The State Of Niples During Breastfeeding
FLAT OR INVERTED NIPPLES
My nipples don't stick out as much as I think they should. Will I be able to breastfeed successfully?
Yes, you can breastfeed even if your nipples are flat or inverted. Babies feed on areolas, not nipples. When babies latch on and suck, they draw the nipple out, making it just the right size and shape for effective breastfeeding.
If you're wondering about whether or not your nipples are inverted, gently compress the areola (the pigmented area around the nipple) between your thumb and forefinger. Most nipples will protrude. Flat nipples don't do anything at all. Inverted nipples will retract. It's not unusual to have one nipple that is flat or inverted and one that is not.
It used to be common practice to treat flat or inverted nipples prenatally with nipple-stretching exercises and/or breast shells (plastic cups worn inside the bra that press on the areola, forcing the nipple out). Yet studies comparing treated with untreated groups showed the treated groups actually were less successful at breastfeeding. Most breastfeeding specialists no longer recommend prenatal nipple treatment. They believe that all the attention given to nipples prenatally makes the mother feel that her breasts are inadequate, setting her up for breastfeeding failure.
GETTING BABY STARTED AT THE BREAST
An alert newborn who latches on and sucks well is the best remedy for flat or inverted nipples. It's easiest for baby to learn to latch on in the first day or two after birth, before your milk comes in. Engorgement tends to make flat nipples flatter, which makes learning to latch-on more difficult. Plan on rooming-in with your baby right from the start, so that the two of you can have lots of practice with breastfeeding.
If you are having difficulties latching your baby on because of flat or inverted nipples try these suggestions:
- Pay close attention to how baby takes the breast. Review Latch-on basics and get hands-on help from a lactation consultant. Baby should grasp the breast with a wide-open mouth.
- "Make" a nipple. Use the "breast-sandwich" technique to get more breast tissue into baby's mouth. Hold your breast well back on the areola, with your fingers underneath and thumb on top. Press in with thumb and fingers while at the same time pushing back toward your chest wall. This elongates and narrows the areola, which enables baby to latch on more easily.
- Use a breast pump to draw out your nipples before feedings. The high-quality electric pumps available on hospital maternity wards will do the best job of drawing out the nipple without damaging it. You can also purchase a device specially designed to draw out an inverted nipple before feeding the Evert-It Nipple Enhancer , or ask a nurse or LC to help you make your own with a 10 cc disposable syringe. Remove the plunger, and with a sharp knife cut off a half inch from the nozzle end. Insert the plunger into the cut end of the syringe. Place the uncut open end of the syringe over your nipple so it rests up against your areola. Gently pull on the plunger to draw out your nipple just before putting baby to the breast.
- Try wearing breast shells designed for flat or inverted nipples between feedings or for thirty minutes before feedings. Breast shells are made of plastic. They have two parts: a back with a hole through which the nipple can protrude and a rounded dome that fits inside your bra. Pressure on the shell from your bra against the areola gradually stretches out adhesions and allows the nipple to protrude. Be sure to wash these shells with soap and hot water between feedings and discard any milk that collects in them while you wear them in your bra. Note that shells come with two types of backs; the one with the larger hole is meant for treatment of sore nipples. Be sure to use the back with the small hole, which fits close to the nipple base.
- If baby continues to have difficulty latching on, try a nipple shield. You can get these from a lactation consultant who will also advise you on how to use the nipple shield without compromising your milk production.
Sore nipples are not inevitable during the early days of breastfeeding. Painful feedings are a signal that something's not right and you need to make a change.
WHAT'S NORMAL, WHAT'S NOT
You can expect some tenderness in your nipples during the first days of breastfeeding. As baby grasps the nipple and stretches the breast tissue, you may feel a pulling sensation that is uncomfortable. However as baby begins to suck and your milk lets down, breastfeeding should become more comfortable. This initial soreness should improve within two to four days after birth, if baby is positioned well at the breast and latched-on properly.
If baby is having difficulty learning to latch-on efficiently, you can expect that your nipples will be sore. Pain that lasts throughout the feeding or soreness that persists beyond one week postpartum indicates that something needs to be changed about the way that baby is latching-on or sucking. It's important to do something about nipple soreness before it gets worse and your nipples develop painful cracks. If you are dreading the next feeding because your nipples hurt, get some help from a lactation specialist.
