Catherine answers Lynn's question with:

<I have not noticed formerly inverted nipples to be more
friable, but it would make sense if the nipple retracted somewhat and
moisture became trapped, or if there were still adhesions preventing the
extension of the nipple in the baby's mouth...  I imagine if the
adhesions were preventing full lengthening of the nipple, it might
stress the skin and lead to injury.  I'm going to keep my eyes open in
this situation in the future, and I'll let you know if I notice more
friability in formerly inverted nipples.>

A previous mother I photographed with inverted nipples had the most
unusual ones I've ever seen, and I have photographed 4 other severe
cases, each one seemingly with very different characteristics.

It seemed as if the surface of her nipples were not epithelialized.
Squamous epithelial cells are supposed to extend all the way down into
the nipple ducts to the level of the lactiferous sinus as part of fetal
and neonatal development.

This looked to me like a developmental irregularity.
That is, the surface was really what looked to be strands of membranous
tissue much deeper red that the inside of the mouth or eyelid.

The strands were not united into a "bulb", as though the connective
tissue giving rise to the circular and radial muscle layer had never
formed around the galactophores in the first place.

Due to her disappointing experiences with 2 previous children, she had
already made the firm decision to pump and feed by bottle even before I
saw her. Though I tried to encourage her to try direct breastfeeding by
explaining some of the benefits of the "process" itself, she could not be
dissuaded.

Frankly, my first suggestion would have been a shield due to the apparent
friability of the tissue, in hopes that it would one day epithelialize. I
was prepared to offer her any necessary home visits and support without
charge in return for the privilege of documenting with photos, but I
can't imagine whether it could have been worked out with nipples intact.

There are varying types and degrees of congenital inversion, depending on
what embryonic layer is involved, or abnormally developed or absent, and
what part of the developmental process did not go on to completion. An
individual mother may even have very different types of formation for
each of her nipples.

Therefore, I find it important to avoid any  generalization about
inverted nipples. This is a most important example of where care must be
individualized, and nipples should be closely inspected by someone who
has become familiar with developmental anatomy. If an advance lactation
plan can be made, so much the better.

That is in addition to the fact that the word "inverted" is much too
loosely used. Too often, it is used to describe a nipple that might
really have only a tendency to retract on compression of the areola, and
with good lactation management, will be able to serve mom and babe just
fine.

Anticipatory guidance must include a great deal of reassurance for the
mother, to counteract the marked psychological vulnerability that often
goes along with the term "inverted nipples".

Lynn, I posted you privately, I believe. Did the prone position work at
all? If the arm nearest the baby's head is well supported with a pillow
(with mom in supine position with perhaps 2 pillows under her head and
shoulders), I have found this to be an excellent position for brand new
moms, especially when there are latch problems.

The weight of the breast "falls away" from the baby's face, and the
weight of the head helps keep baby on deeply. The body can lie well away
from CS incision, either over the opposite breast, or toes pointed at
either hipbone. Mom may need assistance till she can learn to rest the
baby between her breasts and entice him over as he awakes.

Jean
**********
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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