Posted by: Dany G. | February 7, 2012

Inverted Nipples Cause Breastfeeding Difficulties: True or False?


This post is for Bessie Gillis, CHR in Waskaganish. She is a grandmother who spent many nights helping her daughter breastfeed her grandchild. I know how you feel Bessie! I have been in the same boat twice now, helping my own daughter breastfeed my two grandchildren. It is difficult to help our own daughters as we feel the pain they go through and we would like to just magically take their troubles away!

Most of us are convinced that inverted or flat nipples cause breastfeeding difficulties, but are we right? First, what is an inverted nipple? Inverted nipples are shy, they hide inside instead of standing proud when receiving attention, lol. Simply speaking, the nipples are not everted; they do not stick out. They disappear when touched, stimulated and sucked on by a baby. In some cases, they are inverted all the time and hide even more when touched. So how can a baby latch on when there is no nipple? What is the baby going to use to breastfeed?

The answer is quite simple: it should not matter!

Surprised? Babies need to latch on to the areola and not on the nipple. Well, let me be more specific: some babies do latch onto the nipple but that is not the right way. The mother will know right away that something is wrong. When a baby latches only on the nipple, he closes his gums on it and bites into it. It hurts. A baby needs to open his mouth really wide and take as much as he can from the areola (the areola is the dark part around the nipple) in his mouth. When he does this, his gums close on the areola which is made for that. The real problem is that mothers are so convinced their nipples are wrong for the job that they immediately blame the difficulties on their own body. Just to set the record straight, many women have inverted nipples. Actually, up to 9 % of women have inverted nipples and probably more than 30 % have flat nipples before they breastfeed their first baby. Most of them are able to breastfeed successfully, but only a very small amount of women with flat or inverted nipples persist until they do succeed.

In conclusion: most women with inverted or flat nipples can breastfeed, but not many successfully breastfeed. What is the problem? I will explain. First, watch this video clip carefully and notice how the baby has to open really wide to have his gums on the areola:

Did you see the difference when the baby grabs only the nipple? The nerves that send the message to the brain to produce milk do not pass there. The baby simply latches on to a little piece of skin, a very sensitive one at that. Sadly, this happens often. It is not “normal” in the sense that a baby should not be latching on this way, but it happens often even when mothers have “everted” nipples (that stick out).

WHY?

Most of the time, it is caused by the type of labor and birth the baby went through. When everything goes smoothly, the newly born baby is alert and his rooting (the inborn reflex to open wide and latch) and sucking instincts are strong. A baby that went through a very long and difficult labor and birth and/or that received medications through his mother during labor, might be more sleepy or subdued, and his sucking and rooting reflexes might be weak. For a baby to open really wide, he needs to open wide like when he yawns. We all see our babies yawn and we see they can open their jaws wide. When a baby needs to breastfeed, he must have a strong rooting reflex. This is what will help him to open his mouth wide. A small change in the baby’s alertness can make a world of difference in breastfeeding. The baby has to be an active participant when he breastfeeds. It is not like when he is bottle-fed: the bottle is inserted in his mouth. He does not have to actively participate for that bottle to stay in his mouth.

Also, once the baby has latched on correctly, the nipple needs to stretch to touch the area of the palate that triggers the sucking pattern of the baby. When the nipple is flat or inverted and it has never been stretched this way, it can lack a little bit of flexibility. This gets better with time.

If you have a sleepy baby and a mother with flat or inverted nipples, more efforts will be needed to make breastfeeding work. The baby might have difficulty latching on and he will become frustrated. Now you might think you are home-free if you have a sleepy baby and a mother with everted nipples, but no! The baby might have an easier time latching on, but if he latches on the nipple only, it can still cause problems.

WHAT we should NOT DO

Nipple Shields can be dangerous

Breastshells are not effective

Ten years ago, we thought that wearing breastshells or putting on a nipple shield would evert the nipples, and many people still think they will help. However, breastshells have been shown to be ineffective, and they also hinder the mother’s confidence in her ability to breastfeed.  Nipple shields can be quite dangerous in the first few days as they might not allow the baby to obtain enough milk, causing him to become dehydrated quickly.

What we SHOULD DO

Our best action is prevention!

1- All pregnant women do not need to have their breasts examined, but they need to be asked about the shape of their nipples.

