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Monday, February 03, 2014

Breastfeeding: Inverted Nipples - how do you know you have it and what do you do?

Now you know if you have a inverted or flat nipple…what do you do?
Well, first and foremost it to:-

1.)    Knowing what a proper latch looks like. I have searched online and always refer to the Breastfeeding Guro of Dr Jack Newman. He has a video posted on Youtube that can help describe what the good latch is all about.
Proper Latch:
Latch with a Lactation Aid:
More videos are here:

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).

For initial learning period of breastfeeding, try to 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 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 until he settles down. You want him to associate feedings with positive feedback, not negative.

2.)    What is an inverted/flat nipple?

A) The nipple on this breast protrudes normally.

B) This nipple is flat

C) A simple "pinch test" will show you whether your nipple is inverted: Using your thumb and index finger, gently squeeze the areola about 1 inch behind the nipple. This technique will make a normal nipple protrude.

 D) The pinch test will make an inverted nipple pull inward.

3.)    What if you DO HAVE an INVERTED NIPPLE? It’s not the end of the world. 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.

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 lanolin or olive oil.
Here are some of consolidate tested techniques in getting them out and easy for your baby to latch on:-

a.       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.

b.      Nipple stimulation.
After birth (unless the nipples retracts completely), if the nipple can be grasped, a mother can roll her nipple between her thumb and index finger for a 30 seconds to a minute or two and then quickly touch the nipple with a moist, cold cloth or ice wrapped in 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 can also to help the nipple evert immediately before nursing.

NOTE: Avoid prolonged use of ice as it can inhibit the letdown reflex and numb the nipple too much

c.       Pulling back on the breast tissue/areola before you latch the baby 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.

d.      Nipple Shield.
Nipple shields should only be used when a lactation professional recommends them and supervises their use, they can be helpful in certain situations.
This is a thin, flexible silicone nipple with holes in the end that fits over your nipple during feedings. Nipple shields, in the past, were made out of thick rubber that 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. Modern nipple shields are made from a clear, thin layer of silicone, which means that more stimulation reaches the areola, and the reduction of milk volume is minimized.

The below is from Dr Jack Newman’s account regarding Nipple Shields on his Facebook account.

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. She 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.

***UPDATE!!! (Source International Breastfeeding Center)

MYTH: Women with flat or inverted nipples cannot breastfeed

ANSWER: Not true! Babies do not breastfeed on nipples, they breastfeed on the breast. Though it may be easier for a baby to latch on to a breast with a prominent nipple, it is not necessary for nipples to stick out. A proper start will usually prevent problems and mothers with any shaped nipples can breastfeed perfectly adequately. In the past, a nipple shield was frequently suggested to get the baby to take the breast.

Though it may seem a solution, its use can result in poor feeding and severe weight loss, and makes it even more difficult to get the baby to take the breast. (See Finger and Cup Feeding). If the baby does not take the breast at first, with proper help, he will often take the breast later. Breasts also change in the first few weeks, and as long as the mother maintains a good milk supply, the baby will usually latch on by 8 weeks of age no matter what, but get help and the baby may latch on before. See When a Baby Does not yet Latch.

e.       High Quality Pump.
If the soreness lasts for more than a week or two, you may need to use a high quality pump (See article Pumping and Storing Breastmilk) 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. This is a situation in which renting a pump may really be worth it. In some extremely rare cases, the baby never successfully goes on the breast and you may need to continue pumping and feeding your expressed breastmilk by bottle. (See article Introducing Bottles and Pacifiers to the Breastfed Baby) for information on using bottles as well as alternative feeding methods.)

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.

4.)     Other Resources:
a.       Breastfeeding Canada Inc

b.      Dr Jack Newman on FB with a relevant posting:-

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, whether you invest in gadgets or not. Remember that the baby doesn’t ‘nipple feed’, instead the baby BREASTFEEDS. Once he is able to draw the nipple into his mouth, the shape of it doesn’t matter much at all.

Babies grow unbelievably fast, and his tiny mouth will ‘grow into a large/ flat/ or inverted nipple before you know it. Once the nipple inverts consistently, it seldom inverts again. Also, inverted nipples are much less common with second babies. Their older siblings seem to have paved the way, and pulled out the nipples for their baby brother or sister and making everyone in the family much happier!

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