My doctor said I have inverted or flat nipples. Can I still breastfeed my baby?
Remember that babies BREASTfeed, not NIPPLEfeed. As long as baby can take a good portion of the breast into his mouth (baby's mouth and gums should bypass the nipple entirely and latch on to the areola), most types of flat or inverted nipples will not cause problems with breastfeeding. Some types of nipples are more difficult for baby to latch on to at first, but in most cases, careful attention to latch and positioning, along with a little patience, will ensure that baby and mother get off to a good start with breastfeeding.
How can I tell if my nipples are flat or inverted?
Just looking at the breast often won't tell you the answer. Instead, you can determine whether or not your nipples are flat or inverted by doing a "pinch" test. Gently compress your areola (the dark area around the nipple) about an inch behind your nipple. If the nipple does not become erect, then it is considered to be flat. If the nipple retracts, or becomes concave, it is considered to be inverted. It should be noted, too, that true inverted or flat nipples will not become erect when stimulated or exposed to cold. If the nipple becomes erect during the "pinch" test, it is not truly inverted and does not need any special treatment.
Different Types of Inverted and Flat Nipples
Only part of the nipple protrudes. The nipple can be pulled out but does not stay that way.
Only one breast has an inverted or flat nipple
There are different possible degrees of nipple inversion. The lesser degree of inversion is classified as slight. A baby with a normal suck will likely have no problems with bringing a slightly inverted nipple out, although a premature baby or one with a weak suck might have difficulty at first. Moderate to severe inversion means that the nipple retracts deeply when the areola is compressed, to a level even with or underneath the areola. A nipple with moderate to severe inversion might make latching-on and breastfeeding difficult, but treatment and deep latch techniques can help. Treatment to stretch out the nipple might be helpful, especially during pregnancy. If the inverted nipple is only discovered after birth, treatment will still be useful, but good positioning and latch-on are most important.
Treatments For Flat Or Inverted Nipples, and Techniques To Make Latching Easier
Although opinions and experiences vary, many women have found treatments for inverted or flat nipples helpful and many breastfeeding experts continue to recommend them. Breastfeeding experts disagree on whether pregnant women should be screened for flat or inverted nipples and whether treatments to draw out the nipple should be routinely recommended. For example, the British Royal College of Midwives says that hormonal changes during pregnancy and childbirth cause many mothers' nipples to protrude naturally. Although treating flat and inverted nipples during pregnancy is debated, if your newborn is having difficulty latching on to a flat or inverted nipple you may find some or all of the following helpful.
Worn inside your bra, breast shells may help draw out flat or inverted nipples. Breast shells are in two pieces and are made out of plastic. The inner piece has a hole that fits over the nipple. The pressure on the tissue around the nipple causes the nipple itself to protrude through the hole. Breast shells may be worn during pregnancy to take advantage of the natural increase of the elasticity of a woman's skin by applying gentle but steady pressure to stretch the underlying adhesions (connective tissue) and draw out the nipple. After birth, they can be worn for about a half an hour before feedings to draw out the nipple. They should not be worn at night, and the milk collected while wearing them should not be saved.
This procedure may help loosen the adhesions at the base of the nipple, and can be used during pregnancy as well as after the birth. 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. This will stretch out the nipple and loosen the tightness at the base of the nipple, which will make it move up and outward. Repeat this exercise twice a day, working up to five times a day, moving the thumbs around the base of the nipple.
After birth, an effective breastpump (See How Do I Choose a Breast Pump? for more information on pumps) can be used to draw out the nipple immediately before breastfeeding. This makes latching easier for baby. A pump can also be used at other times after birth to further break the adhesions under the nipple by applying uniform pressure from the center of the nipple.
Evert-it™ Nipple Enhancer
Designed by lactation consultants, the Evert-It™ consists of a syringe with a soft, flexible tip made of silicone, either end of which may be used to provide suction to help nipples protrude for easier latch-on. Use it before feedings as you would a breast pump.
Nipple stimulation before feedings
If the nipple can be grasped, roll the nipple between the thumb and index finger for a minute or two. Afterwards, quickly touch it with a moist, cold cloth or with ice that has been wrapped in a cloth. This method can help the nipple become erect. Avoid prolonged use of ice, as numbing the nipple and areola could inhibit the let-down reflex.
Pulling back on the breast tissue during latch-on
As your hand supports the breast for latch-on with thumb on top and four fingers underneath and behind the areola, pull slightly back on the breast tissue toward the chest wall to help the nipple protrude.
A nipple shield is a thin, flexible silicone nipple that is worn over the mother's own nipple. It has holes in the tip to allow milk to flow to the baby. If other strategies are not working, a nipple shield could help baby latch on and nurse well by providing the stimulation to the roof of the baby's mouth that signals his suck reflex. Nipple shields should only be used with the guidance of a lactation professional as they can lead to problems if not used properly.
