Nipple Knowledge

Knipple Knowledge
Presented by Diana West, BA, IBCLC
NIPPLE
Knipple Knowledge
Derived from the

Old English word neb,
meaning "beak," "nose," or "face"
cxxxw u
Diana West, BA, IBCLC
dwestIBCLC@gmail.com
NIPPLE
PURPOSE
SirAstleyCooper(1840)
Almost infinite
nipple variations
(Montagna, 1974)
Genetic
expression
Nipple = Mammal
Characteristic
Handle infant
to grasp breast
Point of
interaction
between breast
and infant
Conduit through
which milk passes
Look cute
Nipple = Mammal
Characteristic
Most animals have specialized skin

areas to interface with environment
Total number of nipples =

maximum litter size
Characterized by
Half the total number =

average litter size
(Eastwood, 2007)
Reduced hair/feathers/scales
Specific patterns of cell differentiation
Adaptation to changing states
Distinctive keratins to
withstand mechanical strain
Copyright 2014 by Diana West, BA, IBCLC
Knipple Knowledge
Nipple Growth and

Development
Fetal
4th week gestation:

Formation of
symmetrical
ectodermal
thickening along
embryos ventral
lateral sides
6th week gestation:
Milk lines develop
Tanner Stages of Nipple

Development
Nipple/Areola Pigment
Contains melanin
Protection from ultraviolet rays
Resists abrasion
Nipple Growth and

Development
Fetal
2-3 months
gestation: Breast
glandular tissue
forms near 4th and
5th ribs, ectodermal
lines recede
This is when
malformations
(supernumerary
nipples/polythelia)
occur
Nipple Size and Position

Can vary between breasts
Pregnancy and nursing can
increase size, often
permanently
Nipple/Areola Pigment
Melanin increases (darkens) during
pregnancy to increase resistance to
UV rays and abrasion
Knipple Knowledge
Nipple/Areola
Pigment and Pain
Nipple Tips
No research has shown

a relationship between
nipple sensitivity or pain
and amount of melanin
BUT redheads have
melanocortin-1 receptor
gene (MC1R) that
makes them more
sensitive to pain
Tips have dense

clusters of
protrusions
and
crevices
(Delaney, 2010)
Drupelet:
The small sections of a

raspberry or blackberry
fruit, each containing a seed
Kay Hoover, MS, IBCLC
Nipple Sides
Sides have
intersecting
grooves for
expansion when
not erect
Hoover,K.Proposinganewterm:drupelet.
ClinicalLactation 2013:4(1);36.
Nipple Muscles
Muscles converge toward nipple in

radial, circular pattern
Longitudinal muscles most prominent
in center where they meet ducts
Nipple Muscles
Connective tissue has extensive

elasticity
Particularly near tip and around ducts
Variation in muscle peptides =

Variation in leaking
Knipple Knowledge
Nipple Muscles
Erection of nipples NOT due to erectile
tissue
Due to contraction of smooth
muscle under control of autonomic
nervous system
Like hair follicle standing on end
NOT like sexual erection
Same pilomotor reflex that causes

goose bumps
Nipple
Nerves
Location of nerves can vary by women

and by breasts (Sarhadi, 1996)
Nerves inside the nipple run along milk
ducts
Few nerves on nipple side or base
Copyright 2012 by Diana West, IBCLC
Wax cast of Human Breast

Prepared by Sir Astley Cooper (1840)
20 of 140
Nipple Ducts
Most ducts
branch at 2mm
below surface
(Ramsay, 2005)
Closer than
previously
thought
Geddes Ultrasound Study

International Breastfeeding Journal, 2009
Nipple Ducts
Number of ducts IN
the nipple is greater
than number of
ducts ON the nipple
(Going and Moffat, 2004)
Converge
# greater than
0.5mm
(sonogram limit)
5-9 (Love and Barsky, 2004)
4-18, avg 9 (Ramsay, 2005)
Knipple Knowledge
Flat Nipples
Nipple
Variations
Problematic
for Latching
or Milk
Removal
Short shank
NOT retracted,
but no or very
little protrusion
Incidence (Dewey, 2003)
9% Day 1 pp
7% Day 7 pp
Edema
Flat Nipples
(Cotterman, 2004; Miller, 2004)
Creates traction on areola

Can be caused by:
Typically improve with nursing

Dose dependent
Excess IV labor fluids

Dilutes plasma proteins
Pitocin (labor or pp)

