By Barbara Wilson-Clay, BSEd, IBCLC
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)
|A erect nipple.
||An inverted nipple.
||A flat nipple.
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 anIBCLC, midwife, or informed health care provider.
Kathleen B. Bruce, BSN, IBCLC
Catherine Watson Genna, BS, IBCLC
Mary Bibb BA, IBCLC
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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.