Getting breastfeeding off to a good start
Get help with positioning and latch-on
Getting skilled help is critical for a mother with inverted or flat nipples. It is important for the baby to learn how to open his mouth wide and bypass the nipple, allowing his gums to close further back on the breast. Experimenting with different positions is a good way to find what is most comfortable for the mother and helps baby latch most effectively. Some mothers find that the football (clutch) hold or cross-cradle hold gives them the most control, which also makes it easier for baby to latch on well.
Breastfeed early and often
Plan to breastfeed as soon after birth as possible, and at least every 2-3 hours thereafter. This will help you avoid engorgement, and will allow baby to practice at breastfeeding before the milk becomes more plentiful or "comes in". Lots of practice at breastfeeding while mother's breasts are still soft often helps baby to continue to nurse well, even as the breasts become more firm (which can make a flat nipple more difficult to grasp).
Achieve a deep latch
When latching your baby on, hold him in close against your body, with his ear, shoulder, and hip in a straight line. Align baby's nose with your nipple. Pull back on your breast tissue to make it easier for him to latch on. Tickle baby's lips with nipple and wait for baby to open wide (like a yawn). Then latch him on, assuring that baby has bypassed the nipple and is far back on the areola. The resulting latch should be off-center -- deeper on the bottom (more breast taken in on the chin side than the nose side). Baby's nose should be touching (but not buried in) the breast, and his lips should be flared out like "fish lips".
Use calming techniques if baby becomes upset
Baby should not associate breastfeeding with unpleasantness. If baby becomes upset, immediately take a break and calm him. Offer a finger for him to suck on, walk, swaddle, rock, or sing to him. Wait until he is calm before trying again.
If nipple soreness occurs
Discomfort as adhesions stretch
Some mothers experience nipple soreness for about the first two weeks of nursing as their flat or inverted nipple(s) are gradually drawn out by baby's suckling. If the soreness is severe, or continues past the initial two weeks, call your local LLL Leader or IBCLC for assistance. You may also find relief by using these treatments for sore nipples.
Moisture becoming trapped as nipple inverts after feeding
If the nipple retracts after feedings, that skin may remain moist, leading to chapping of the skin. After feeding, pat your nipples dry and apply a 100% lanolin preparation intended for nursing mothers. You may also wish to use a Velcro Dimple Ring, which is a device designed to hold the nipple out between feedings so that the skin can dry. Call your local LLL Leader or IBCLC for information on the use of this product, and where to obtain it.
When nipple soreness is prolonged
Rarely, a mother may experience persistent sore nipples for a longer period of time because instead of stretching, the adhesions remain tight. This can create a stress point which may lead to cracks or blisters.
When a mother has deeply-embedded nipple, rather than compressing the mother's milk sinuses (milk storage area) under her areola, the baby compresses the buried nipple instead. Because baby is unable to get the nipple correctly positioned in his mouth, he will not receive much milk for his efforts, and nursing will be painful for the mother. In this case an automatic double electric breast pump can help because, rather than compressing the mother's areola, it uses uniform suction from the center of the nipple to draw the nipple out. Over time, this usually works to break the adhesions that are holding the nipple in.
If one breast is easier for baby to grasp and he nurses well from that breast, the mother can continue to feed on that side. The mother can pump the breast with the deeply inverted nipple until the adhesions loosen and the nipple is drawn out. The baby will get all the milk he needs from one breast as long as he is allowed unlimited and unrestricted time at the breast.
If both nipples are deeply inverted, the mother can pump both breasts simultaneously for 15-20 minutes every 2 hours. The mother can feed her baby with an alternative feeding device until her baby is able to latch on effectively and comfortably.
How long a mother will need to pump in order to draw out her nipples depends upon the strength of the adhesions and the degree of inversion. For some mothers, one pumping is enough to completely draw out the nipple. If the nipple continues to deeply invert, the mother may need to continue pumping. When the nipple stays out after pumping, the mother can resume breastfeeding immediately.
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. This could be due to the radical correction to the nipple.
After a nipple correction, rarely, 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 baby back to the breast. As a temporary transition to exclusive breastfeeding, breast compressions or the use of a nursing supplementer might help to encourage continuous sucking and swallowing so that the nipple won't be as likely to invert during feedings.
Our FAQs present information from La Leche League International on topics of interest to parents of breastfed children. Not all of the information may be pertinent to your family's lifestyle. This information is general in nature and not intended to be advice, medical or otherwise. If you have a serious breastfeeding problem or concern, you are strongly encouraged to talk directly to a La Leche League Leader. Please consult health care professionals on any medical issue, as La Leche League Leaders are not medical practitioners.