Anne describes:

<literally firm tissue (maybe like a bicep) and a nipple that does not evert (possibly has a lot of connective tissue?)>

So what you have described seems to me to be some degree of inversion. There may also be some degree of abnormality in the subareolar tissues. In several decades past, I was very interested in scenarios like this, and did a number of unpublished case studies. I know there has since been a more or less "official classification" but the plastic surgeon's article from which description I was visualizing the mother used the terms "umbilicated" and "invaginated" to describe two main categories, which he ascribed to varying degrees of incomplete formation in the development of the breast/nipple.

"Umbilicated" nipples he described using the familiar concept of "inny" or "outy" of our belly buttons. This nipple is well formed but is "buried'' inside the areola by the tightness/tug of the underlying tissue combined with the circular muscles of the areola contracting over and above it, and when the nipple comes out (with some effort as you have described) it appears to be a well formed nipple, but often these nipples "draw" back inwards between the feedings, at least in the early weeks. 

 
"Invaginated" nipples he described as the skin that would ordinarily cover the nipple actually lining the "pit" at the bottom of which was the skin of the tip of the nipple which would never fully develop and evert under any circumstances due to the lack of connective tissue that is supposed to be laid down in the last several months before and the first several weeks after birth.


I remember two specific moms. The first mom had one fairly well everted nipple, and one that appeared to be invaginated. We used a hand pump, following Egnells's original 1950-or-so directions for prenatal encouragement of inverted nipples to evert themselves. The fairly everted side became even more well everted, but the inverted side never came out. In the hospital, milk was released from that side during the MER however. I explained several choices that involved nursing on one breast and pumping the other for use as supplemental feeding, versus gradually removing less and less by pump to let that side dry up, and continue to nurse on one side only, similar to mothers of twins who are able to produce enough for one "breastful" per each baby, or more. Due to some personal family situation, she chose to do the latter and the last I heard from her was at 4 months, and she was still nursing exclusively on the one side.


The second mom had two of what appeared to be invaginated nipples looking exactly like the invaginated nipple described above. She was from the far east and her sisters had all nursed and she wanted to do the same.  Long story short, with her doc's permission, at 37 weeks, we had her use a double electric breast pump using Egnell's original directions, and a week before birth a very obvious pair of umbilicated nipples began to peek out for 5 minutes or so after pumping. She was familiar with the pump prenatally, and found that if she used the pump prior to latching, her baby was easily able to latch. This despite the fact that she had had a CS and edema in her legs up in her thighs! 


This was long before I paid much attention to pre-L-II edema of the breasts in mothers with a lot of IV fluids, or thought of the eventual concept of RPS. Somehow, I don't remember her describe any problems by using the pump to cause the nipples to evert themselves either prenatally or postpartum. For other reasons she later started supplementing at home, saying "He's not fussy. He'll latch on to either", eventually weaning at 6 weeks and very happy with her success that equaled that of her sisters.


Thank heaven these ideas all occurred to me before the Main trials and the advice not to advise any prenatal nipple care for fear of making the mother have negative sensations and decide not to breastfeed at all. Otherwise I, too, may have decided to ignore examining the breast and nipple prenatally as so many moms still seem to report. In that case, I would also have chosen not to offer moms the choice of a "nipple-function test" in the late third trimester. Instead, if the mom did accept the offer, I explained her breast changes simply, tested for obvious retraction or inversion, and also showed her how to do gentle breast compression, hand express a drop, and where the baby's  tongue and jaw should press, (and saw the light bulb light up over her head) and left her feeling confident after I commented positively about how normally her nipples seemed to look and function. Only those mothers with obvious such problems were counseled in the Egnell directions with a pump. That is also part of the reason I firmly believe in the kinesthetic learning route, both in the care provider and the mother.

Best wishes to this mom. She is fortunate to have had your insights to help her.


K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC      Dayton OH

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