Breastfeeding With Flat or Inverted Nipples

The thing to understand first

The Australian Breastfeeding Association puts the central point in one line: babies breastfeed, not nipplefeed. With a large enough mouthful of breast, a baby can feed effectively whatever kind of nipple you have.

That reframes the problem. Flat or inverted nipples do not stop milk being made or removed. What they can do is make the first few days of latching harder, because there is less protruding tissue for a newborn to find and draw in.

Flat, inverted, or neither

A flat nipple sits level with the areola rather than protruding. An inverted nipple is drawn inwards; some come out with stimulation or cold, and some stay retracted. Many people have one of each. Nipples also change — they often become more protractile during pregnancy and after a few weeks of feeding.

What matters more than the appearance at rest is protractility, meaning how the tissue behind the nipple responds when it is drawn. That is something a midwife or lactation specialist can assess in seconds, and it is worth asking for antenatally if you know your nipples are flat or inverted.

One caution: a nipple that becomes newly inverted, having previously been normal, is a change that should always be checked by a doctor. That is a different situation from lifelong flat or inverted nipples.

Before the birth

The HSE's advice for pregnancy is to prepare by getting expertise lined up rather than by doing anything to your nipples: "Talk to a lactation nurse or midwife in the hospital before your baby is born" to help you prepare for latching your baby.

Nipple preparation exercises, rolling, stretching or toughening nipples in pregnancy are not part of current guidance, and nipple stimulation late in pregnancy carries its own caution because it releases oxytocin. If someone suggests a device or an exercise regime, ask your midwife first.

The first days: what actually helps

The HSE's list is short and evidence-led.

Skin-to-skin contact, as soon and as often as possible. The Australian Breastfeeding Association notes that laid-back positions make the most of a baby's inbuilt feeding instincts, and that babies often lick the nipple or touch it with their hands to stimulate it before latching — which is exactly the behaviour you want when the nipple needs drawing out.

Laid-back feeding positions, so gravity works with you rather than against you and your baby's chin drives deeply into the breast.

Hand expression before a feed. The HSE says "good hand expressing skills will help to soften the areola before feeding". This is the single highest-value skill on this page: a soft areola is drawable, a firm one is not.

Reverse pressure softening, where you press gently inward around the base of the nipple with your fingertips for a minute to move fluid backwards and soften the area. The HSE says this "will let your baby latch more easily."

Breast shaping, sometimes called the sandwich hold: compressing the breast in line with your baby's mouth so the shape matches the gape, rather than trying to push the nipple in.

Engorgement is the real enemy

When milk comes in around day three, a firm, full areola can turn a manageable latch into an impossible one. This is the point at which many people with flat nipples conclude breastfeeding is not working, when the actual problem is temporary and mechanical.

Soften first, then latch. Hand express a small amount or use reverse pressure softening before every attempt during that period, and feed frequently so it does not build again.

Bottles, dummies and the first fortnight

The Australian Breastfeeding Association suggests trying to avoid bottles and dummies at first, because they are very different in shape from a nipple, and that if your baby needs extra milk you can ask to feed them using a cup or syringe.

This matters more when latching is already difficult. A baby learning to draw out a flat nipple is doing something harder than taking a firm teat, and easy alternatives in the first fortnight can make that learning slower.

Nipple shields: the honest position

A shield can be genuinely useful here, giving a baby a firm shape to latch onto. La Leche League GB lists flat or inverted nipples among the situations where a shield may help.

But the HSE's instruction is unambiguous and should be followed: "Do not use nipple shields to help your baby latch on without support from a lactation nurse or midwife." Size matters, supply can drop, and weight needs monitoring. Get one fitted rather than bought off a shelf, and have a plan for coming off it.

Devices sold to draw nipples out before or between feeds, including modified syringes and suction cups, are used in some settings but should also be discussed with a specialist rather than improvised.

It usually gets easier

The tissue changes. Weeks of feeding, and a baby whose mouth is bigger and whose latch is more practised, resolve most of these difficulties without anything else being done. The people who find it hardest are those in the first fortnight, which is exactly when skilled help makes the most difference.

When to get help

Ask your midwife, health visitor, public health nurse or a breastfeeding specialist if:

• Your baby cannot attach at all, or slips off repeatedly.
• Feeding is painful, or your nipples are cracking.
• Your baby's weight gain or nappy output is not as expected.
• You are considering a nipple shield or a nipple-drawing device.
• A nipple has newly become inverted when it was not before — see a doctor about this.

Where to get real help

In the UK the National Breastfeeding Helpline is 0300 100 0212, run by the Breastfeeding Network and the Association of Breastfeeding Mothers, and open every day of the year. La Leche League GB runs local groups and a helpline. In Ireland the HSE offers an "Ask our breastfeeding expert" live chat and email service. Ask for a feed to be watched in person — this is a problem that is solved in minutes by someone experienced and can take weeks alone.