to make sure the baby is
breastfeeding adequately. Nipple shields are not meant as a substitute for
skilled breastfeeding help.
If a mother suspects she may have flat or inverting nipples, or if a
previous breastfeeding relationship has been disrupted by this condition,
she should seek help from an
IBCLC, midwife, or informed health care provider.
Editors:
Kathleen B. Bruce, BSN, IBCLC
Catherine Watson Genna, BS, IBCLC
Mary Bibb BA, IBCLC
References:
J. Alexander, A Grant, M Campbell, Randomised controlled trial of breast
shells and Hoffman’s exercises for inverted and non-protractile nipples,
British Medical Journal 1992; 304:1030-1034.
M Neifert, Clinical Aspects of Lactation, Clinics In Perinatology 1999;
26(2):281-306.
M Woolridge, The ‘anatomy’ of infant sucking, Midwifery 1986; 2:164-7.
B. Wilson-Clay, Clinical Uses of Nipple Shields, Journal of Human
Lactation 1996, 12(4):279-285.
Mother’s nipples come in many shapes and sizes.
While most nipples protrude and are easy for baby to grasp,
there are some variations in size and shape that make it difficult for
them to nurse successfully. In
order for a baby to nurse effectively, he must be able to grasp the
nipple and stretch it forward and upward against the roof of his
mouth. Flat or inverted
nipples may make it difficult for your baby
to nurse.
In women who are pregnant for the first time, it is very common
for the nipple to not protrude fully.
About one third of mothers will experience some degree of
inversion, but as the skin changes and becomes more elastic during
pregnancy, only about ten percent will still have some inversion by
the time their baby is born. The
degree of inversion is likely to become less with each subsequent
pregnancy.
Because your baby forms a teat not just from the nipple but
also from the surrounding breast tissue, most inverted or flat nipples
will not cause problems during breastfeeding.
Some types of flat or inverted nipples will cause problems,
however, and there are some steps you can take to help correct the
problem both before and after the baby is born.
The first thing you need to do is determine whether your
nipples really are flat or inverted.
You can do this while you are pregnant by performing a simple
“pinch” test: Hold your breast at the edge of the areola between
your thumb and index finger. Press
in gently but firmly about an inch behind your nipple. If your nipple
protrudes, that’s great. If
it does not protrude or become erect, it is considered flat.
If it retracts or disappears, it is truly inverted. Nipples
that are severely flat or inverted will not respond to stimulation or
cold by becoming erect. If
you perform the pinch test and your nipples protrude, they aren’t
truly inverted and will probably not cause any problems when you nurse
your baby.
A truly inverted nipple is caused by adhesions at the base of
the nipple that bind the skin to the underlying tissue.
While the skin does become more elastic during the third
trimester of pregnancy in preparation for nursing, some of the cells
in the nipple and areola may stay attached.
Sometimes the stress of vigorous nursing will cause the
adhesion to lift up rather than stretching or breaking loose, and this
can cause cracks in the nipple tissue and pain for the mother.
Because the breasts function independently of each other, it is
not unusual for a mother to have one flat or inverted nipple, or to
have one nipple that protrudes more than the other.
For the same reason, it is not unusual for a mother to produce
more milk from one breast than the other.
 The
degree of inversion varies greatly, ranging from the nipple that
doesn’t protrude when stimulated, but can be pulled out manually, to
the severely inverted nipple that responds to compressions by
disappearing completely. (See
illustrations).
How much difficulty a flat or inverted nipples presents to a
nursing baby depends on the degree of inversion as well as the baby
himself. If you have a
strong, healthy, full-term, vigorous nurser, he may be able to draw
out the nipple and dislodge the attachments with relative ease.
If you discover that your nipples are flat or inverted before
your baby is born, you may want to use breast shells (see product
information). These are
plastic cup shaped shells that exert a constant, gentle pressure to
the areola during the period of pregnancy when the skin is most
elastic. They are worn inside your bra, which may need to be a size
larger in order to accommodate the shell.