Sore nipples in the first days and weeks postpartum are usually the result of poor latch-on or baby's sucking technique. Sore nipples that persist beyond the early weeks postpartum or that occur after weeks or months of pain-free breastfeeding may have other causes, such as a candida infection.
PREVENTING SORE NIPPLES
Careful attention to how your baby takes the breast will prevent, or at least minimize, problems with sore nipples. prevention is by far the best cure! If you have problems with positioning and latch-on, get hands-on help from a lactation consultant before your nipples get terribly sore and your baby develops poor nursing habits.
WHAT TO DO ABOUT SORE NIPPLES: FIXING THE CAUSE
The first and most important thing to do if you have sore nipples is to check how baby is being positioned at the breast and how baby is latching on. When baby is positioned and latched-on correctly, the sucking pressure and the action of his tongue and gums is on the areola (the pigmented area around the nipple), rather than on the sensitive nipple itself.
If your nipples are very sore, baby is probably not getting enough breast tissue in his mouth. A horizontal red stripe across the tip of your nipple or a temporary indentation at the base of your nipple are signs that the nipple is not far enough back in the baby's mouth during sucking. The baby's tongue may be rubbing against the tip of the nipple (ouch!) or the baby's gums are chomping at the base of the nipple instead of on the areola over the milk sinuses. This kind of sucking is painful for mom, and inefficient for baby. Baby will not get enough milk if he sucks only the tip of your nipple.
Here's how to work on the problem:
- Review Latch-on basics. Is your baby well-supported at the level of your nipple? Is she turned on her side and pulled close to the breast during feedings? Is she taking the breast with a wide-open mouth? Are both her top and bottom lips turned out like a fish? Are your back, shoulders and arms well-supported so that baby does not slip down onto the nipple as the feeding continues and you relax your hold on her? Are you supporting the breast with your fingers underneath, thumb on top and keeping the weight of the breast off baby's chin?
- Encourage baby to take more breast tissue into her mouth. At least one inch (2.5 cm) of breast beyond the nipple should disappear into baby's mouth. Wait for baby to open her mouth very wide before pulling her in close to take the breast. Be sure that baby is latched on far enough back on the areola.
- Try the "breast sandwich" to help you cram more breast into baby's mouth. Support your breast with fingers underneath, thumb on top, well behind the areola. Press in with your thumb and fingers to flatten the breast while at the same time pushing back toward your chest. This makes the areola longer and narrower and easier for baby to take into his mouth.
- Use the index finger on the hand supporting the breast to push down on baby's chin as she latches on. This will help keep her mouth open wide. You can continue putting gentle pressure on her chin throughout the feeding. Keeping her mouth open wide throughout the feeding should keep her from "tight-mouthing" the breast. This will make breastfeeding more comfortable for you.
- Check that baby's lips are turned out. Sucking in the lower lip will cause soreness underneath the nipple. It's often hard for a mother to see if baby's lower lip is turned out when he is latched on, so ask someone else to peek under the breast and check this for you. You can gently pull baby's lip into a more comfortable position while he is latched on. This is the lower lip flip described in Latch-on basics.
- Check baby's tongue while breastfeeding. If you gently pull down on baby's lower lip, you should be able to see the front of the tongue extended over the lower gum between the baby's lower lip and your areola. The tongue is cupped under the breast to help draw the milk from the reservoirs and channel it to the back of the mouth for swallowing. The tongue also protects the nipple from vigorous sucking. If you don't see baby's tongue under the breast during sucking, it may be pulled back and up in baby's mouth, where it will rub on the nipple causing soreness.
- To correct the position of the tongue, be sure that baby is taking the breast with a wide open mouth and the tongue forward and down. To encourage baby to bring her tongue forward and down, use the index finger of the hand supporting the breast to press down gently on baby's chin during latch-on. Opening the jaw wider naturally causes the tongue to protrude further. Tucking baby's chin down before latch-on will also help to bring the tongue down when baby latches on. Breastfeeding in the clutch hold may also be helpful.
- If it seems as if baby's tongue can't protrude over the lower gum or if it seems to curl downward rather than cupping under the breast, consider the possibility of tongue-tie. If baby's tongue seems to push the breast out of baby's mouth, he may have a tongue thrust.
