Margaret writes:

<The archives also mentioned that there are different varieties of
inverted nipples -- could someone discuss that in more depth.  How would
I know what I'm really seeing when I meet with this woman prenatally.>

There are differing points of view within the lactation community re: types.
I got my information from a plastic surgery article and it helped me in
differentiating between "invaginated" and "umbilicated" types, and a
separate category for functional retraction, of my own definition.

Unbilicated is almost self explanatory, like an "innie" unbilicus. In this,
the nipple button is fully formed, but is retracted inside the circle formed
by the circular muscles in the areola. Some can be stimulated and will come
out spontaneously, or with actual pulling with the fingertips. Others seem
really deeply "stuck" and you can't really tell that that's what you are
dealing with until they finally can be persuaded to emerge.



Schwager RG, Smith JW, Fray GF, Goulian D Jr., Inversion of the Human Female
Nipple, With a Simple Method of Treatment, *Plastic & Reconstructive
Surgery, Nov. 1974, Vol. 54, No. 5 pp. 564-569.*





This is the original article I found with embryology reference to Keith
Moore, and includes classifications of inversion. This gives pictures and
explanation of results of autopsies and surgery showing 50-100% more dense
connective tissue of everted nipples.



Invaginated nipples seem to have the skin and connective tissue that was to
have been the nipple button permanently spread out to line a tube (likened
to the vagina) that ends in a pit and never formed into a nipple button. For
me, the most telling aspect is that in the failure of the eversion process,
the lactiferous sinuses also stayed deep inside, and they are buried so
deeply that even if they do fill to the usual degree (less than 1/8 to 3/16"
in my experience, they are so deep that palpation and compression can never
each them.



However, if a good MER is establshed, milk released can be collected by
pump. This depends greatly onhaving the other nipple everted, nursed and/or
pumped however. I have never observed a mother with two invaginated inverted
nipples.(Not that there may not be some, but I have not yet had the chance
to observe one.)



I suggest you try to take closeup photos from several different angles now,
during mid pregnancy, and follow up during the subsequent stages of any
treatment. I no longer believe in very much effectiveness of shells to "draw
out" nipples. There are holes in shells, therefore there could be no actual
vacuum. Whatever success others may have had, I believe it purely
permissive-the absence of pressure over the central areola itself simply
permits umbilicated nipples that are not very deeply buried to emerge in
their own time.



Given the difficulty of telling which kind of structure lies beneath when
viewing the pit itself, if gently trying to manually palpate brings no
insight, if the mother desires to prepare, for medico-legal reasons, I
myself would now wait till 37 weeks, and even then, inquire whether the
doctor has placed any restrictions on sexual activity. This allows time for
what plastic surgeons call tissue expansion (the best example of which is
the skin and musculature of the pregnant abdomena). This is why I believe
that prenatal preparation is superior to postpartum measures when mother is
agreeable. I do not agree with the Main trial that it is of no value to even
examine for nipple protractility since their findings were that many mothers
would simply be discouraged by findings and instructions to prepare. I
personally believe the mother deserves information and the chance to make
that decision herself.



Then, based on my last "stubborn" case that eventually fully everted without
interim retraction in time for the initial nursing period, I would use the
original Egnell pattern from his 1940's article: Double electric pump for 5
minutes three times a day for  one week, then build up to 10 minutes at a
time, 4 times a day till term, giving the mother guidance on observing
herself for Braxton-Hicks contractions and being guided by the severity of
them whether to slow down the stimulation and keep in contact with you.



I would be glad to offer any help to you (or others) privately, especially
if close-up photos are made.



Jean

**************************

K. Jean cotterman RNC, IBCLC

Dayton OH USA

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