The consistent, painless pressure exerted by the shells may
help break the adhesions under the skin that keep the nipple from
protruding. Begin wearing
them for a few hours a day, starting in the last trimester.
As you become used to them, increase the time until you are
wearing them all day. You
should not sleep in them. Remove
them before going to bed, wash them, rinse, and air dry them
overnight. Any colostrum that collects should be discarded.
They should be emptied frequently and washed every day.
Medela’s shells come with disposable pads that absorb the
leakage.
After your baby is born, you may want to wear the shells for 30
minutes before nursing in order to help draw the nipple out further.
Once again, any milk that collects during usage should be discarded
and not given to your baby.
The Hoffman Technique is a manual exercise that may help break
adhesions at the base of the nipple that keep it inverted.
Place the thumbs of both hands opposite each other at the base
of the nipple and gently but firmly pull the thumbs away from each
other. Do this up and
down and sideways. Repeat
this exercise twice a day at first, then work up to five times a day.
You can do this during pregnancy to prepare your nipples, as
well as after your baby is born in order to draw them out.
Gentle manual or oral stimulation of your nipples can be a part
of lovemaking, and may encourage your nipples to protrude.
Your partner will enjoy helping you prepare your nipples for
nursing.
After your baby is born, you can use a breastpump to draw out a
flat or inverted nipple immediately before putting your baby on the
breast. Pumping can also
be useful in order to break the adhesions under the skin by applying
uniform pressure from the center of the nipple.
If the nipple is truly inverted, (which is usually present in
only one nipple rather than both), you may need to use the pump to
provide stimulation and supplement with your milk.
This is especially the case if the inversions are present in
both nipples. Usually, after the first few nursings, the baby’s
vigorous sucking will exert negative pressure and help the tissue
protrude. With both flat
and inverted nipples, the baby will become better at grasping and
drawing the nipple into his mouth as he gets bigger and stronger.
If your nipples are flat or inverted, it is helpful if you have
help from a Lactation Consultant if possible during the first
feedings, as these are likely to present the most problems.
Useful techniques include:
Stimulating your nipple.
Unless it retracts completely, grasp the nipple and roll it
between your thumb and index finger for 30 seconds, then touch it with
a moist, cold cloth immediately before offering it to your baby. A
disposable nursing pad that is dampened and put in the freezer makes a
great ice pack to help the nipple evert immediately before nursing.
Pulling back on the areola
before you latch the baby on. Support
your breast with your thumb on top and your other fingers underneath,
and pull back on the breast toward the chest wall.
This will help the nipple protrude.
Using a nipple shield.
This is a thin, flexible silicone nipple with holes in the end
that fits over your nipple during feedings.
Nipple shields got a very bad reputation years ago when they
were made out of thick rubber, and caused a significant decrease in
the mother’s milk supply. They were handed out freely to new mothers
in order to ‘reduce nipple soreness’ or to get babies to nurse at
the breast. Under these
circumstances, they created more problems than they solved.
While nipple shields should only be used when a lactation
professional recommend and supervises their use, they can be helpful
in certain situations. They
should be used cautiously, since their misuse can cause a decrease in
the amount of milk the baby receives, as well as causing nipple
confusion.
One of the situations in which a nipple shield can be useful is
in helping an infant latch on to a severely inverted or flat nipple,
especially when other measures described above have failed. Mothers
who use the shield should be instructed on how to wean the baby off
the shield as soon as possible, and should weigh their baby frequently
to assure adequate milk intake. For
many mothers, use of a shield is the first step in getting her baby to
nurse at the breast, and may mean the difference between continuing to
nurse or weaning. The
mother’s ability to feel her baby sucking at her breast may
encourage her to continue nursing after other attempts have failed.
The mother needs to be encouraged to periodically put her baby
on the breast without the shield until she is able to discontinue its
use entirely. If the baby
will take one breast without the shield, she should nurse him on that
breast at each feeding, and use the shield only if the baby won’t
take the other breast without it.
While some babies move quickly from nursing with the shield to
nursing without it (sometimes after only one or two feedings) other
babies have to be weaned from it gradually.
