Nipples (and breasts) come in all shapes and sizes and not always in matching pairs. Not all nipples protrude like half a cherry on a cup cake. Some nipples may be quite shallow or flat, perhaps level with the areola, others can be dimpled or folded, very long or wide. And some nipples are inverted—caused by short milk ducts or tight bands of connective tissue pulling the centre of the nipple into the breast. This article looks at whether flat or inverted nipples can affect breastfeeding and how to deal with any challenges.
Can you breastfeed with inverted nipples or flat nipples?
Yes, because breastfeeding relies on a baby having a big mouthful of breast to stimulate the milk glands behind the nipple rather than simply being a matter of hanging on to a nipple. However, while many babies find breastfeeding with inverted nipples or flat nipples quite straightforward, others can find it very difficult. Potential difficulties include:
The way a baby attaches to the breast is often referred to as latching. A protruding nipple is easier for a baby to find and grasp and guides a baby’s latch. However, a flatter, short shanked nipple may be quite difficult for a baby to find and grasp, especially at first while a baby is learning to breastfeed.
Knowing when to suck
The stimulus of a nipple deep in a baby’s mouth triggers the sucking reflex by stroking the baby’s hard palate. Faced with a soft, flat nipple, a baby may feel confused and disorientated. Barbara Wilson-Clay explains:
Some parents may notice that the baby will suck strongly on a finger, pacifier or bottle nipple, but appear apathetic, disinterested or frustrated by the breast. This may be because the nipple is not elastic or everted [protruding] enough to reach back to stroke the palate. When this happens the baby doesn’t know what to do next. The baby may bob back and forth and seem unable to “locate” the nipple, may pull away and cry, or may fall asleep each time the breast is offered. Skilled help from an IBCLC and close follow-up from the physician will make it easier to overcome this challenge.
Forming a teat
If the breast tissue is very firm instead of soft and stretchy, a baby may find it difficult to shape the breast into a teat shape to suckle and stay latched. If a baby is premature, has low muscle tone (floppy) or has high muscle tone, a small mouth, poor latch or poor tongue function such as having a tongue-tie, it may compound his difficulties. The after effects of birth medications or birth trauma can also be causes of difficulty latching.
If a latch is too shallow, a mother’s nipples can rub against a baby’s hard palate and quickly become sore. Laid back feeding may help some mothers or cross cradle position can give more control for an assisted latch, see below for more ideas.
Risk of low weight gain
With some types of deeply inverted nipples, when the baby tries to take the breast, rather than compressing the mother’s breast tissue under her areola, he may compress the buried nipple instead. In this case the baby may not receive much milk and breastfeeding may be painful for the mother.
How flat is a flat nipple?
There is a wide variation of normal, but some experts describe an average nipple diameter as 16mm and height as 7mm (Wambach and Riordan, 2015). Whether there will be any problems for your baby if your nipples are much flatter (or much larger) than average will depend on the size of your baby’s mouth, how stretchy the breast tissue is and whether you have good help to get breastfeeding started.
Do I have an inverted nipple?
Press on the areola either side of and about an inch behind your nipple. An inverted nipple will pull into the breast (retract) while common nipples stay out like a cherry on a cake. If you can coax the nipple out, that’s a good sign that your baby will be able to do the same if he is latched well and has good tongue function.
Truly inverted or infolded?
There can be different degrees of inversion from mild to severe. The retracted nipple is the most common type of inverted nipple. The retracted nipple appears erect but on stimulation it pulls into the breast which can make latching difficult. Some nipples may look inverted but become erect on stimulation (pseudo-inverted or infolded). The truly inverted nipple that is retracted both before and after stimulation is not common but if you have one (or two) it makes it more difficult for a baby to latch on 3.
Inverted nipples may resolve
Nipples continue to develop during pregnancy so that an inverted nipple may turn out (evert) by the end of pregnancy. And they may protrude a little further with each subsequent pregnancy.
During pregnancy, the nipples become more elastic and enlarge, which may explain why some women characterise their nipples as “flat” or “inverted” at the beginning of pregnancy but not at the end. How the nipple looks when the baby is not suckling bears little resemblance to its appearance in the baby’s mouth, and it is not necessary for the nipple to be everted when not in the baby’s mouth.
If your baby can manage to latch and feed regularly this can loosen the adhesions that keep some nipples inverted. A good pump can also do this.
Tips for breastfeeding with flat or inverted nipples
Some babies may not have any difficulties breastfeeding with inverted nipples or flat nipples. But some will. Paying careful attention to latch and positioning can help your baby. Useful articles providing general information to help all babies latch include Breastfeeding Tips for Newborns, Latching Tips, Breastfeeding Positions for Newborns and Why Skin to Skin? Further tips include:
#1 Getting a good latch
A breastfeeding specialist such as an IBCLC lactation consultant can help to get breastfeeding off to a great start and can help you one-to-one with latching techniques and helpful positions. Ideas to help a baby latch to a flat or inverted nipple include:
Shaping or flattening the breast
Variations of breast shaping, sometimes called an assisted latch, nipple tilt or breast sandwich can help your baby get a deeper latch. Ensure your fingers are far enough back from your nipple so your baby can get a big mouthful of breast. See Latching Tips for a description and video clips. You may need to continue to support the breast through the feed if the latch is fragile.
