It sounds like you are describing tethered inverted nipples, which are less
often seen. The more common type can be pulled out and eventually may even
stay out. With a tethered nipple, however, the ducts themselves may be
short, tightly holding the nipple in.  I've had a couple of intractable
cases myself in the past couple of years. They drain poorly/slowly in many
cases, at least by electric pump. You might try different sizes of the
flange, and even the soft "comfort" flange, to see if that makes a
difference in pump performance, but manual expression may be the best still.

In my research, I learned that the most effective treatment of tethered
nipples is surgical release.  First, this simply is not a viable option
during lactation, and secondly it often involves severing the ducts, which
is not good, either.  If there is another technique that is less
destructive, I have not read it.  The other possible option is the use of
the Avent nipplette, which in essence is a small cup that is suctioned onto
the nipple and left in place several hours daily to slowly stretch the
tethering structures. This also is not a viable option during lactation
because milk leakage will release the suction. It is best done prior to or
at least during pregnancy and requires months of therapy for significant
change. I have not had the opportunity to try this yet as most of my clients
are low income and don't seek me out that far in advance.

Nipple shields work poorly with tethered nipples because the nipple does not
pull into the shield, and thus the baby is nursing on largely an empty cone.


See Ch 8 of Breastfeeding Management for the Clinician by Marsh Walker--
excerpt online (fourth entry of google search under "tethered inverted
nipples").

Lisa Marasco

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