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Videos on many aspects of breastfeeding including positioning, attachment, expressing, etc.

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Breastfeeding after breast surgery

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Inverted or flat nipples

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The size and shape of nipples and breasts vary widely between women. These differences have little to do with the ability to breastfeed-though if one or both nipples are flat or inverted some mothers find that establishing breastfeeding takes a little extra time and patience in the early days.

Inverted nipples? Many nipples will protrude when stimulated. If you think yours may be inverted, try placing your thumb and finger on opposite sides of the areola (the darker area of skin surrounding the nipple) and squeezing gently inwards. A nipple that stands out when stimulated is not inverted. Sometimes nipples may be partly inverted, looking dimpled or folded. Severely inverted nipples usually retract deeply when compressed or stimulated.

It's common for nipples to change shape during pregnancy, gradually protruding more. After your baby is born, your nipples may appear flatter but babies often lick the nipple to stimulate it before latching on. Your nipples may also appear flatter if your breasts are very full or engorged.

Causes

Inverted nipples may be caused by:

Tiny bands of connective tissue connecting the nipple to the inner breast tissue

Short milk ducts

Less dense connective tissue beneath the nipple than in women with protruding nipples

Treatment

There is no agreement about whether it is helpful to treat inverted nipples. The Royal College of Midwives believes that a diagnosis of flat or inverted nipples serves only to damage a mother's confidence in her ability to breastfeed. While individual mothers sometimes find one of the treatments suggested overleaf for inverted nipples helpful, no controlled studies have shown any particular treatment to be effective. Whether or not you try the techniques overleaf, do learn how to hand express milk. You may also like to try expressing your colostrum in the last four weeks of pregnancy. Any colostrum you collect can be frozen and given to your baby after the birth if needed. Antenatal Expression of Colostrum provides more information.

Good attachment is the key

Whatever breastfeeding specialists think about the different treatment options, they all agree that getting a deep latch is crucial. Babies breastfeed-not nipple feed-so with effective positioning and attachment your baby can learn to nurse well even if you have flat or inverted nipples. When a baby takes in a large enough mouthful of breast he will be able to feed effectively, so the shape of your nipples may not be an issue at all. Reading La Leche League books and leaflets before your baby is born will help you learn about breastfeeding and how to avoid common difficulties. Try to attend an LLL Meeting too-pregnant women are always welcome.

Comfortable breastfeeding

Comfortable positioning and attachment are important for all mothers. You will have time to practice with your baby while your breasts are soft before your milk comes in. Whether or not you have flattish nipples, start as soon as possible by holding your baby in skin-to-skin contact right after the birth. The earlier you start, the easier it is. laid-back or 'natural' positions can be a great help in encouraging your baby to latch on well, as well as being comfortable for you.

If your baby isn't nursing well

Hand express or pump to stimulate your breasts to make milk. Aim to express as often as your baby would be feeding, about 8-12 times in 24 hours. Your expressed milk can be offered by spoon, cup or syringe while you both learn how to breastfeed. Avoid using bottles or dummies as they may cause nipple confusion, making matters worse.

Soften your breast

Breastfeed as often as you can. When your baby bobs his head and licks the nipple, he naturally makes it easier to latch on. If your breast is full and hard, you can use reverse pressure softening to move fluids away from the nipple area so your baby can latch on well. Apply gentle steady pressure with your fingertips on the areola around your nipple for about a minute. You can also press with the sides of your thumbs or fingers. Denting the breast at the edge of the areola with a finger and placing your baby's chin in the dent may also help. Gently hand express a little milk if needed.

Stimulate your nipples

If your baby's head bobbing and licking isn't enough to stimulate your nipples, try:

Rolling your nipple gently between your thumb and finger

Touching your nipple with a cold moist cloth

Try using a breast pump

With some deeply inverted nipples, when a baby tries to breastfeed, he compresses the buried nipple beneath his mother's areola. If simpler techniques of stimulating your nipples before a feed fail, an automatic electric pump may be needed to provide suction to draw the nipple out before a feed. Once may be enough, or you may need to pump before each feed for a few days or perhaps weeks.

Nipple shields

A nipple shield is a thin, silicone teat that can be placed over a mother's nipple and may help a baby who is having difficulty learning to breastfeed. Nipple shields can be used temporarily to help establish breastfeeding. They come in different sizes-a comfortable fit is very important.

