As a breast surgeon, I struggle with the lactation term “flat” nipples. Histologically (under the microscope), nipples, as erectile smooth muscle, are similar to the clitoris and penis. They may appear flat — particularly in the setting of large breasts with gravity working against them, and lots of intravenous fluid during labor making the breast swollen. But unless a nipple sits in a completely fixed (immovable) position from cancer (which has other associated findings), scarring, or very significant congenital fibrous tissue tethering it, it’s not possible for a nipple to be “flat.” It’s always possible to stimulate the nipple to become erect and provide better palate stimulation for a sleepy infant to latch.
Often, one of the first things a postpartum mom is told in the hospital is that her “nipples are flat” and she “needs a nipple shield.” Not only are new moms exhausted from labor, but they are biologically and hormonally vulnerable to any implied or direct critique of their body’s capacity to take care of their infant. In the outpatient world, we hear the stories of moms feeling unsure and anxious that they can’t breastfeed their infant without a prop like a shield. It can feel like a woman’s first failure as a mom.
If moms are engorged and edematous (swollen from intravenous fluid) and a baby is sleepy after a long labor, I talk to them about lymphatic drainage (remove excess fluid) and how to stimulate their nipples to be erect in the side lying breastfeeding position. If a baby is still struggling, I tell mom to express milk to stimulate her nipple and give the baby expressed milk. The baby can continue to work at familiarizing himself with the texture and taste of the nipple over the next coming days.
Left nipple in upright position appearing “flat” (above). Left nipple in side lying position unstimulated and still not completely erect (below). Left nipple stimulated and erect with associated constriction of areola muscle fibers enabling a firm surface for baby to latch.
Patient told to use nipple shield because of nipple inversion. Nursed easily without shield in side lying position with gentle nipple stimulation and eversion.
Reason why the “sandwich hold” doesn’t work and people continue to struggle to latch baby: it flattens the areola and nipple like a balloon. The areola does not have subcutaneous fat underneath it specifically for the purposes of having a baby latch to the tented areolar skin. “Sandwiching” a breast eliminates this opportunity.
It makes all the difference in the world to take a little section of areola and gently hold between thumb and first finger. You can “stent” the nipple into the erect position and hold in baby’s mouth until baby starts sucking and swallowing for 10 or 20 seconds. The baby will naturally move to a deeper latch on its own without being forced.
When this mom returned to clinic two months later for a check in after we met several times early postpartum, her right nipple remained everted on its own (the congenital bands had released naturally once she stopped using a nipple shield). The baby preferred the right breast and so the left did not evert as dramatically, but still produced milk and the baby latched.
Mom got lots of intravenous fluid in labor and told to use shield (even though she said “but my nipples never looked like this before!”)
Nipple and areola stimulated in side lying position.
Right nipple appearing “inverted” (left) that everts easily with stimulation (right).
