Nayana* vividly remembers her early moments of motherhood – the joy of seeing her firstborn, the happy shrieks and excited cooing from those around. And then it was time. The most harrowing experience in her life was about to begin. The baby had to get his first feed, but however hard Nayana tried, he couldn’t latch on. Something was wrong. Nurses came in to help, but even then, the baby wasn’t able to grasp the nipple. It was then that they all realised that Nayana had flat nipples – her nipples were at level with the areola, making breastfeeding difficult.
What followed was a series of torture – both mental and physical. Nayana recalls, “After trying to stimulate using thumb and fingers, we gave up as it wasn’t working. Then the nurses brought a disposable syringe, cut off its tip, pulled out the plunger and reinserted it through the cut end. Using suction method, they started trying to draw out the nipples which were fully stuck inwards. After a point, my nipples cracked and started bleeding.”
Adding to her pain and pressure were advices and opinions from insensitive visitors. “Everyone’s focus will be on the baby and milk, no one bothers about the mother’s mental state. She will be in a vulnerable position, insecure, anxious and at the verge of a nervous breakdown. People walk in, share anecdotes about how they or the women they know used to lactate and how engorged their milk-surplus breasts were. They offer advice and simply blame the mother for reasons unknown, without even considering her heartbreak and trauma,” says Nayana.
Nandana* too shares a similar story. Hers were inverted nipples, something she was not aware of until the moment of breastfeeding. “I wasn’t aware that such a condition exists till I faced it myself. I was already approaching motherhood with self-doubt and anxiety; inverted nipples added to the woes. My baby was crying and I could do nothing. Everyone around, instead of being supportive, was busy guessing what went wrong to ‘seal’ the milk ducts – was it the mother’s habit of sleeping on tummy, or lack of/improper oil massage as part of traditional pregnancy care, or the worst – is it some illness, say breast cancer?”
Unfortunately, unlike Nayana’s baby who was fed after she breast-pumped, lack of timely intervention took a toll on Nandana’s newborn. Her delivery was in a small hospital which had neither neonatal care nor facilities to arrange for a breast pump to express milk. Since the doctor insisted that the baby should be given only breastmilk, formula was not given. The child suffered seizures and slipped into a temporary coma, from which he recovered, but it inflicted permanent damage on his brain.
Nandana says, “My nipples couldn’t be brought out using the syringe suction technique. I couldn’t understand if it was blood or milk which filled the syringe. The trauma continued for another day; by then I was almost suicidal. My baby was crying, everyone was playing Sherlock and even a nurse asked me how I could be so stupid to not have identified the issue earlier. How could I? Mine are the only breasts I have seen, and I honestly didn’t realise that there was a ‘defect’. By then, the baby’s health worsened and my life changed forever. I still can’t bring myself to think about those days. I dread breastfeeding, and no, I won’t have another child. I don’t want another baby to go through the same.”
About 10-25% of women are believed to have latching problems due to their nipples being flat or conical or inverted, but the lack of awareness about the condition when addressed, can solve latching problems. According to a study conducted by the International Journal of Health Sciences and Research, more than 90% of women with flat nipples can breastfeed the baby with adequate support and 75% of them can be corrected after giving birth. Inverted nipples, caused by short milk ducts or tight bands of connective tissue pulling the nipple in, that can’t be brought out using suction and stimulation methods, account for 9.6% of women.
Dr Deepa Ganesh, a Chennai-based gynaecologist, explains, “It’s absolutely normal to have flat nipples. Nipples and breasts, like women, come in different sizes and shapes. Large or small, hairy or hairless, dark or pale, protruding or flat or inverted or conical, each nipple might be different, but normal. Flat nipples can be a congenital condition; in some cases, only one of the breasts has flat or inverted nipple. Women don’t start noticing until they start breastfeeding. In many such cases, nipples pop out as pregnancy progresses when breasts engorge due to milk production, and sometimes, after childbirth as the mother starts lactating.”
When none of this happens, stimulation methods like hand expressing are deployed. Using thumb and fingers, the mother tries to stimulate the nipples, elongating and narrowing the areola, and putting the baby to the breast, stimulating the milk glands.
If that too fails, devices such as syringe and the painless ones – nipple shields, nipple retractors, nipple pullers, cold stimulation or breast pumps can be used. Nipple shields or nipple enhancers help the baby latch on, but care should be taken to avert infection.
Dr Deepa adds, “Sometimes, it will get corrected during lactation as the baby sucks frequently. At time, exercises help too. But in severe cases of inverted nipples, express milk and feed the baby. Breastmilk is very important in developing immunity for the newborn. Even if only very little milk can be expressed, feed it to the baby and if the milk is not sufficient, add formula and supplements to the baby’s food. Feed the baby at regular intervals, check the bowel movements and monitor the weight to know if the feed is sufficient.”
There are surgical methods to pull out the nipples; the wound will heal in a couple of weeks. “But that can’t be done in pregnant or lactating women. If a woman had trouble with breastfeeding due to flat nipples, surgery can ensure that it doesn’t happen during her next pregnancy,” she adds.
However, if your nipples suddenly become inverted at a later stage of life, consult a doctor to rule out any disease.
For mothers with flat nipples, breastfeeding is an exhaustive task, says Dr Deepa. “Compared to other mothers, they require extra patience and extra time to feed the baby. With confusion and never-ending advices, the stress will build up and it will again affect lactation. Once you realise that you have flat or inverted nipples, try all stimulation methods and express milk for the baby. Do not pay attention to random advices and suggestions.”
In India, where society is obsessed with ‘good news’, parenthood is embraced casually. Everyone is having children, and so we shall too – is the general attitude. There are monthly health checkups, regular shots and scans, but how many moms-to-be take prenatal classes which help them prepare for the changes in the body? Supportive measures and preparation are very important for a woman who has the condition.
A specialist in postpartum support including lactation and breastfeeding, Bincy Shibu Thomas, a community midwife at Birthvillage, a natural birthing centre in Kochi, opines that nipple size need not affect a woman’s confidence.
“Just realising that each body is created differently to suit and work in sync with the different systems in our body, is the most important thing. Comparing ourselves with others would just bring frustration when we are much better than the other person in our own way. The pressure to look like other women or celebrities would lower the confidence but otherwise, a woman’s confidence should not be affected due to a retracted nipple. Confidence levels, in terms of breastfeeding, can shoot up sky high simply by mastering the technique of feeding with a retracted nipple,” she says.
It's true that it won’t be easy, but breastfeeding is not impossible for women with flat or inverted nipples. With the right support, know-how, devices and most importantly, confidence of the mother, the baby can latch on, blissfully.
Vandana is a movie-maniac, an unapologetic feminist, a believer of human rights, and admits it if she is wrong or ignorant, or both.