by Anne Smith, IBCLC
Mother's nipples come in many shapes and sizes. While most nipples protrude and are easy for baby to grasp, there are some variations in size and shape that make it difficult for them to nurse successfully. In order for a baby to nurse effectively, he must be able to grasp the nipple and stretch it forward and upward against the roof of his mouth. Flat or inverted nipples may make it difficult for your baby to nurse.
In women who are pregnant for the first time, it is very common for the nipple to not protrude fully. About one-third of mothers will experience some degree of inversion, but as the skin changes and becomes more elastic during pregnancy, only about ten percent will still have some inversion by the time their baby is born. The degree of inversion is likely to become less with each subsequent pregnancy.
Because your baby forms a teat not just from the nipple but also from the surrounding breast tissue, most inverted or flat nipples will not cause problems during breastfeeding. Some types of flat or inverted nipples will cause problems, however, and there are some steps you can take to help correct the problem both before and after the baby is born.
The first thing you need to do is determine whether your nipples really are flat or inverted. You can do this while you are pregnant by performing a simple "pinch" test: Hold your breast at the edge of the areola between your thumb and index finger. Press in gently but firmly about an inch behind your nipple. If your nipple protrudes, that's great. If it does not protrude or become erect, it is considered flat. If it retracts or disappears, it is truly inverted. Nipples that are severely flat or inverted will not respond to stimulation or cold by becoming erect. If you perform the pinch test and your nipples protrude, they aren't truly inverted and will probably not cause any problems when you nurse your baby.
A truly inverted nipple is caused by adhesions at the base of the nipple that bind the skin to the underlying tissue. While the skin does become more elastic during the third trimester of pregnancy in preparation for nursing, some of the cells in the nipple and areola may stay attached. Sometimes the stress of vigorous nursing will cause the adhesion to lift up rather than stretching or breaking loose, and this can cause cracks in the nipple tissue and pain for the mother.
Because the breasts function independently of each other, it is not unusual for a mother to have one flat or inverted nipple, or to have one nipple that protrudes more than the other. For the same reason, it is not unusual for a mother to produce more milk from one breast than the other. The degree of inversion varies greatly, ranging from the nipple that doesn't protrude when stimulated, but can be pulled out manually, to the severely inverted nipple that responds to compressions by disappearing completely.
How much difficulty a flat or inverted nipples presents to a nursing baby depends on the degree of inversion as well as the baby himself. If you have a strong, healthy, full-term, vigorous nurser, he may be able to draw out the nipple and dislodge the attachments with relative ease.
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