BREASTFEEDING WITH FLAT OR INVERTED NIPPLES|
Babies breastfeed, not "nipple-feed", and if a baby is able to take in
a good mouthful of breast, most types of inverted or flat nipples will
not cause a problem during breastfeeding. However, some types of
nipples are harder for the baby to latch onto, especially at first, but
in most cases, patience, persistence, proper latch-on technique, and
perhaps a few other helpful measures will pay off.
FLAT OR INVERTED?
You can determine whether or not you have flat or inverted nipples by
doing a simple "pinch" test: Gently compress your areola about an inch
behind your nipple. If your nipple does not protrude or become erect,
then it is considered to be flat. If your nipple inverts, retracts into
the skin tissue, or becomes concave, it is considered to be inverted.
True inverted or flat nipples also will not become erect when
stimulated or cold. If your nipples protrude when stimulated as
described above, they are not truly inverted and do not need any
special treatment in order to breastfeed.
DIFFERENT TYPES OF INVERTED NIPPLES
One type of inverted nipple, known as a dimpled or folded nipple - in
which only part of the nipple is inverted - will not protrude when
stimulated but can be pulled out manually with the fingers.
Unfortunately, in most cases, this type of nipple will not stay pulled
out and will perhaps benefit from some special treatment measures.
There also are varying degrees of nipple inversion from the slightly
inverted nipple to the moderately to severely inverted, which when
compressed, retracts deeply to a level even with or below the
It also is not unusual for the same woman to have one flat or inverted
nipple while the other nipple protrudes well, or a woman who has two
flat/inverted nipples to have one that protrudes more so than the other.
TREATMENTS TO DRAW OUT A FLAT OR INVERTED NIPPLE
While it's very important to remember that most babies who latch-on
well can draw out even an inverted or flat nipple, and that a baby does
not "nipple-feed", there are several possible options for treating a
flat/inverted nipple that may make latch-on easier for the baby. Some
of these treatment measures can be employed before birth and others
will want to be delayed until the baby arrives. Still others can be
used as treatment options both during pregnancy and after breastfeeding
- Breast shells.
Breast shells, also referred to as milk cups, breast cups, or breast
shields, take advantage of the natural elasticity of the skin during
pregnancy by applying gentle, but constant pressure to the areola in an
effort to break the adhesions under the skin that prevent the nipple
from protruding. The shells are worn inside the bra, which may need to
be one size larger than normal to accomodate the shell. Ideally, shells
should be worn starting in the third trimester of pregnancy for a few
hours each day. As the mother becomes comfortable wearing the shells,
she can gradually increase the amount of time she wears them during the
day. After the baby is born, these same shells can be worn about 30
minutes prior to each feeding to help draw out the nipple even more.
They should NOT be worn at night and any milk collected in them should
NOT be saved.
- Hoffman Technique. Doing this technique several times a
day may help loosen the adhesions at the base of the nipple. To employ
this technique: place a thumb on each side of the base of the nipple -
directly at the base of the nipple, not at the edge of the areola. Push
in firmly against your breast tissue while at the same time pulling
your thumbs away from each other. By doing this you will be stretching
out the nipple and loosening the tightness at the base which will make
the nipple move up and outward. This exercise should be repeated 5
times a day, moving the thumbs in a clockwise fashion around the
nipple. It can be used during pregnancy and after baby begins
- Breastpump. After birth, the use of an effective breastpump
can be helpful at drawing out a flat or inverted nipple immediately
before breastfeeding to make latch-on easier for the baby. It also can
be used at other times following delivery to help further break the
adhesions under the skin by pulling the nipple out uniformly from the
- Evert-it Nipple Enhancer. Available through La Leche League, this device helps to draw out the nipple by providing uniform suction similar to that obtained with a breastpump.
- Nipple stimulation. After birth, if the nipple can be
grasped, a mother can roll her nipple between her thumb and index
finger for a minute or two and then quickly touch the nipple with a
moist, cold cloth or ice wrapped in cloth (avoid prolonged use of ice
as it can inhibit the letdown reflex and numb the nipple too much).
- Pulling back on the breast tissue at latch-on. As you
support your breast for latch-on with thumb on top and four fingers
underneath and way back against the chest wall, pull slightly back on
the breast tissue toward the chest wall to help the nipple protrude.