Pulling back on the breast tissue or areola during a latch
Pulling back on the breast tissue as baby gapes to latch can help a nipple to protrude more (Mohrbacher, 2010).
The “nipple nudge”
This involves pushing up into the breast through the areola and behind the nipple to help expose the nipple for the latch i.e. push it inside out 4.
A nipple shield can help some babies to latch to a very flat or inverted nipple
See Nipple Shields Good or Bad? for further information about shields. If used, it’s important that the nipple shield fits well. Listen for your baby’s swallows and keep an eye on his weight gain and dirty nappies to ensure he is getting enough milk. Pumping regularly will protect your milk supply until you’re sure feeding is going well. Wetting the shield can help keep them in place either with breast milk or some mothers use a little lanolin around the edges of the shield. Avoid using a shield during the first few days before your milk comes in as thick and sticky colostrum doesn’t flow well through a shield; hand express instead and feed this to your baby by cup, spoon or syringe.
#2 Try to bring your nipples out before a feed
Some flat nipples can protrude more with a little stimulation and provide the latching focus a baby is looking for. To bring out the nipple before a feed try rolling your nipple between your finger tips, cold stimulation, letting baby lick and bob about on the breast or try using one of the commercial gadgets described in the next section.
#3 A natural birth if possible
Your baby will be better able to master latching after birth if he isn’t too sleepy and disorientated from drugs such as strong pain killers that have crossed the placenta.
#4 Keep breasts soft
Nipples can flatten out when breasts are very full or engorged and nipples that were already quite flat can ‘disappear’ completely. Practice latching in the days before your milk comes in while your breasts are still soft. A little hand expressing, pumping or reverse pressure softening can help soften an engorged breast so your baby can latch.
#5 Avoid bottles and dummies
Bottles and dummies have very different firm teats compared to the average human nipple. This can cause nipple confusion for some babies and is a particular issue for the baby who is learning to breastfeed with inverted nipples or very flat nipples. A baby may quickly favour the bottle—particularly if he associates the breast with frustration and hunger. Try using a cup, spoon or syringe for top-ups to keep your baby well fed if he can’t latch. If you do need to use a bottle see our Tips to Bottle Feed a Breastfed Baby.
Preferring one nipple over another
If one nipple is inverted or very flat and the other sticks out, a baby may prefer the easier breast with the protruding nipple. A nipple shield on the inverted nipple helps some mothers to use both breasts. Alternatively, pumping the side baby refuses can stimulate the milk supply to supplement back to your baby and it may help evert the nipple. Some mothers allow milk production from the side with the inverted nipple to dry up while continuing to feed on the other breast. The breast that is still used will compensate by increasing milk production.
More ideas to bring out inverted nipples
If your baby is still struggling to latch there are a number of ideas and gadgets available to try and draw out an inverted nipple before a breastfeed. However, the success or otherwise of some of these gadgets hasn’t really been proven, and care should be taken not to cause nipple damage by over use of suction.
A breast pump
A breast pump can help pull out an inverted nipple and can help stretch and break the underlying adhesions with repeated use. Sometimes the adhesions under the nipple will remain tight and repeated pumping or latching can create cracks or blisters. Sometimes pain might continue even when breastfeeding is going well, because the nipple has undergone major changes (Mohrbacher, 2010).
The authors of The Womanly Art of Breastfeeding discuss making your own suction gadget from a plastic syringe that is a little larger in diameter than your nipple:
Take the plunger out. Using a serrated knife, cut the needle end off and put the plunger in the “wrong” end. Now you have a little suction device with a smooth end that you can put over your nipple. Pull out on the plunger far enough to draw your nipple out, but not so far that it’s uncomfortable, and keep the suction up for about a minute
Your partner may be able to help draw out your nipples with gentle oral suction.
Worn inside the bra these used to be recommended to provide pressure around the base of the nipple to encourage it to protrude. However a research study found they weren’t helpful and shells caused pain, discomfort, skin problems, and embarrassment 6. Some mothers may find them useful but if used, breastfeeding charity La Leche League GB says:
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.
The Hoffman technique or Hoffman exercises
This technique involves placing a thumb either side of the base of the nipple and pressing into the breast while you move your thumbs apart and stretch the nipple. It can be tried in pregnancy as long as it isn’t painful but the research by Alexander et al 7 did not find the exercises were beneficial.
Other sorts of nipples
A dimpled or folded nipple is a partially inverted nipple. This nipple may extend during a breastfeed but after the feed it folds back over and can become damp and sore inside. Try patting the nipple dry after a feed or holding it open until it is dry.
Very large or very long nipples
Very large or long nipples can fill a baby’s mouth and not leave any room for a good mouthful of breast tissue. However after a few weeks, baby’s mouth will have grown to accommodate these normal nipple variations.
Some babies can breastfeed quite happily with flat or inverted nipples, but others, such as a premature baby or a baby with a small jaw or poor tongue function may find it very difficult. If your baby can’t latch, hand expressing initially, followed by frequent pumping will stimulate your milk supply and provide a supplement to keep your baby well fed until you can get skilled help with positioning and latch. Latching may naturally improve once your baby’s mouth has grown or your nipple becomes more stretchy. It’s a good idea to avoid bottles and dummies while your baby learns to breastfeed so that he doesn’t develop a preference for the bottle teat.