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.

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 surrounding areola.

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.

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 has begun.

• 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 breastfeeding.

• 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 center.

• 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.

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 and unrestrictedly.

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 breast.

Last Revision: December 31, 1998