Chemically close to vasopressin
(antidiuretic hormone)
Preeclampsia
Renal (kidney) clearance impaired
Breast pump
Pulls fluids into areola
Photo courtesy Mahala Lactation

and Perinatal Services, LLC
Flat Nipples
Other Causes of Flat Nipples

Obesity (Jevitt, 2007)
Ducts and fibrous

tissue stretch
Adipose tissue (fat) expands and creates

traction on areola
Knipple Knowledge
Inverted Nipples
AKA: tied, invaginated, tethered,
non-protractile
Inverted Nipples
50% congenital
50% from trauma, disease,
surgery
Caused by short ducts or fibrous

adhesions
3-10% of all nipples
(Alexander, 1992, Park, 1999, Sanuki, 2008)
Inverted Nipples
Han & Hong Inverted Nipple Classification System
Grade 1
Nipple is easily pulled out

manually, maintains protrusion
Nipple can be pulled out
Grade 2 manually, but does not maintain
protrusion
Grade 3
Other Causes of
Inverted Nipples
FLN
Funny Looking Nipple
Nipple can pulled out manually

with difficulty
Other Causes of
Inverted Nipples
Cancer
Timing is
very important
If it happened
recently and
spontaneously:
Could be from
scar tissue in or around lesion or duct
Unilateral, even slight, is more suspicious
Other Causes of
Inverted Nipples
Fat necrosis
Benign
inflammatory
condition
Secondary to:
Breast injury or
trauma
Surgery or
biopsy
Radiation
Common in
very large
breasts
Knipple Knowledge
Other Causes of
Inverted Nipples
Breast abscess
Duct ectasia
Inverted Nipple Surgeries

Inverted due to
adhesions
Plug and
inflammation
when NOT
lactating
Benign
Inverted Nipple Surgeries

Inverted due to short ducts
Nipple Nudge for Flat or

Inverted Nipples
Positional Modifications for

Flat or Inverted Nipples
Laid-Back/
Biological Nurturing
Nipple Shield for Flat or

Inverted Nipples
Can be excellent tool if baby cannot
otherwise latch (Wilson-Clay, 2003)
Does not affect prolactin levels or
reduce milk transfer (Chertok, 2006)
Extended use has not been shown to
be detrimental (Bodley, 1996)
Knipple Knowledge
Nipple Shield for Flat or

Inverted Nipples
MUST be
applied
correctly
Nipple Shield for Inverted

or Flat Nipples
Baby MUST
be latched
deeply
Supple Cup for Flat

or Inverted Nipes
Reverse Pressure Softening

(RPS) for Flat Nipples Due to
Edema
Pumping to Evert Flat or

Inverted Nipples
Other Suction Devices for

Avent Niplette
(McGeorge, 1994)
Knipple Knowledge


Maternal Concepts Evert-It
Lansinoh LatchAssist

Modified Syringe
(Thorley, 1997)
Whats NOT EFFECTIVE for

Hoffmans exercises
No permanent effect
(Alexander,1991; MAIN Trial, 1994)
Breast shells
No permanent effect
(Alexander,1991)
Retracted or Dimpled Nipples

Unilateral or
bilateral
Sides normal
Center area pulled
inward
Retracted or Dimpled Nipples

Interior
retains
moisture
Susceptible
to infection
Knipple Knowledge
Nipple Tags
Bulbous Areola
May
indicate
hypoplasia
(insufficient
glandular
tissue)
Supernumerary Nipples
Polythelia
Accessory nipple
Can Have Accessory

Breast Tissue
May or may not

include glandular
tissue
May or may not
include areola
May or may not
include hair patch
Can appear on areola (Abramson, 1975;
Arranz Lpez, 2005; Onesti, 2010)
Most common location: on milk line

just below breast
Can form
anywhere
along milk
lines
10
Knipple Knowledge
Kajavas 1915 Supernumerary

Nipple Classification System
Description
Classification
1
Polymastia
nipple,areola,glandulartissue
nipple,glandulartissue
areola
glandular tissue,areola
nipple
glandulartissueonly
nipple,areola,adipose tissue
glandulartissue
6
Polythelia
nippleonly(mostcommontype)
7
Polythelia areolaris
areolaonly
8
Polythelia pilosa
hairpatchonly
Population
Prevalence
0.22%
0.6%
1.6%
2.5%
4.7%
5%
0.22-6%
population
Ethnic,
geographic
variance
Distribution of
Among Selected Populations
CaucasianEuropeans
Caucasian Americans
AfricanAmericans
Israelis
Arabs
Japanese
Citation
Mathes,2006
Kenny,1997
Rahbar,1982
Mimouni, 1983
Jaber,1988
Johnson,1986
14.5% have kidney and urinary tract
malformations (Varsano, 1984; Kenney, 1987; Mimouni,
1988; Ferrara, 2009)
Tend to run in families

(Casey, 1996; Cellini, 1988)
Incidence of kidney
and urinary tract
malformations 30%
(Casey, 1996)
Held magical powers
Sign of virility and
divine powers in men
Sign of a witch in women
To suckle the devil
Bifurcated or Double Nipples

Actually two
nipples
IntraAreolar
Polythelia
May or may
not be fused
together
Each nipple
has own
duct system
(Onesti, 2008)
11
Knipple Knowledge
Bifurcated or Double Nipples
Surgery for Bifurcated or

Double Nipples
Usually
hereditary
(Abramson, 1975)
Often
unilateral
Affected
breast may
have larger
areola
(Lopez, 2006)
Very Large Nipples
Nipple Reduction
Very Long Nipples
Very Small Nipples
(OBD Oral-Boobular Disproportion)
12
Knipple Knowledge
Nipple and
Areola
Conditions
Problematic
for Latching
or Milk
Removal
Nipple Candida (Yeast)

