Hi, Tara.  I have experience working with a mother with nipples that
measured 3.5cm beforing puming and at least 4cm after.  Breasts were ample,
but not huge.  I say about a DD cup size.  Mother repeatedly put babies to
the breast both before and after pumping.  I say babies, because she had
twins!  I believe they were born at or around 36 weeks.
 
I first saw mom when babies were three weeks old.  There was some nipple
trauma, and mother was feeding in a variety of ways, including at the
breast, via finger, and via bottle.  I immediately made sure that everyone
involved in bottle feeding the babies were using the Kassing Method, and I
carefully monitored milk intake via bottle to ensure that babies were hungry
when coming to the breast.
 
My basic technique with this mother was to first help heal the nipples with
traditional methods and then to focus on getting each baby attached in
whatever way best suited each of them.  Though mom's nipples were very
large, as long as mom positioned baby in way that faciliated a deep latch
*for that baby*, baby was able to latch and feed well without causing
further nipple trauma.
 
I can't say that there is one magical position, though.  I first just
observed mom and babies and how they *were* behaving at the breast; I
carefully watched mom, observed how her breasts hung and how each baby
responded to them.  We tried different positions with each baby, and tried a
number of different pillows and supports.  With trial and error, mom had the
most success feeding lying down with one baby (I taught her how to feed in
the positions with the bottom breast and the top breast, so that she didn't
have to move), and in straddle with the other.  I *really* like the straddle
position for large nippled mothers, because with proper spinal support and
tipped back head it allows baby to 'expand' his or her chest and jaw.  I get
these moms to have baby straddle their leg (or if baby's legs are too small/
mom's legs too large, I have baby 'kneel'on mom's leg) so that baby's pelvis
is right up aginst mother's.  Then, I have her tip the baby back at an
angle, deploy typical assymetrical latching techniques and once baby is
latched, to settle back into couch or chair.  Each dyad will have a slightly
different variation, and some may need extra pillow support, etc.  Please
note that this positions works well with large nipples and large breasts,
but not if mother has a short torso, as baby is often too high above the
breast to latch well.  In a mother with short torso, I modify it by having
baby kneel beside mom on the couch or chair or what have you.
 
The key, in my humble opinion, is to find a position in which the breasts
can hang naturally with being forced toward baby... latching on can happen
much more effectively when we are not also artificially manipulating the
breast tissue.
 
On last report, mom and babies were exclusively breastfeeding at 4.5 months
with no further nipple trauma!
 
I hope I have helped you.  Good luck!
 
Karyn-grace Clarke, IBCLC
Happy Tribe Consulting
Nanaimo, BC, 
250-739-3146

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