- Always break the suction before taking baby off the breast. "Popping" baby off the breast hurts--and leaves your nipples hurting for a surprisingly long time. Slip a clean finger into the corner of baby's mouth to release the suction before taking baby off the breast. Or, try pressing down gently on the breast near baby's mouth.
- Avoid artifical nipples during the time that your baby is learning to breastfeed. Getting milk from bottles requires a different technique than breastfeeding. Using the bottle technique at the breast leads to latch-on and sucking problems. Babies who get both the bottle and breast in the early days are likely to have problems with nipple confusion. Avoid pacifiers as well as artificial nipples on feeding bottles.
In the early days of breastfeeding, you'll have to keep working at getting your baby latched-on properly, even if it means taking the baby off the breast and starting over several times at the beginning of feedings. If you do this, you'll soon be rewarded with pain-free breastfeeding. If you are struggling with latch-on or your nipples have gone beyond the mildly-sore stage to the painfully, cracked or bleeding stage, get help. The sooner you get help, the easier it will be to fix the problem. Call a lactation consultant or a La Leche League Leader.
WHAT TO DO ABOUT SORE NIPPLES: MAKING BREASTFEEDING MORE COMFORTABLE
Improving your baby's latch-on and sucking techniques will make breastfeeding more comfortable in the days to come. Realize this soreness won't last forever - in a few days the pain should begin to lessen. To make breastfeeding less painful right now, try these suggestions:
- Use different breastfeeding positions, including the cradle hold, the clutch hold, and the side-lying position. Varying positions from one feeding to the next changes the distribution of pressure on your areola and nipple during sucking.
- Feed baby on the side that is least sore first. Start the feeding on the less tender breast. If you need to empty the sore breast, switch baby to that side after you have had a milk-ejection reflex. The pain from sore nipples is usually less intense after the milk is flowing.
- Feed baby before he is desperately hungry, so his sucking is less vigorous and he can cooperate better with your latch-on lessons. Shorter, more frequent feedings are easier on your nipples than longer nursing sessions spaced farther apart.
- Pad your nipple. As you're putting baby to the breast, use your thumb and index finger to slide the skin of the areola forward with gentle compression. This forms a wrinkle at the base of the nipple, which adds extra padding to protect the sore nipple.
- If baby needs to suck for comfort and your nipples are wearing out, let him suck on your index finger instead of a pacifier. Long periods of comfort sucking at the end of feedings may be hard to endure. Dads, use a well-scrubbed "pinky" finger. When baby sucks on an artificial pacifier, he learns sucking habits that will make it more difficult for him to learn to latch-on and suck correctly at the breast. Sucking on an adult finger that extends well into baby's mouth is a better alternative in the early weeks of life.
- Avoid engorgement. It is more difficult for a baby to latch-on to a breast that is swollen and engorged. Frequent feedings will help prevent this. While you may want to limit the amount of comfort sucking your baby does when your nipples are very sore, be sure that you breastfeed often enough and long enough for baby to get the milk out of your breasts. Engorgement can make problems with latch-on and sore nipples worse.
- Numb your nipples. If your nipples are exquisitely tender, try numbing your nipples before breastfeeding by applying ice wrapped in a damp cloth.
WHAT TO DO ABOUT SORE NIPPLES: CARING FOR SORE NIPPLES
You'll want to do everything you can to help your nipples feel better and heal quickly. Here are some time-tested tips for soothing tender nipple skin:
- After each feeding, manually express a few drops of milk and massage this natural skin-soother into the skin of your nipples. This stimulates circulation and promotes healing. Colostrum is an ideal nipple "cream."
- Be sure the surface of your nipple is free of moisture when not "in use." Pat your nipples dry with a soft cotton cloth after feedings. If patting hurts, let your nipples air-dry. Leave your bra flaps down and your shirt open, if practical, until the nipple is no longer moist. Or, go without a bra, especially at night. You can sleep on a towel to absorb any leaking milk. Use fresh, dry breast pads after feedings, without plastic liners, to be sure no moisture stays in contact with your tender skin.
- Don't use quick drying methods, such as a hair dryer (even on a low setting), to dry your nipples. While some nipples tolerate this technique, it can cause more delicate nipples to crack because it dries the skin itself, not just the surface of the skin.