It is very important to seek skilled help with positioning, attachment and any other problems if you are already using nipple shields or planning to use them. Whilst a nipple shield can be a useful tool it should be regarded as only a temporary solution-continue to offer your baby some time in skin-to-skin contact every day without a nipple shield so he has the opportunity to latch on if he is able.

Practicalities

First breastfeeds
Breastfeed early and often after your baby's birth to minimize engorgement. Many babies have no difficulty feeding from mothers with inverted nipples, so start off by putting him to the breast and see how he gets on. If he latches on well and you are comfortable he will get plenty of practice and will probably continue to feed well after your milk comes in and your breasts feel fuller.

If your baby won't breastfeed
Don't panic! A baby usually starts to suck spontaneously if he can snuggle up close to his mother's bare chest for periods of time. Try letting your baby lie on your body as you recline so that both his chest and tummy are against you. This kind of contact, sometimes known as Biological Nurturing™, usually stimulates a baby's instinct to attach and suckle well at the breast. In such positions babies can also latch on when sleepy or in light sleep. Watch for signs your baby is stirring and gently encourage feeding.

Practical tips
Getting a deep latch
Help your baby get a deep mouthful of breast using the following tips:

Bring baby to breast, not breast to baby. Relax comfortably with your breast in its natural position

Keep your baby's whole body close against your body

Help your baby approach the breast 'nose to nipple' with his chin on or close to the breast. Keep his body tucked in close as he attaches and feeds but make sure he can tip his head back easily to open his mouth wide

As your breast touches his tongue, it will push his lower jaw open wider. If you are sitting up, as he opens his mouth to take the breast pull his body in firmly against you and give a little push between his shoulder blades

This will help him open his mouth very wide to get his top lip over the nipple area to latch on, resulting in a bigger and better mouthful of breast

His lower jaw will be tucked into your breast well away from the base of your nipple and his nose will be free. Active sucking is triggered when your breast tissue reaches the back of his mouth

Once your baby is attached you can make small adjustments to maximise your own comfort. If you're sitting up to feed, try shifting your weight back onto your tail bone and reclining your body back a little to open up a space for your baby. This allows more of his weight to be supported by your body and less by your arms. Gravity can help him stay attached deeply.

You can als o experiment with different holds to help you find what works best for you. An LLL Leader can help you find the most effective approach. You can find more detailed information by reading our page Positioning & Attachment.

Some women like (or need) to hold their breast when nursing. They flatten their breast as they would a big sandwich they were offering to the baby, matching it to the oval of his mouth. This can help their baby grasp more breast tissue. It doesn't matter if fingers are closer to the upper jaw but try to keep the "lower jaw fingers" out of your baby's way.

Exaggerated latch
To help get an even deeper latch you could try placing your thumb or finger near the base of the nipple where the middle of your baby's upper lip will be, lined up with his nose. As you press, your nipple will tilt away from your baby, presenting him with your breast rather than your nipple. As he opens wide, snuggle him in close and use your thumb or finger to tuck the breast into his mouth. Your nipple will be taken in last and unroll in his mouth. You can then slip your finger out.

Seek Support

Many mothers experience challenges with breastfeeding and find attending LLL meetings supportive. They will give you the chance to see that, whatever challenges you may face, breastfeeding can become a rewarding experience. If there is no LLL group in your area, you can still contact an LLL Leader for support.

Treating inverted nipples

Various techniques can be used to draw out nipples-though research on their effectiveness is inconclusive. If using devices, it is important to follow the manufacturer's instructions.

The Hoffman Technique
This technique is used during pregnancy. With a thumb on each side of the base of the nipple, press in firmly against the breast tissue and at the same time pull your thumbs away from each other. If this feels comfortable, repeat five times each morning, moving your thumbs around the base of the nipple. If you experience pain this technique may not be appropriate for you.

The Nipplette™
The Nipplette™ is a device that uses suction to help a nipple protrude. It consists of a transparent nipple mould from which air is sucked using a small syringe. The device is placed over the nipple area for increasing time each day during the first six months of pregnancy. One device is needed for each inverted nipple. The manufacturers do not recommend use in the last three months of pregnancy. While breastfeeding, limit use to a few minutes to draw out the nipple immediately before breastfeeding.

