I answered Martha's post privately, intending to cc. Lactnet. Since I
have not seen it, I presume I failed to do so and need to carry through.
Martha, On 6/5, you wrote, regarding previous nursing experiences of a
mom who is now expecting twins:
< she has true inverted nipples on both sides, we were able to
get one side out enough for her first baby to feed successfully, >
I am not certain as to your definition of "true inverted nipples".
Working from the definition of invaginated vs. umbilicated nipples, it
sounds to me as if she has at least one umbilicated nipple, since you did
in fact get to see a nipple and get it to protrude, at least part of the
time. The other nipple might be either type.
(The name umbilicated is quite descriptive. There is a fully formed
nipple there, but down INSIDE the ring of areolar muscles rather than
protruding through the circular areolar muscles and stabilized above the
areola, as in most mothers. Some references attribute this to failure of
connective tissue to develop adequately underneath it. Others say the
fault lies in short ducts behind the nipple. It could also be a
combination of the two factors.)
I have had at least one client with an invaginated nipple. That mother
opted to let that side dry up and used only the side with the everted
nipple, and did well with one sided nursing.
In this situation, there is no actual nipple. Down inside the ring formed
by the circular muscles of the areola, the skin that would ordinarily
cover the surface of the nipple simply lines a pit, and there is no
visible, or at best, a very, very tiny nipple formation, tightly bound to
the underlying tissue.
The milk reservoirs are so deep they are not palpable, and while breast
massage and a good MER can move milk forward through the ducts to exit
into the pit, actual manual expression is ineffective.
Once the milk gets into the pit, the breast pump easily draws the milk
into the bottle. It is conceivable that a good MER, and massage might
also allow a baby using a shield to get some milk simply due to the
vacuum. But it would not be possible to "latch" as we usually define it.
Another client I observed had nipples so deeply umbilicated that I was
unable to be certain whether they might actually be invaginated ones,
till we added double pumping with a hospital grade electric breast pump
at 37 weeks gestational age.
We had her start out at minimum vacuum for 10 minutes, 3 times a day for
the first few days, and increase it to 15 minutes, 4 times daily,
gradually increasing the strength of the vacuum. (This was based on a
very old Egnell reference.)
This yielded little or no colostrum, and caused her no problems with
contractions. But we did caution her to limit the pumping if it caused
discomfort. A twin pregnancy would certainly alter this plan. The
experience did, however, make her an expert at the pump, and allowed her
an early, copious milk supply with little or no engorgement.
Even this took several weeks before we could see that there were in fact,
nipples there. By the time she was at term, they came out fully and
stayed out for 5-10 minutes before inverting again. We had of course had
her in shells from 28 weeks on, and gentle Hoffman exercises from 32
weeks, with no visible change.
Everyone has inverted nipples at a certain stage during fetal life. But
the developmental process is supposed to include proliferation of
connective tissue beneath to cause eversion, being finished by roughly
near the end of the neonatal period.
I hope my insights provide some help.
Jean
******************************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio
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