Is baby having difficulty coming onto your breast because your nipples are 'flat'?

Have you been told that your baby won't come on to, or keeps slipping off, the breast because your nipples are 'flat'?

Most of the women who have been told their breastfeeding problems are due to 'flat nipples' actually have breast tissue drag problems. Most nipples which have been labelled flat project quite substantially once the smooth muscle under the skin has contracted, either due to stimulation with your fingers, or after the baby has been feeding. Most babies manage nipples that have less height when contracted perfectly well - as long as they are able to draw up lots of breast tissue into their mouth as they suckle, without breast tissue drag.

For example, a woman with generous breasts which fall quite low, compromising the landing pad, could also have nipples which seem less prominent. Her difficulty bringing baby on to the breast are blamed on the 'flat' nipples, but no-one has identified or dealt with the compromised landing pad! We can trust your baby's ancient mammalian reflexes to sustain breastfeeding, as long as we don't accidentally set up breast tissue drag as he tries to come on to the breast.

Sometimes the face of a woman's nipple is what she's thought of as her nipple her whole adult life - but in fact when her baby breastfeeds, she realises that she is only looking at the face of the nipple. The border between the sides of her nipple and the areola, which have not been particularly apparent until now, becomes visible after breastfeeds, and she discovers that her nipple is much larger than she thought.

What studies about nipple height tell us

In a group of 300 Japanese women, their nipples were measured anywhere between 6 mm and 23 mm wide at the nipple base, and could be anywhere between level with the areola, measured at 0 millimetres, to 20 mm high. That is, there is a remarkable variety of normal nipple sizes, shapes, and colours. Your nipples will fall into this great spectrum of natural variation!

There is no established link between nipples that are level with the areola and breastfeeding failure. A 2013 Thai study of 449 women who were one day postpartum showed that nipple lengths under 7 mm were associated with less latching on success, measured by the LATCH scale. The nipple height was measured after the nipples had been stimulated and the smooth muscle had contracted.However, this study was conducted on day 1 and no conclusions about breastfeeding success or capacity to latch after day 1 can be drawn from it.

The authors of a 2003 Californian study claimed to show a link between flat or inverted nipples and delayed onset of milk production, as well as a link between flat or inverted nipples and suboptimal infant breastfeeding behaviour on days 0, 3 and 7. But the IBCLCs assessing the nipples in this study only distinguished between two categories, 'normal' nipples and 'flat or inverted' nipples, so we don't know to what extent the inverted nipples alone caused the breastfeeding problems. And needless to say, the study did not take into account fit and hold methods being used.

Strategies to experiment with when your nipples are not much higher than your areolas

1. Roll or stimulate the nipple with your fingers prior to offering the breast so that the nipple contracts. Some people say to use ice but I find that starts to get more complicated since you've got to go to the fridge with a baby who has suddenly decided she urgently needs to feed. It's best to keep everything very simple!

2. Apply usual gestalt strategies for eliminating breast tissue drag and positional instability. You can find this starting here.

3. You may find, as you experiment, that it works best to use your fingers to compress your breast into a 'teat' shape, using the cross-cradle hold as you bring baby on. Sometimes this really does help. But if you do use your fingers to shape your breast for baby's mouth, remember not to lift your breast to the baby, but to bring the baby has close as possible to the usual fall of the breast. As soon as you shape the breast with your hand, you risk breast tissue drag when you let go. Using the gestalt approach and applying micro-movements as soon as you let go of your breast will compensate for any breast tissue drag and protect your nipple.

4. Nipple shields can be very useful in this situation, once other approaches haven't been tried and aren't helping. You can find out about nipple shield use here.

5. Sometimes it's difficult to know, too, if the nipple is quite level with the areola, where the nipple ends and the areolar begins. This can be confusing when nipple shields are being fitted - and is a reason to experiment with different sized nipple shields.

6. A baby who has been dealing with breast tissue drag and difficulty coming on to the breast might quickly develop a conditioned dialing up. This baby is very sensitive and won't tolerate much experimentation. You can find out about conditioned dialling up here. Again, nipple shields can be helpful in this situation.

Selected references

1. Thompson RE, Kruske S, Barclay L, Linden K, Gao Y, Kildea SV. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study.* Women and Birth*. 2016;29:336-344.
2. An Israeli study of 109 breastfeeding women found that ladies who were bigger overall tended to have larger breasts. Ladies with larger breasts tended to have larger nipple diameter, nipple length and areola. The overall rate of latching difficulties was 15.5%, without differences between the four BMI groups.
3. Puapornpong P, Raungrongmorakot K, Paritakul P, Ketsuwan S, Wongin S. Journal of the Medical Association of Thailand.* 96*. 2013;1(1). ↑
4. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss.* Pediatrics*. 2003;112:607.