- Try exposing your nipples to a few minutes of sunshine during the day. Only two or three minutes--sunburned nipples would be a disaster!
- To soothe and help heal sore nipples, use a modified lanolin ointment, such as Lansinoh. Massage a small amount into your nipples after nursing. Don't use oils or creams that are not safe for baby and would need to be washed off before breastfeeding. Medical-grade, modified lanolin works on the principle of moist wound healing, allowing the skin of the areola and nipple to retain its natural moisture. This prevents cracking and speeds up the process of healing.
- Avoid using soap on your nipples. The little bumps on the areola around your nipples are glands that secrete a natural cleansing and lubricating oil. Soaps remove these natural oils, causing dryness and cracking.
- Check your bra. Be sure your bra is not so tight that it compresses your nipples or so rough that it irritates them. Your nipples may feel better if you go without a bra and wear a soft t-shirt instead.
- If your nipples are too tender to touch, try wearing breast shells in your bra. These will hold the bra fabric away from your sore nipples and allow nothing but air to touch them. You can obtain breast shells through a lactation consultant, who will also help you determine the cause of your sore nipples and help resolve the problem.
WHEN NOTHING ELSE IS WORKING
If your nipples are still very sore after using the above measures, you may need to take more drastic action. If you haven't seen a lactation consultant yet, now is the time. You need expert help in fixing the cause of the soreness. A lactation consultant can show you how to teach your baby to suck better so that he will not traumatize your nipples. If your nipples really need a rest, try the following suggestions:
- Try a nipple shield. This is a soft, flexible silicon artificial nipple that fits over your nipple and areola. The baby sucks on the shield to get milk out of the breast. Nipple shields can ease the pain during vigorous sucking and can also provide a temporary solution to some latch-on difficulties. Nipple shields, however, should be used with a great deal of caution. Studies show that babies get twenty to fifty percent less milk during sucking with a shield because they are unable to compress the milk sinuses beneath the areola very well. To lessen this problem, use only the new thin, soft, silicon shields, and be sure baby's lips are turned out and positioned high on the part of the shield that covers the areola - and not just on the nipple. Try to use the nipple shield only temporarily, since some babies develop problems with latch-on if these shields are overused. Also, long-term use of a nipple shield can lead to problems with your milk supply, since the breasts don't receive as much stimulation. To wean your baby from the shield, try using it only at the beginning of feedings. Once the baby is latched on and nursing, quickly slip the shield off and get baby attached directly to the breast. Eventually, baby will take the breast without the shield at the start of the feeding. You can obtain a nipple shield from a lactation consultant, who will also help you resolve the problems that have made the nipple shield necessary.
- Rest the breast with a pump. Let baby suck on the nipple that is less sore while you pump the sore side for a day or so. But be careful. Pumping can irritate the nipples if you use too much suction, pump for too long, or if the nipple rubs against the flange of the pump. Offer the milk that you pump to your baby using a cup, a feeding syringe, or a spoon. Avoid giving supplements with artificial nipples. Feeding pumped milk with an artificial nipple will often make it more difficult to solve the latch-on problems that caused the sore nipples in the first place.
- Consider other causes. If after trying all the above measures your nipples remain exquisitely tender, suspect a yeast infection, called candida. Sore nipples that appear after weeks or months of comfortable breastfeeding are almost always caused by yeast. Other causes of persistent sore nipples include eczema or Reynaud's syndrome.
CANDIDA (YEAST OR THRUSH) INFECTION ON NIPPLES
Candida (also called yeast, monilla or thrush) is a fungus that thrives in warm, dark, moist environments, such as the mucus membranes of the mouth and vagina, the diaper area, skin folds, bra pads, and on persistently wet nipples.
Suspect candida as the cause of your sore nipples if:
* Your nipples are extremely sore, burning, itching, red, or blistery.
* You experience shooting pains in your breasts during or just after feeding (especially during your milk ejection reflex).
* The usual remedies for sore nipples aren't working.
* Baby has oral thrush (white, cottage-cheese-like patches on the tongue and sides of the mouth) and/or a yeasty diaper rash.
* Your nipples suddenly become sore after a period of pain-free breastfeeding.