Breast shells
Sometimes, two-piece breast shells are suggested to apply steady pressure to encourage flat or inverted nipples to protrude. Whilst individual mothers report that using breast shells is a help, research has found them to be ineffective. They can be worn during pregnancy or before breastfeeds. If you decide to try breast shells, wear them for no longer than 30 minutes before feeds to reduce the risk of nipple soreness due to lack of air circulating around the nipple and blocked ducts due to pressure. You may need a bra with a larger cup size than normal. Breast shells need to be washed daily and any milk collected should be discarded because of the risk of bacterial growth.

Other concerns
Sore nipples
You may experience some discomfort in the first couple of weeks of breastfeeding as your baby gradually draws your nipple out. This is temporary and different from nipple damage and soreness caused by a baby who isn't latching on well. Pat your nipples dry after feeds, replace breast pads frequently and change wet bras. Your aim is for comfortable, relaxed feeds for you and your baby. So seek skilled help if you do experience nipple damage.

One breast preference
Differences in your nipples can lead to your baby preferring one breast to the other. You can encourage your baby to breastfeed on the least preferred side by putting your baby to the breast when he is in light sleep, offering it first at feeds and by breastfeeding frequently. Some mothers express from the least preferred breast to maintain milk production. However, some babies are quite determined in their preferences and end up breastfeeding from only one side. If this happens, milk production from the preferred breast will increase to meet your baby's needs as the other breast produces less. Any lop-sidedness will be temporary.

When further help is needed

If you have flat or inverted nipples and then experience additional challenges such as a premature birth or a thrush infection, seek help from your midwife or LLL Leader.

Written by Karen Butler, Sue Upstone & mothers of LLLGB. Photos courtesy Lois Rowlands and Kate Riley.

Further Reading
Antenatal Expression of Colostrum Beginning Breastfeeding Comfortable Breastfeeding
Engorged breasts - avoiding and treating
Hand Expression of Breastmilk
Is My Baby Getting Enough Milk?
My Baby Won't Breastfeed Nipple Confusion Nipple Shields Sleepy Baby - why and what to do

From LLLI
Inverted nipples don't stop breastfeeding

Books
The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010.

References
Breastfeeding Answers Made Simple. Mohrbacher, N. Amarillo, TX: Hale Publishing, 2010.
Biological Nurturing; Laid-back breastfeeding for mothers DVD. Colson, S. et al. 2012.
An Introduction to Biological Nurturing; New angles on breastfeeding, Colson S. Amarillo, TX: Hale Publishing, 2010.
Supporting Sucking Skills Watson Genna,C. Burlington, MA: Jones & Bartlett, 2012.
How to do Biological Nurturing
This information is available to buy in printed form from our Shop.

Copyright LLLGB 2016

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The size and shape of nipples and breasts vary widely between women. These differences have little to do with the ability to breastfeed-though if one or both nipples are flat or inverted some mothers find that establishing breastfeeding takes a little extra time and patience in the early days. Inverted nipples?

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Laid-back breastfeeding

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Getting a deep latch: step-by-step pictures

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Video: getting a deep latch with mother sitting upright

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Good attachment really is the key to successful breastfeeding. Use this guide to get it right from the start, but if you find you are still struggling - ask for help!

Before you start - Make sure your baby's head, neck and body are in a straight line - a baby cannot suckle or swallow easily if the neck is twisted. Good attachment is difficult for a baby to maintain if his body is twisted at the waist. The baby should be held so that the back of his shoulders is supported, and his head is free to tilt back. If you are unsure about the attachment of your baby, seek help from your midwife, health visitor or maternity support worker. You can also visit your local support group. Someone observing how your baby feeds can really help to get it right.

This is a link from our Breastfeeding by mums, for mums DVD which shows good attachment.

Below are still photos of attachment too.
1. The baby should face the breast with nose to nipple - this allows the baby to tilt his head back so that the nipple is aimed at the roof of the mouth. 2. When baby gapes wide open, press on the back of his shoulders to bring him in quickly - and you will need to move quickly! 3. Chin and tongue leading, head tilted back, the nipple goes into the back of the mouth as baby is brought towards the breast. 4. Attachment shouldn't be painful, baby should keep suckling and should let go on his own at the end of the feed. The nipple should look the same shape as before the feed.

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Good attachment really is the key to successful breastfeeding. Use this guide to get it right from the start, but if you find you are still struggling - ask for help! Before you start - Make sure your baby's head, neck and body are in a straight line - a baby cannot suckle or swallow ...

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Video of breastfeeding mother in a laidback position