My niece, who had one normal nipple, and one that was severely
inverted, used the shield on and off for several months.
She monitored her baby’s weight gain carefully, and he is now
happily nursing (without the shield) at the age of 18 months.
Considering the severity of her inversion, I am not sure that
her baby would have ever been able to nurse on that breast without the
use of the shield.
While use of a nipple shield should only be considered when
other measures have failed, it can be a useful tool under the guidance
of an experienced lactation professional.
Medela offers a several sizes and types of thin, flexible,
silicone nipple shields. Because the shields are made of silicone,
there is no risk of latex allergy. The thin silicone layer means that
more stimulation reaches the areola, and the reduction of milk volume
is minimized. Medela also makes a Contact Nipple Shield, which
includes an open cut-out section
which helps the baby maintain more skin contact with your breast.
During your initial feedings, your baby may be able to open his
mouth wide enough and suck vigorously enough to draw the nipple far
into his mouth and close his gums on the areola, so the flat or
inverted nipple may not present a major problem.
Having someone to help you with latch on and positioning can be
very helpful.
You will want to nurse as soon as possible after birth, and
every 2-3 hours after that. You
want to avoid engorgement, because breast swelling can cause the
nipples to flatten out, making them more difficult to grasp. (See
article on “Engorgement” for tips on how to avoid this problem).
During the initial learning period of breastfeeding, avoid the
use of any artificial nipples. Supplement
with alternative feeding methods, because the baby who is learning how
to nurse, especially on a nipple that isn’t the ideal shape for
nursing, is more likely to become nipple confused.
(See article on “Introducing Bottles and Pacifiers to the
Breastfed Baby”) to get more detailed information on alternate
feeding methods.
If feedings become stressful, stop and comfort your baby.
Try rocking, swaddling, walking, giving him your finger to
suck, or offer him some expressed milk (or water or formula) until he
settles down. You want him to associate feedings with positive
feedback, not negative. Supplementing
your baby or using a nipple shield temporarily is preferable to having
a baby who screams every time you open your nursing bra.
Many mothers with flat or inverted nipples experience some
degree of nipple soreness. You
may experience soreness as the nipple is drawn into the baby’s
mouth, and the adhesions are stretched or broken.
If the nipple draws back into the baby’s mouth during or
immediately after feedings, moisture may become trapped and contribute
to soreness. Try patting the nipples dry after feedings and apply a
thin coating of Purelan 100 (ask for free .25 oz. tube with any
order). See the article on “Sore Nipples” for more treatment
options.
If the soreness lasts for more than a week or two, you may need
to use a high quality pump (such as the Lactina, the Classic, or the
PumpIn Style to help maintain your milk supply.
When a nipple is severely inverted, the baby may compress the
nipple buried inside the tissue, rather than the milk sinuses
underneath the areola. The
sucking action of the pump pulls out the center of the nipple
uniformly, rather than compressing the areola.
This can help gradually break the underlying adhesions.
If both nipples are severely inverted (which is not usually the
case) you may need to double pump every 2-3 hours and feed your baby
with an alternative method until the adhesions are broken and the
nipples protrude. In some
rare cases, the baby never successfully goes on the breast and you may
need to continue pumping and feeding expressed breastmilk by bottle.
Usually, only one nipple is inverted and one breast is easier
for the baby to grasp. In
this case, you may want to feed on the ‘good side’ while you pump
the other breast until the adhesions are loosened.
You can feed the baby the milk you expressed on the inverted
side after nursing on the other breast.
Some mothers can draw their inverted nipples out with just one
pumping session. Others
may need to continue pumping for days, weeks, or even months,
depending on the degree of inversion and the baby’s sucking
patterns. If the nipple
inverts again during pauses in the baby’s feeding, you may need to
stop and pump again for a few minutes and then put him back on the
breast. In almost all
cases, the adhesions will loosen and the baby will be able to nurse
effectively as he grows bigger and stronger and becomes more efficient
at nursing.
Medela
Website
http://www.medela.com
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