Breastfeeding with flat nipples: it can be done!

Expectant women often worry about whether their nipples will be okay for breastfeeding. They worry that the nipples are too big, too small, too long or too flat. Fortunately, breastfeeding is not so fragile that only a “perfect” nipple will work (whatever that may be!); babies can manage to breastfeed just fine from most shapes and sizes of breast and nipple. In this post, I want to look at the one “class” of nipples that probably causes the most distress for moms: flat nipples and inverted nipples.

When is a flat nipple really flat?

That may seem like a silly question – but it isn’t really, not if you look at things from a breastfeeding perspective. We’re not interested in what the nipple looks like when it’s just hanging there; we want to know what it does inside the baby’s mouth. The problem with just looking is this: a nipple that looks flat at rest may be just fine once baby latches, while another nipple that looks identical at rest may be much more difficult for baby to feed on. In order to know the difference, we do a “pinch test”: place the thumb and forefinger on the areola about 2-3 cm behind the nipple, and pinch. The nipple will do one of three things:

• Stand out – this nipple is elastic and baby should be able to feed from it very easily
• Stay flat and not protrude – this is what true flat nipples look like
• Pull inwards into the breast, forming a dent – this is an inverted nipple, and these are the most difficult ones to deal with. Fortunately, they tend to only be found in one breast rather than both.

How flat nipples and inverted nipples affect breastfeeding

Here’s a surprising thing: nipples are not really vital for breastfeeding. This clicked for me when one of my mentors pointed out that “babies BREAST feed, they don’t NIPPLE feed.” So the nipple isn’t there for the baby to suck on, it just helps baby to suck on the breast. In short, the nipple has two functions:

1. It gives baby something to aim at, so that he knows where his mouth should go.
2. It stimulates baby’s suckling reflex by pushing against the roof of the mouth. Baby needs to feel something quite deep in the mouth to stimulate an effective suck, and the nipple usually stretches all the way to the back of the hard palate.

If you have a “flat” nipple of the first kind, that sticks out when you do the pinch test, you should be able to get baby feeding relatively easily – you can look at the latching techniques described in this post for some advice on how to help baby latch on. Remember, baby latches on to the areola, not the nipple. The moment baby gives the first suck, the nipple will be drawn deep into his mouth and you can proceed as normal.

If you have a true flat or inverted nipple, it can take a bit more effort to help baby breastfeed, but in most cases it can be done. These nipples have trouble protruding because there is some inelastic fibrous tissue (called adhesions) that anchor the nipple to the inside of the breast. What this means it that when baby sucks, the breast nipple does not elongate and stretch in the way that it usually would. Instead, it just stays where it is, or if it is severely inverted it may even pull back into the breast, causing baby to lose his grip on the breast. This makes it difficult for baby to suckle, because there is nothing for the tongue to push against. Fortunately, there are many techniques that can help babies breastfeed even from flat and inverted nipples.

Helping baby to breastfeed from a flat or inverted nipple

Oftentimes, it is possible to loosen those adhesions that anchor a flat or inverted nipple. This will allow the nipple to stand out a bit more, which makes it easier for baby to latch on and suckle effectively. Here are some things that you can do to help:

During pregnancy

Letting nature take its course

During pregnancy, your body releases a lot of hormones that help your pelvis and other muscles and tendons to relax. Luckily, these hormones also seem to affect the nipples: about two thirds of women who have flat or inverted nipples before pregnancy find that they have disappeared by the time that baby is born. Flat and inverted nipples are also much less common in second-time moms.

The Hoffman Technique

If you want to increase your odds of success, you can do some nipple stretching exercises called Hoffman exercises: place both your thumbs on the areola right at the base of the nipple, and gently pull the thumbs apart to stretch the base of the nipple. Do it in both directions (up-down and sideways); initially do it twice a day and work up to five times a day. The research is not very clear that these exercises work, but some midwives have reported good results. Just please be gentle – you don’t want to overdo it and have cracked nipples even before your baby arrives! You also shouldn’t fiddle with your nipples if you are at high risk of premature labour, since it can help to bring on labour. You can continue with these exercise after baby is born, if you feel it is still necessary.

Have some fun with it!

Of course, there is a much more enjoyable way to draw out a nipple: get your lover involved! Gentle manipulation and sucking of the nipples during lovemaking will help to draw them out. In my experience, dads love this technique!

Breast shells

Someone may also recommend that you wear a breast shell, which is a hard plastic dome that you wear inside your bra. There is no evidence to support this practice – studies have found that women who wear breast shells have no more change in their nipple elasticity that those who do nothing. They can also cause blocked ducts, so I do not recommend them.

Shaping the nipple to help baby latch

The pinch

The simplest thing you can do to help baby latch is to shape the nipple and areola when baby is latching on. This is very similar to the “sandwich technique” that I describe in this post on latching. You simply place a thumb and forefinger about 3-5 cm behind the areola, push your hand back toward your chest, and squeeze to flatten the breast. One important note: be sure that the flattening of the breast lies in the same direction as baby’s mouth! When baby opens his mouth to latch, pull him in close so that as much as possible of the areola goes into the mouth. You can release your fingers once baby has started suckling and he is firmly attached to the breast.

This technique basically just helps baby to latch deeply and get a good mouthful of breast. As long as baby’s mouth is full of breast, it’s easy for him to suckle effectively; it really doesn’t matter whether it’s nipple or areola that’s lying against baby’s tongue. This technique by itself is often enough to let a baby breastfeed from a flat nipple, but an inverted nipple may need a bit more help.

Pull out the nipple before feeds

For a more stubbornly inverted nipple, it can be useful to stretch the nipple using gentle suction immediately before latching baby. One simple way to do this is to use a breast pump before you put baby to the breast – simply pump for long enough and hard enough to draw the nipple out a bit. Pumping in-between feeds can also help to loosen the adhesions under the nipple. If your baby is having trouble latching, you will need to pump to stimulate your milk supply too, so it’s a double win.

If you do not have access to a breast pump, you can make a “nipple puller” from a normal 10 ml or 20 ml syringe: just cut off the tip-end of the syringe and insert the plunger from the cut end (this is just because the cut end has sharp edged that you don’t want against your skin). Before feeds, place the open end of the syringe over your nipple and pull gently to create suction. You should create enough suction to pull the nipple out, but not so much that it hurts – if you overdo it, you can cause cracks at the base of the nipple, and that hurts! I used this method for many years when I worked in government hospitals, and it really works like a charm.

There are also commercial “nipple pulling” devices available on the market. They work on a similar principle to the syringe gadget, they just cost an awful lot more. I always say, keep it simple; there’s no need to buy and expensive gadget if a cheap one will do the job. Of course, you can again enlist dad’s help to suck the nipple out a bit before latching baby. Some men are quite enthusiastic to help in this way!

Nipple shields

If all else fails, a nipple shield may be a useful tool to help baby latch. If you do use a nipple shield, be sure to read this post, which will give you lots of info on how to use it and also on how to prevent any negative effects. You should also enlist the help of a lactation consultant to help you monitor your milk supply and to help transition you to feeding just at the breast.

Give it time

One thing is clear from all the information I’ve looked at: flat and inverted nipples improve over time. The hormones of pregnancy and the sucking action of breastfeeding and pumping all help to make the nipple more elastic. So be patient; in most cases you will eventually get to a point where you can just breastfeed normally without worries. And as always, I advise you to team up with a lactation consultant that can help you and guide you through the process.

Do you have flat or inverted nipples? Did you manage to breastfeed? Please share your tips and tricks by leaving a comment below!