* You are taking, or have just finished taking, a course of antibiotics. Yeast infections are common following antibiotic treatment.
Here are some simple suggestions that may help prevent a yeast infection on your nipples, or cure a mild case of yeast infection:
* Yeast organisms hate sunlight, so give your bra and breasts a sun bath. Expose your nipples to sunlight for several minutes several times a day. After washing them, dry your bras in the sunlight.
* Air-dry your nipples after each feeding
* Avoid plastic-lined breast pads that irritate skin and trap leaked milk.
* Change nursing pads after each feeding.
* Wear 100 percent cotton bras and wash them daily in very hot water.
Thoroughly wash pump parts that come in contact with your breasts in a bleach solution and boil them in water for five minutes daily.
TREATING CANDIDA: INFECTION OF THE NIPPLE
If the simple home remedies listed above don't bring relief, consult your healthcare provider about the following treatments:
- Apply an antifungal cream (mycostatin, clotrimazole, myconazole) to your nipples as suggested or prescribed by your doctor.
- If you have a candida infection in your nipples, baby should be treated for thrush even if you can't see any white patches in the mouth. Your healthcare provider will prescribe an oral antifungal suspension that should be painted on baby's tongue, roof, and sides of the mouth three or four times a day for a couple of weeks.
- If baby has a candida diaper rash, treat it with an over-the-counter antifungal cream.
- Eat lots of yogurt (the kind with live active cultures) and take oral acidophilus. This encourages good bacteria to live in your gut and discourages the growth of yeast.
- If the candida is resistant to the standard treatments described above, in consultation with your healthcare provider, try a 0.25 - 0.5 percent solution of gentian violet applied to your nipples twice a day for three days. Gentian violet is effective, but messy. Also, apply a small amount once a day to baby's mouth, but be aware that overuse of gentian violet may irritate the sensitive oral mucus membranes of baby's mouth. Apply Vaseline to baby's lips before using the gentian violet to avoid purple stains.
- Warning - gentian violet has been used for many years to treat thrush. A recent study done in Australia has linked gentian violet to cancer of the mouth. However, many other professionals around the world believe that it is safe, and continue to recommend it. For this reason, we suggest you use this remedy sparingly, and for as little time as possible.
- If your baby has thrush but your nipples are not yet sore, apply the prescribed medicine to baby's mouth just before feeding so that your nipples get the preventive benefit of the medication as well.
- If your healthcare provider advises you to wash the creams off your nipples prior to breastfeeding, do so gently with warm water.
- While nursing on a candida-infected nipple can be exquisitely painful, it is necessary to keep the affected breast empty to prevent mastitis, or even a candida infection deeper into the breast tissue. Pay particular attention to proper latch-on and easing your baby off your nipples at the end of the feeding, since infected nipples are more sensitive and prone to injury from improper sucking patterns.
Yeast infections can be very persistent. Use the full course of medication suggested by your doctor, and continue using the home remedies for several weeks so that the infection will not reoccur.
There are some basic mechanical differences between how a baby gets milk from a bottle and how a baby gets milk out of the breast. Giving bottles or pacifiers to young, breastfeeding babies often leads to nipple confusion. Baby tries to use the bottle-feeding technique on the breast and has difficulty latching-on and sucking. Baby gets very frustrated, and so does mother. Nipple confusion can even lead to baby refusing the breast. Here's an explanation.
To get milk from the breast, baby must coordinate tongue and jaw movements in a sucking motion that's unique to breastfeeding.
- When baby latches onto the breast, he opens his mouth wide and draws the very stretchable nipple and areolar tissue far back into his mouth.
- The tongue holds the breast tissue against the roof of baby's mouth while forming a trough beneath the nipple and areola.
- The gums compress the milk sinuses underneath the areola (the pigmented area around the nipple) while the tongue rhythmically "milks" the breast with a wave-like motion from front to back, drawing the milk from the areola and the nipple.
- Since the nipple is far back in baby's mouth, it's not compressed by the gums, so it's less likely to get sore.
Babies suck from a bottle entirely differently. Thanks to gravity, milk flows from a bottle so easily that baby does not have to suck "correctly" to get milk.
- He doesn't have to open his mouth as wide or correctly turn out the lips to form a tight seal.
- The bottle nipple does not need to be far back into the mouth, nor is the milking action of the tongue necessary.
