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Remember that babies BREASTfeed, not NIPPLEfeed. As long as your baby can take a good portion of your breast into their 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 a 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 you and your baby get off to a good start with breastfeeding.

How can I tell if my nipples are flat or inverted?

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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

• Dimpled:
  Only part of the nipple protrudes. The nipple can be pulled out but does not stay that way.
• Unilateral:
  Only one breast has an inverted or flat nipple
• Inverted:
  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. Wearing breast shells 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.

• Breast Shells
  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 your 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.
• Breast Pump or Modified Syringe
  After birth, an effective breast pump or other device that pulls to elongate the nipple can be used to draw out your nipple immediately before breastfeeding. This makes latching easier for your baby. These devices 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.
• Products Designed to Lengthen and Evert Nipples
  There are many products on the market that may be helpful to try designed to lengthen and evert the nipples.
• Nipple Stimulation Before Feedings
  If you can grasp your nipple, roll it between your 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 your nipple become erect. Avoid prolonged use of ice, as numbing the nipple and areola could inhibit your 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.
• Reverse Pressure Softening
  Using your finger tips to encircle the base of the nipple and push toward the chest wall for 1-3 minutes prior to latching may help push other fluids aside, trigger milk flow and allow your nipple to protrude so baby can more easily grasp it.

• Nipple Shield
  A nipple shield is a thin, flexible silicone nipple that is worn over your 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 your baby latch on and nurse well by providing the stimulation to the roof of his 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 if you have 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 you 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 your breasts are still soft often helps baby to continue to nurse well, even as your 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 Your Baby Becomes Upset
  Baby should not associate breastfeeding with unpleasantness. If your 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 for assistance.

Moisture Becoming Trapped as Nipple Inverts After Feeding
If your nipple retracts after feedings, that skin may remain moist, leading to chapping of the skin. After feeding, pat your nipples dry and apply an emollient safe for breastfeeding. You may also want to wear breast shells or other device to keep your nipple out between feedings so the skin can dry

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 milk ducts, 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, you can continue to feed on that side. You can pump the breast with the deeply inverted nipple until the adhesions loosen and the nipple is drawn out. Your 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, you can pump both breasts simultaneously for 15-20 minutes 8 or more times in 24 hours. You can feed your baby with an alternative feeding device until he is able to latch on effectively and comfortably.

How long you will need to pump in order to draw out your 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, you may need to continue pumping. When your nipple stays out after pumping, the mother can resume breastfeeding immediately.

Once your nipple can be drawn into the baby’s mouth correctly and the baby can breastfeed effectively, you should be able to discontinue pumping and breastfeed without discomfort.

On rare occasions you may continue to feel some discomfort even after your 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 your baby pauses during a feeding. In this case, you 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.

If you are experiencing difficulty with flat or inverted nipples you might benefit from remaining in contact with your local LLL Leader.