Anatomical variation as an issue in breastfeeding is the subject of one of
the lectures I am giving in NYC this week.  I have lots of pictures and
measurements about these "fit" issues.  Rachel is right that you don' t want
to make mom feel like a freak, but it is information she has the right to
have.  Here is what I say in a (hopefully) reassuring, factual manner:

"Noses and nipples are all diff. sizes and shapes and usually all work just
fine.  However, here is the size of your baby's palate (measured on my
finger with a pen mark).  We know that the human nipple elongates when the
baby's sucks (you can see this if you pump.) Even with the nipple at rest,
your baby can't quite reach the sinuses at the base of the nipple/areola.
As a result, the jaw closes on the nipple shaft, pinching you, and pinching
off the milk flow.  We also know that milk ejects during sucking after
maximal compression (flattening) of the teat against the palate.  (I'm using
my fingers here to mimic the jaws compressing the teat.) Your nipple
diameter may make it diff. for such a small baby to compress you
sufficiently.  This also will limit the milk flow causing frustration and
perhaps low intake.  If we can fit you with an appropriate size pump flange
or teach you effective hand expression, we can protect your milk supply and
provide your baby with your milk until growth takes care of the problem.
Using the breast as a pacifier will preserve the baby's orientation to the
breast.  As baby grows, the mouth will eventually accommodate the nipple.
Your nipples are so everted they will "compete" well with bottles so long as
you keep your supply robust. This is a real problem but it is a temporary
problem."

We have a picture and brief case study of a mom with large nipples (long and
too big in diameter to accommodate baby's mouth) in the Bfg Atlas.  Mom was
a fam. practice doc very committed to bfg. Naturally her baby would be
preterm and small. She pumped 6 weeks, fed bottles, and baby was
subsequently bfed 18 mo.

Now sometimes these bulbous nipples are associated with other issues that
may impact milk production.  I have some wonderful new pictures of an Asian
lady with 36 gest. week twins (around 5 lbs or 2280 g each).  Her nipple
diameter is 22 mm and under pressure during pumping her nipples evert to 4
cm!  She was a fertility pt with a hx of infertility due to hormonal
imbalances.  Her breasts did not grow/change during this preg. nor during
her first.  She failed to successfully lactate 4 yrs ago when she delivered
a term singleton.  So one has to wonder if the breast development here is
fully normal.  When she pumps she gets virtually nothing.  Of course she had
a standard size flange because no one told her she should have a larger one
to prevent strangulation at the nipple base.  I haven't heard back from her
yet about how the larger one is working.  I hope better, but I suspect this
woman won't make much milk.

Barbara Wilson-Clay BSEd, IBCLC
Austin Lactation Associates
http://www.lactnews.com

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