2-Once we know the nipples are flat or inverted, the mothers need to receive information about the importance of a medication-free birth, about alternative methods to have a pain-free delivery, and about how to help their babies latch on.

3- Practice makes perfect: Have the mother role-play with a doll so she understands how to position her baby.

4- Make sure she understands that she will need help the first few days, and make the necessary contacts to make sure she receives that help at the hospital. Sometimes, the prenatal clinic nurse can send in a form explaining the need for more help at the beginning of breastfeeding.

5- We need to make sure the mother receives an immediate follow-up once she returns to the community. The initial engorgement brought by the milk coming in can be dramatic as the nipples will invert even more and the baby might have more difficulty latching onto hard breast tissue.

6- If the mother does not succeed in latching her baby on even with help, there is the possibility of using a breastpump for a few minutes to evert the nipple right before putting the baby at the breast. There is also an accessory called the inverted syringe that can be used to pull out the nipple a few times right before the baby latches on. You can see a picture and a description of it in this scientific article:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2255362/?tool=pubmed

But mostly, mothers with flat or inverted nipples can breastfeed, just like any mother can! They should not be made to feel like their breasts are inadequate or be told that they need an accessory to breastfeed their baby. The first intervention they need is to be encouraged and supported by all: health care workers, friends and family!

 

N.B. For women who are self conscious about their inverted nipples, before reverting to invasive surgeries that may make breastfeeding almost impossible, there is a product made by Avent that can be used to evert the nipples, but it is NOT TO BE USED during pregnancy or breastfeeding. Here is the link:

http://www.boobybits.com/avent-niplette.shtml

 

 

References

(1994). “Preparing for breast feeding: treatment of inverted and non-protractile nipples in pregnancy. The MAIN Trial Collaborative Group.” Midwifery 10(4): 200-14.

Alexander, J. M., A. M. Grant, et al. (1992). “Randomised controlled trial of breast shells and Hoffman’s exercises for inverted and non-protractile nipples.” Bmj 304(6833): 1030-2.

Arsenault, G. (1997). “Using a disposable syringe to treat inverted nipples.” Can Fam Physician 43: 1517-8.

Chakrabarti, K. and S. Basu “Management of flat or inverted nipples with simple rubber bands.” Breastfeed Med 6: 215-9.

el Sharkawy, A. G. (1995). “A method for correction of congenitally inverted nipple with preservation of the ducts.” Plast Reconstr Surg 95(6): 1111-4.

Jiang, H. Q., X. Wei, et al. (2008). “Nipple aspirator: a self-designed instrument for inverted nipple.” Plast Reconstr Surg 121(3): 141e-143e.

Kesaree, N., C. R. Banapurmath, et al. (1993). “Treatment of inverted nipples using a disposable syringe.” J Hum Lact 9(1): 27-9.

McGeorge, D. D. (1994). “The “Niplette”: an instrument for the non-surgical correction of inverted nipples.” Br J Plast Surg 47(1): 46-9.

Neifert, M., S. DeMarzo, et al. (1990). “The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain.” Birth 17(1): 31-8.

Neifert, M., J. Gray, et al. (1988). “Factors influencing breast-feeding among adolescents.” J Adolesc Health Care 9(6): 470-3.

Ozcan, M. and R. Kahveci (1995). “The ‘Niplette’ for the non-surgical correction of inverted nipples.” Br J Plast Surg 48(2): 115.

Park, H. S., C. H. Yoon, et al. (1999). “The prevalence of congenital inverted nipple.” Aesthetic Plast Surg 23(2): 144-6.

Patel, Y. (2008). “Inverted nipples: correction using a simple disposable syringe.” East Afr Med J 85(1): 51-2.

Scholten, E. (1999). “A novel correction of inverted nipples during pregnancy.” Am J Obstet Gynecol 181(1): 228-9.

Scholten, E. (2000). “The classification of inverted nipples.” Plast Reconstr Surg 106(3): 737-8.

Terrill, P. J. and M. J. Stapleton (1991). “The inverted nipple: to cut the ducts or not?” Br J Plast Surg 44(5): 372-7.

Vogel, A., B. L. Hutchison, et al. (1999). “Factors associated with the duration of breastfeeding.” Acta Paediatr 88(12): 1320-6.

Wilson-Clay, B. (1996). “Clinical use of silicone nipple shields.” J Hum Lact 12(4): 279-85.


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