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Common Breast Issues- Flat and/or Inverted Nipples

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Flat and inverted nipples are not uncommon, especially in first time mothers. Due to normal breast changes during pregnancy, many flat appearing nipples will resolve by the end of pregnancy. Most types of flat or inverted nipples will not pose any problems to breastfeeding. However, depending on the degree of inversion or flatness, some challenges-- such as difficulty for the infant to latch at the breast, soreness from improper latch, and inadequate milk transfer-- could arise. The good news is that successful breastfeeding can be accomplished.
Do You Have Flat or Inverted Nipples?
Flat and inverted nipples may often go unnoticed until after your baby has arrived and breastfeeding has begun. Here's how you can tell if you have flat or inverted nipples:
  1. Place your thumb at the top margin of your areola (the dark area around your nipple) and your fingers on the bottom margin of your areola.
  2. Gently compress your breast.
If your nipple flattens when you compress your breast, you have a flat nipple. If your nipple retracts into the breast tissue, you have inverted nipples.If your nipple protrudes, your nipples are everted.
 
Retracted nipples are the most common type of inverted nipples. Retracted nipples, retract inwards when stimulated. A truly inverted nipple is one in which the nipple is retracted at rest and after stimulation.
 
This article from Barbara Wilson-Clay provides great drawings of everted, flat, and inverted nipples.
 
What Can You Do If Your Nipples are Flat or Inverted?
First and foremost, seek the assistance of a lactation consultant. She will be able to assess the degree of nipple protrusion, assess your baby's ability to latch to the breast, and guide you in interventions to stimulate protrusion of your nipple(s). According to current research, prenatal preparation of nipples is not necessary.
 
When breastfeeding, be sure to pay close attention to your baby's position and ensure his mouth is open wide before allowing him to latch at the breast. Ensuring your baby has a wide open mouth before latching will facilitate a deep latch which allows your baby to stretch the nipple-areola complex to 2-3 times it's normal length to form a "teat". A proper latch will allow your baby to draw the nipple out and effectively remove milk from the breast.
 
Compressing the breast into a "breast sandwich" can also help to draw out and elongate the nipple. To do this, place your fingers close to the outer edge of your areola. Your thumb and index finger should be on opposite sides (for example, the thumb on the top margin of your areola and the index finger on the bottom) and you should be able to draw a straight line between the two. Now compress the breast and gently push back towards the chest wall. Remember that the "breast sandwich" should match of the position of your baby's mouth (think of how you position and hold a sandwich to fit in your mouth and position the breast to line up to your baby's mouth accordingly).
 
You can try any of the following interventions to stimulate nipple protrusion once your baby is born:
  • Manually manipulate your nipple(s) by gently pulling, stroking, or rolling your nipple using clean fingers. Do not forcibly pull, squeeze, or twist nipples since this can cause damage to the breast tissue.
  • Apply ice packs, frozen vegetables, or anything cold directly onto nipples. Be careful not to leave the ice pack on for too long since the cold can interfere with your letdown reflex.
  • Try using a breast pump to pull out the nipple prior to nursing. Caution: If you are suffering from engorgement or your breasts are swollen, pumping could aggravate the tissue causing more swelling. If suffering from edema or engorgement, try using reverse-pressure softening (learn more here).
  • Insert breast shells in your bra 30 minutes prior to feeding. There are two sizes of breast shells, one is for use with sore nipples (the larger hole size) and the other is to help correct inverted nipples (the smaller hole size). Be sure you are using the shells with the smaller hole which will put pressure on the connective tissue and help draw out the nipple. Do not keep the shells in for long periods of time since this can damage the tissue and contribute to plugged milk ducts. Be sure to wash the breast shells after each use and discard any milk that collects in the shells.
  • A lactation consultant may advise the following devices to assist with nipple protrusion:
    • Inverted Syringe: A needless disposable syringe can be converted into a device to help draw out flat or inverted nipples. Take a clean 10 mL syringe (the size of the syringe can vary depending on your nipple size) and cut the end of it (at the "0 mL" line). Remove the plunger of the syringe and reinsert the plunger into the cut side of the syringe. Push the plunger all the way in and place the uncut side of the syringe over your nipple and against your breast. Gently pull back on the plunger to draw out the nipple. Do not pull plunger out too far that it causes pain. If you experience any pain, push the plunger back to decrease the suction. Be sure to break the suction of the syringe before removing it. All parts should be disassembled after use and washed with hot, soapy water. Discard any milk that collects in the device.
    • Evert-It Nipple Enhancer: The Evert-It™ is a medical device that resembles a modified syringe with a small breast flange. Be sure to wash the device prior to first use. To use the device, center the flange over your nipple and pull back on the plunger with one hand while holding the barrel of the syringe with the other. Pull out the nipple to a level that is comfortable for you and maintain this pressure for about 30-60 seconds. If you experience any pain, push the plunger back to decrease the suction. The vacuum that is created causes the inverted or flattened nipple to become more erect. Once the nipple is sufficiently everted, break the suction and remove the device. Quickly put your baby to breast. The nipple may revert back to its original position soon after the device is removed, therefore, it is best to use the Evert-It™ just prior to attempting to latch your baby onto the breast. The Evert-It™ can be used up to three times before each feeding and several times a day in between feedings to improve nipple protractility. All parts should be disassembled after use and washed with hot, soapy water or boiled after use. Discard any milk that collects in the device.
    • Latch Assist: A device used to evert nipple(s) right before feedings. Be sure to wash the device prior to first use. To use the latch assist, squeeze the bulb and position the shield over the center of the nipple. Gently press the shield slightly into the breast (being careful to avoid pain). Slowly release the bulb to the desired pressure and suction. If needed, squeeze the bulb to release the suction. Repeat the process if needed. Once the nipple is sufficiently everted, bring your baby to breast. The nipple may revert back to its original position soon after the device is removed, therefore, it is best to use it just prior to attempting to latch your baby onto the breast. All parts should be disassembled after use and washed with hot, soapy water or boiled after use. Discard any milk that collects in the device.
    • Nipple Shield: A thin and flexible artificial nipple which is placed over the nipple-areola complex to help an infant to latch and/or protect sore nipples. The nipple shield will help to stimulate the baby's palate and initiate the sucking reflex to draw the nipple out. Some mothers find that they are be able to start the feeding with the nipple shield and remove the shield once the nipple becomes erect. Others, however, may need to use the nipple shield for a few days or weeks until the nipple as become pliable and easily erects without the use of the shield. Since nipple shields can interfere with the amount of milk your baby gets, it is important to monitor your baby for signs of adequate milk intake. After each feeding, clean your nipple shield with warm, soapy water and allow to air dry. Nipple shields can also be sanitized daily by boiling.
Sources:
Texas Department of State Health Services Nutritional Services and Texas Association of Local WIC Directors. Lactation Counseling and Problem Solving. Attended January 2011.
Walker, M (2011). Breastfeeding Management for the Clinician (2 edition). Boston: Jones and Bartlett Publishers.

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