- Baby can lazily gum the nubbin of the rubber and suck with only his lips.
- When the milk comes out too fast, baby may thrust his tongue forward and upward, to stop the flow from the nipple.
- Milk keeps on coming during feedings from bottles--whether or not baby sucks--so there are no pauses to rest during bottle-feedings.
Problems occur when babies apply the lessons learned from bottle-feeding to nursing at the breast. When you compare the illustration of sucking at an artificial nipple with the illustration of sucking at the breast, you will see that if baby sucks from the breast the same way he does the bottle, the tongue and the gums will traumatize mother's nipple.
- Babies who get bottles soon after birth may thrust their tongue upward during sucking and push the breast nipple out of their mouth.
- They don't open their mouths wide enough when latching-on, so they suck only the tip of the nipple. They don't get enough milk, and mother's nipples get sore.
- Baby becomes accustomed to the immediate flow of milk that comes from the bottle; at the breast, babies have to suck for a minute or two to stimulate mother's milk ejection reflex and get the milk flowing.
Does this mean that bottle-feeding is easier than breastfeeding? Yes, and no. Bottles require less sucking finesse and less effort. However, studies comparing premature infants during bottle-feedings and during breastfeedings have shown that breastfeeding is actually less stressful.
- Babies' breathing and heart rate are more stable during feedings at the breast.
- Babies have more control over the milk flow and can establish a more regular rhythm of sucking, swallowing, and pausing.
- Feeding at the breast also requires less energy.
PREVENTING NIPPLE CONFUSION
It is easier to prevent nipple confusion than to fix it--though it is a problem that can be solved, should it occur (see below). Breastfed babies should not be given artificial nipples during the first three to four weeks when they are learning and perfecting their breastfeeding skills. Avoiding artificial nipples means avoiding pacifiers as well as bottles. Supplements, if medically necessary, can be given in ways that don't involve artificial nipples.
Will it be more difficult to introduce the bottle later? Many mothers, because they are going back to work or because they eventually plan to get out for a few hours by themselves, want their breastfed babies to accept feedings from bottles. They have heard stories of babies who adamantly refused anything but the breast. Getting baby to accept a bottle at age two or three months may take some patience, but most babies will catch on after a few tries. (Babies can also be fed with alternatives to bottles when mother is gone.) While introducing the bottle at one or two weeks of age may insure that baby accepts the bottle later, you're taking a risk. Some babies easily go back and forth between breast and bottle, but many others do not. Don't jeopardize your breastfeeding relationship when it has barely begun.
UN-CONFUSING THE NIPPLE-CONFUSED BABY
When a baby who is getting bottles begins to balk at taking the breast, nipple confusion is probably at the heart of the problem. Here's how to re-teach a baby what to do at the breast:
- Banish bottles and pacifiers. Even if your baby will eventually have to learn to use the bottle because you are returning to work, don't ask him to learn both skills at the same time.
- If supplements are needed, they can be given in ways that don't use artificial nipples. (See Alternatives to bottles.)
- Reacquaint baby with the pleasures of breastfeeding. Give her lots of skin-to-skin contact. Carry her in a sling near the breast between feedings.
- Breastfeed when baby is calm, usually in the morning or upon awakening from a nap. Don't wait until baby is ravenously hungry--she'll be in no mood to try something new.
- Review the latch-on basics. Be sure that baby is positioned properly in your arms. Wait until her mouth is wide open and her tongue is down before latching her on to the breast.
- Show and tell. Open your mouth as you say "open" to baby during latch-on. Even newborns can imitate adult facial expressions.
- Provide baby with instant gratification at the breast. Use a breast pump or manual expression to stimulate your milk ejection reflex and get the milk flowing before latching baby on. She'll be rewarded with a hearty flow of milk after the first few sucks.
- Use an eyedropper or feeding syringe to drip milk into baby's mouth as she latches on to the breast. (Get some help with this one.) This may encourage baby to stay latched-on and to continue sucking.
- For more suggestions and support, get help from a La Leche League Leader or a lactation consultant.
Babies often act puzzled or uncertain when they are re-introduced to the breast. Be patient. Praise your baby for every tiny step she takes back to breastfeeding. It may take a few days to woo baby back to the breast, but you can do it.