I often find mothers in the office who attribute breastfeeding problems to the shape of the nipples or wear nipple shields because they were told they had flat nipples and without them breastfeeding would not be feasible.
Most of the nipples protrude slightly over the areola (some more than others) and may favor the latch on of the baby. However, there is no definition of a normal nipple in terms of length and flat or inverted nipples are not at all a contraindication to breastfeeding .
What is a flat or inverted nipple?
Some nipples are barely protruding and others are inverted (inward). However, with stimulation (cold, suction …) most protrude out (protractile).
The true inverted nipples , on the other hand, lack the muscular filaments that make the nipple protrude (or they are very short); Fortunately, they are extremely rare, as they can cause breastfeeding problems.
Having a flat nipple is not a contraindication to breastfeeding
Absolutely. Most women with flat or inverted nipples are able to breastfeed without problems and this should be crystal clear. Only those (rare) cases of truly inverted nipples can have serious difficulties breastfeeding.
Do I have to treat my nipples in any way before giving birth?
No, not only is it not necessary but it can be painful. There are several studies looking at different prenatal treatments for inverted nipples, most of them of low or very low quality, and there do not appear to be significant differences in terms of prenatal treatment and not doing it .
There are two studies (one from 1994, another from 1992) evaluating treatment with nipple-forming shields and / or Hoffman exercises during pregnancy in women with inverted nipples and comparing it to doing nothing. Hoffman exercises consist of a series of nipple movements (turning, traction …) that are performed once or several times a day; Nipple-forming shields are gadgets that expectant mothers place around the nipple.
They did not see significant differences in terms of anatomical changes of the nipple or greater success of breastfeeding (evaluated at six weeks) due to previous treatment. In addition, these treatments have their drawbacks: some mothers did not do the Hoffman exercises because they were uncomfortable and / or time-consuming; Regarding the nipple-forming shields, some mothers felt pain, embarrassed to wear them or experienced changes in the texture of the breasts.
Other treatments during pregnancy, such as syringe use, rubber bands, and marital suction, have also been evaluated; most of these studies are of very low quality.
In the Clinical Practice Guide for Breastfeeding, only a weak recommendation is issued for prior use with a syringe, according to a technique that can be consulted in its annex 19. I do not think it is necessary.
Lastly, there are several studies looking at the use of prenatal nursing shells for short nipples; It seems that they could increase the length of the nipple but it is not known what implication it has on the success of breastfeeding (which should be the main objective of this).
The nipple changes throughout pregnancy and lactation
It has been observed that during pregnancy the nipples lengthen and the areola widens. Specifically, in a study conducted in Thai women, an increase in nipple length from 9.3mm +/- 1.5mm to 11.2 +/- 1.8mm was observed throughout pregnancy. In addition, as breastfeeding progresses, the nipples tend to protrude more .
Keys to successful breastfeeding if you have a flat or inverted nipple
Now let’s focus on what’s important. What to do if we have a flat or inverted nipple?
1. Know that you can
We will repeat it over and over again: having a flat or inverted nipple (which does protrude when stimulated) does not make breastfeeding impossible. Every mother has the best breast for her baby.
2. Have help
Both the NICE guidelines and the Clinical Practice Guidelines recommend that women with inverted nipples receive additional support and care to ensure breastfeeding success. So in these cases it would be very useful if an IBCLC or another professional with experience in breastfeeding could help you.
3. Tips for before breastfeeding
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It is recommended to start breastfeeding as soon as possible. Skin-to-skin contact after childbirth has multiple benefits, including promoting breastfeeding. Babies are very active for the first 2 hours after delivery and are capable of crawling on the mother, finding the breast, and latching on without help (spontaneous latching). The first thing you have a baby in your mouth seems to create an imprint; If you latch on well to that flat / inverted nipple the first time, you won’t have a hard time doing it later. in fact, if there is one inverted and another not, it is recommended to start with that one.
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The cold tends to make most of the nipples protrude, so you can apply a cold compress before feeding, and “shape” the nipple with your fingers.
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In some cases, pre-expression (manual or with a breast pump) can protrude the nipple and make the task easier.
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Save the pacifier for later. In general, we recommend not offering a pacifier until breastfeeding is well established, and this case will not be an exception. If for medical reasons you need to supplement, try to avoid bottles (finger-feeding, with a syringe, with a cup …)
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Breastfeeding should be on demand, no rigid schedules. In the first hours, newborns take between 8 and 12 feedings a day and this is essential to establish breastfeeding.
Nipple shields are not essential
Many moms with flat or inverted nipples directly apply the nipple shields (or recommend them), because they think that without them they will not be able to breastfeed. However, most babies manage to latch onto their mother’s breast without them .
If this is not possible, we can place an ultra-thin silicone nipple shield and try to remove it as breastfeeding progresses.
