Hi everyone,
         I'd like to hear how other people deal with moms with larger breasts
 with large areola and flat (not inverting upon compression, but VERY flat)
 nipples that the baby can latch onto briefly then fusses and cries and lets
 go in a minute or two at the most.
         Positions for best latch on? Frustration level in baby? in mom?
 using a pump and supplemental feeding techniques? how long should she keep
 trying at each feed? what about nipple soreness from repeated missed
 attempts? will the baby "grow into" these nipples? should she pump to
 establish milk supply? what supplemental feeding techniques would help most
 here?

Dear Anne,
I've worked with a lot of moms with the large breasts and very flat nipples.
 If the baby latches on briefly then lets go it is usually because he is
unfamiliar with what he is experiencing. First try squirting EBM into his
mouth when he attemps latch.  Sometimes just a good reward produces results.
 As long as the baby is healthy and full term, this is the exact case where
cup feeding can help. NOTHING else should go into this baby's mouth for a few
days.  They have to learn how to use those powerfull little "vacuum cleaner"
mouths to suck moms breast in and then hold on and not be confused by other
stimuli such as bottles, pacifiers or fingers, parents or baby's.  If the
baby can do it for a few seconds, he has the physical ability, has all the
reflexes he needs, he just isn't convinced this is what he needs to do ---
it's "baby psychology" you are dealing with, not "physiology".  Think about
it. What has he had to suck on up until now?  --- his own little stick-like
fingers.  Mom's brest is so very different he is confused.  His instinct says
"suck" then when he feels moms big soft nipple he says "Naaa.  That's not
familiar" and lets go.  Also mom pinching up the nipple from the side to make
a "bite" for the baby to grasp often works better than the "C" hold for these
moms.
Yes, mom should pump lots to maintain supply and stretch nipple if it is
inelastic.  Yes, baby should be supplemented well so he gets lots of
nourishment and has energy. Use all milk mom pumps and ABM if she can't get
enough. Weak or starved babies suck more poorly.  I would cup feed this baby
close to breast so when he roots he can be quickly offered the breast, or
syringe feed him while walking about, but NOT letting him suck on the syringe
OR ANYTHING ELSE!!  Finger feeding is often the wrong choice here, because
Junior will LOVE it, but continue to refuse the breast because it is so
different from the finger.  Keep baby skin to skin as much as possible and
offer the breast when baby is NOT very hurgry and NOT upset.  Do not force or
fight with baby.  This is never appropriate.  Offer in the middle of feeds
when baby is calm, or after for comfort and lovey time.  No, baby does not
grow into these nipples unless they are truly very wide or long.
Now, some parents can cup feed well, others cannot.  Often 1 or 2 days of
this produces great results with baby making stronger and stronger latch on
attempts, because he NEEDS to suck and the cup just isn't very satisfying
that way. Parents must provide LOTS of comfort for baby:  sound, motion and
body contact, to make up for no sucking.  Mom should do this when Dad or
another helper is with her for a few days.  I have seen very stubborn babies.
Parents have given up and used the bottle, then weeks later the baby does
breastfeed.  I'm often shocked!  Sometimes moving back and forth between
feeding techniques works, but the breast must be the consistant factor,
always snuggled there for comfort, as many times a day as possible.

are there flat nipple cases that simply never work out? is
 perservernce going to pay off in the next couple of weeks? >>

Sometimes, unfortuntately.  But if the nipples are the least bit flexible,
perserverance usually does payoff.

Good luck,
Jane Bradshaw RN, BSN, IBCLC
Lynchburg, VA