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Flat and inverted nipples vary from mild to severe and sometimes make latching difficult. Some will respond to stimulation and should not present a problem, however a severely retracted nipple will remain inverted even when stimulated. If it is compressed between the thumb and forefinger just behind the base of the nipple it will retract inwards and a thick core will be felt.
Measures can be taken antenatally to improve nipple protractility. A nipple enhancer may be used to stretch the adhesions which limit the outward movement of the nipple. It is best used in the late weeks of pregnancy when the nipples are more likely to respond to stretching due to hormonal changes. The Hoffman Technique may also be utilized. It involves placing a thumb on each side and at the base of the nipple and pushing downwards and outwards to stretch the adhesions. This exercise can be repeated up to five times a day. A breast shell, which looks like a donut and applies gentle pressure around the base of the nipple, can be worn inside the bra during pregnancy and prior to breastfeeds. It has mixed success and should not be worn at night.
It is not essential to have a protractile nipple to achieve good milk transfer as the nipple merely acts as a conduit. The breast must be formed well into the baby’s mouth by the mother to achieve a good latch, bearing in mind that it is pressure on the hard palate that stimulates the baby to suck. When latching, support the breast with thumb and fingers on either side then pull back a little to assist the nipple to protrude.
Mechanical means (i.e. breast pump, nipple enhancer or modified 10ml or 20ml disposable syringes) can sometimes be used to draw the nipple out immediately prior to feeding. The brief application of something cold on the nipple may also help to encourage protractility. Stimulation of the nipple by rolling it between thumb and finger or gently stroking it may also help.
Nipple shields may be of some benefit once the milk supply is established but should not be used until there is a good flow of milk. It is very important to initiate breastfeeding immediately after birth and to avoid the use of bottles and dummies to avoid a preference for these developing. Given time, many inverted nipples elongate and the adhesions loosen. Protractility improves with successive pregnancies and lactations so it is important to attempt breastfeeding even if unsuccessful previously.