Shirley, I was just thinking of writing a note to Lactnet about a mom with flat nipples. It is related to your case because I needed to offer interventions for other staff nurses. Although I am the lactation consultant, my primary job is as a staff nurse. I am budgeted for 8 hours a week for strictly lactation consultant time. I live close to the hospital and go in for short periods of time. I also frequently receive calls at home. This week, we had a mother with very large, soft breasts and flat, soft, small, inverted nipples. The baby was small and, due to maternal antibodies, was jaundiced. We work 12 hour shifts. At 7 a.m., the nurse reported that the baby couldn't latch on. She had tried to use a breast pump to pull the nipple out, but didn't have good results. The nurse had finally used a nipple shield and got the baby to latch on and reported that she nursed well. The phrase, nursed well, always makes me ill at ease. I've been charting the phrase, audible swallow, and have done short inservices and provided articles, but change is slow. The mother-baby pair were part of my assignment for the shift. Colostrum could easily be hand-expressed. However, the colostrum just sort of pooled in a little dimple of the mom's breast. The baby would latch onto the breast, but her mouth was far too small to compress the collection ducts. When the baby sucked on the silicon nipple shield, she did not stimulate the breast enough to obtain any colostrum. The baby sucked effectively enough at breast to obtain a supplement through a supplementing device. Since the mother's breasts could not be effectively stimulated by the baby, we ended up by having the mom put the baby to breast, then cup feed, and use an electric pump. When the mom developed a better milk ejection reflex, the baby received some milk at breast, but I expect that supplementation (preferably with mom's milk) will be necessary for awhile. (The jaundice makes adequate intake expecially important). I gave the mother my telephone numbers and will also follow up by calling her. (I gave her other resources, also) Now I'll finally put in my general recommendations to nursing staff. First, get the baby awake. Unwrap the kid, hold her upright. I tell moms that babies are sometimes like those dolls that open their eyes when you hold them up, and close them when they are lying down. Tell the baby (and mom) that babies eat better when their eyes are open. Show the mom how to stimulate the baby's lower lip to open the mouth and stick out the tongue. I also usually unwrap the blanket and try skin-to-skin contact of mom and baby. Next, get the mom in a comfortable, supported position. A lot of nurses don't think about using bedspreads as armrests for the mom. For a baby that doesn't stay on the breast, the football, crosshold, or sidelying positions allow the mother to keep the baby close, because there is more support of the head. One caution about the football or cross-hold is to avoid touching the occipital area (back) of the head. If the mother's hand is at the base of the head (top of the neck), she has good support, but won't be stimulating the baby to push away. Also, if it has been a traumatic delivery, the baby's occipital area may be tender and bruised. The most effective ways I have found to get nipples out are the use of a breast pump (we usually use a hand pump) or to make a "nipple puller" from a syringe (as illustrated in an article in an issue of the Journal of Human Lactation (that issue is at the hospital. Let me know if you haven't seen it and I'll find the reference). An even more important point is that most babies can latch onto flat nipples. I remind nurses and moms that they are BREASTfeeding, not nipplefeeding. The main problem in the hospital is that the baby won't wake up. People concentrate on the fact that mom's nipples don't look and feel like the rubber ones that can be forced into a baby's mouth. After the baby's mouth is open and the tongue is extended, make sure the baby is held close and the lips are everted. I do a lot of "flipping the lips" and gently pulling downward on the chin. If the baby has been sucking on a rubber nipple, it is quite possible that the lips are tucked in and the tongue is bunched up so that the baby is pushing the breast out of the mouth. It's nice to hear that the hospital nurses are interested enough to ask for suggestions. A big part of consulting for me is to praise the mother and praise the nurses. It can be so frustrating to get breastfeeding established and so nice when people can be persistent enough to get things working. That's enough writing. My husband wants the computer. Becky