- Nipple shield. ONLY TO BE USED AS A LAST RESORT,
the nipple shield is a flexible nipple made out of silicone that is
placed over the mother's nipple during feedings so that latch-on is
possible for the baby. To prevent the baby from becoming too addicted
to nursing with the shield, it should be removed as soon as the baby is
latched-on and nursing well. The length of time during the feeding that
the shield is used should also be steadily decreased. Possible problems
associated with the use of nipples shields include a drop in the
mother's milk supply and insufficient transfer of milk to the baby.
Because of these possible risks, it is strongly recommended that you
only use a nipple shield under the direct supervision of a lactation
expert such as as a lactation consultant or La Leche League
leader. It should be noted, however, that even with the possible risks
of using a nipple shield, as long as the mother is aware of what to
watch for, breastfeeding with a nipple shield is much more preferable
to not breastfeeding!
Getting help with latch-on and positioning
is critical for the mother with flat or inverted nipples. The baby must
learn to open his mouth wide in order to by-pass the nipple and close
his gums farther back on the breast.
Breastfeed early on and
often - at least every 2-3 hours - to avoid engorgement and give the
baby the chance to practice breastfeeding many times while the breast
is still soft.
If your baby becomes upset as you attempt to latch him on, stop, calm
him, and take a break if needed. Offer him a finger to suck on, walk
him, rock him, swaddle him, etc. until he calms down.
While you are learning to breastfeed, avoid any artificial nipples -
bottles, pacifiers, and nipple shields (if possible). If you must
supplement, do so with an alternative feeding device such as a nursing supplementer,
medicine/eye dropper, soft , flexible cup, or a spoon. Artificial
nipples may confuse the baby and make an already difficult latch-on
even more difficult.
Some mothers with flat or inverted nipples are prone to nipple
soreness. Discomfort may occur as the adhesions are being stretched
when the baby draws the nipple into his mouth. If the nipple retracts
or inverts during feedings, moisture may become trapped, contributing
to chapping. Patting the nipples dry after feedings and applying a 100%
lanolin preparation, such as Purelan 100,
can help avoid this. A special device called a Velcro Dimple Ring was
also created to hold the dimpled nipple out between feedings. For more
information on this product, contact Chele Marmet at the Lactation
Institute in Encino, CA at 818-995-1913. Other treatment measures for sore nipples may also be helpful.
WHEN NIPPLE SORENESS IS PROLONGED
Some mothers may experience nipple soreness that lasts for an extended
period of time. Instead of being stretched and then broken, the
adhesions under the skin remain tight, creating a point of stress that
can cause cracks and blisters. When a nipple is deeply inverted, rather
than compressing the mother's milk sinuses under her areola, the baby
compresses the buried nipple instead. The use of an automatic electric
breastpump such as the Lactina or Pump In Style
can help with this because, rather than compressing the mother's
areola, it uniformly draws out the center of the nipple and eventually
breaks the adhesions underneath it.
If one breast is easier for the baby to grasp and the baby nurses well
from this breast, the mother can continue to feed on this side while
she pumps the other breast with the deeply inverted nipple until the
adhesions loosen and the nipple is drawn out. The baby can get all that
he needs from one breast as long as he is allowed to nurse unlimitedly
If both nipples are deeply inverted, the mother can pump both breasts
simultaneously for 15-20 minutes every 2 hours while feeding her baby
with an alternative feeding device (see above).
How long a mother will need to pump in order to draw out her nipples
will depend upon the strength of the adhesions and the degree of
inversion. For some mothers, one pumping is enough. If the nipple
continues to invert however, the mother may need to continue pumping.
Once the mother's nipple can be drawn into the baby's mouth correctly
and the baby can breastfeed effectively, the mother should be able to
discontinue pumping and breastfeed without discomfort. On rare
occasions, a mother may continue to feel some discomfort even after the
nipple has been drawn out due to the radical correction to the nipple.
Rarely, after a nipple correction, the nipple may invert again as the
baby pauses during a feeding. In this case, the mother may need to stop
and pump again for a few minutes before putting her baby back to the
When attempting to nurse with flat or inverted nipples, it is
strongly recommended that you seek the support and expertise of a
breastfeeding expert such as a lactation consultant or La Leche League leader.
Written by Becky Flora, IBCLC
Last Revision: December 31, 1998
Source: La Leche League's, "The Breastfeeding Answer Book" (1997) by Nancy Mohrbacher, IBCLC and Julie Stock, BA, IBCLC