Infection
Usually C. albicans
Red skin, shiny
Burning/ stabbing
pain
Can be passed
back and forth
with nursling
Eczema on Nipple
Usually have a prior history of
allergies (Barankin, 2004)
Can include erythema (redness),
fluid-filled blisters, crusts, fissures,
scaling, friable skin
(Rago, 1988, Ward, 1997)
Burning and itching are common
Nipple Galactocele
Nipple Candida (Yeast)

Infection
May have white
crusting
Pacifier and bottle
use greatly increases
risk (Morrill, 2005)
Eczema on Nipple
Can occur after introduction of solids
Inflammation creates opportunity for
staph infection
Common
Not contagious
NO FLAKING
If unilateral, refer to rule out

Pagets Disease (Osther, 1990)
13
Knipple Knowledge
Malignant Tissue on Nipple
Pagets Disease
Pagets Disease (Osther, 1990, Jamali, 1996)

Unilateral
Looks like eczema
1-3% of all breast cancers
medicalpicturesinfo.com/breastcancerpagets/
Psoriasis on Nipple
Thick, red skin
with flaky, silverwhite patches
(scales)
(Islam, 2000)
Itchy
Not contagious
Nipple S. aureus (Staph)

Infection
Risk of mastitis
Risk of
abscess
Nipple S. aureus (Staph)

Infection
Common nipple infection
(Livingstone, 1999)
Can cause
impetigo
vulgaris
Daily water and soap cleansing helps
destroy biofilm (staphs protective
barrier) (Ryan, 2007)
Story of
my client
14
Knipple Knowledge
Nipple and Breast Abscess
Nipple Vasospasm
Infection within Nipple
Nipple Squeeze
for Vasospasm
Intermittent ischemia (lack of blood

supply)
Can be very painful
Often secondary to trauma
Biphasic or triphasic
Lisa Amirs Color Chart

PINK/RED
Candida
YELLOW
Bacteria
BRIGHTRED
Eczema/
Dermatitis
WHITE
Vasospasm
Nipple Bleb
Blocked nipple pore
Leading edge of plugged duct
Pinpoint pain, may radiate deep in
breast
TX:
Lancing with sterile needle
Hydrocortisone cream with occlusive
dressing (plastic wrap)
Massage
15
Knipple Knowledge
Herpes Virus on Nipple

Discrete lesions at juncture of
nipple and areola (Amir, 2004)
Usually herpes simplex type 1
VERY painful
Herpes Virus on Nipple

Can be transmitted TO baby
(Sullivan, 1983)
Can be fatal to baby under 1 month old
Can be transmitted FROM baby

(Sealander, 1989)
Direct breastfeeding on affected

breast should be suspended until
lesions are healed
Safest to pump and sacrifice
Congenital Polands
Syndrome
Absent nipple on one side
Absent chest muscle
Chest often concave on affected

side
Usually missing breastbone (sternal)
portion of the pectoralis muscle
Breast tissue missing or hypoplastic

May be missing nipple/areola on
absent breast
Congenital Polands
Syndrome
Usually webbed fingers
(cutaneous syndactyly)
on same side hand
Severity varies
Congenital Polands
Syndrome
Incidence 1:10,000 - 1:100,000
births
3x more common in boys than
girls
Affects right side twice as often
as left
Nipple Warts
Nevoid hyperkeratosis of the nipple
and areola (NHNA)
Unilateral or bilateral
Asymptomatic
Unknown etiology, may be related to
estogen levels
(Verma, 2011)
16
Knipple Knowledge
After Wart Removal
Neurofibromatosis
Type I
Also known as von Recklinghausen disease

Genetically-inherited disorder
Nerve tissue grows benign tumors
(neurofibromas)
May compressing nerves and other tissues
(Verma, 2011)
Nipple Procedures
Problematic for Latching
or Milk Removal
Nipple Piercings
Recommended by doctors in
Victorian England to improve
breastfeeding
Pregnancy does not affect
(Armstrong, 2006)
High potential for scar tissue

Can block ducts
Nipple Piercings
Milk may leak
through openings
No muscle to
close
Potential for
nerve damage
Areola Piercings
HIGH
Potential
for nerve
damage
(Garbin, 2009)
Reduced milk
ejection
reduced milk
production
17
Knipple Knowledge
Breast Tattoos
Nipple/Areola Injuries
Milk banks will not

accept if tattoo is
less than 1 year old
Risk of infection
Ink molecules too

large to pass into
milk
Nipple/Areola Breast Burns
Its Up to the Baby

Open, connected milk ducts +
Anatomical Fit +
A Determined, Capable Baby
= Nipple Problem Solved!
THE END
Questions?
Thoughts?
Comments?
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presentation?
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Diana West at
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DWestIBCLC
Thank you for helping mothers and

babies breastfeed!
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Knipple Knowledge

Presented by Diana West, BA, IBCLC

Derived from the

Most animals have specialized skin

Total number of nipples =

Half the total number =

Copyright 2014 by Diana West, BA, IBCLC

Presented by Diana West, BA, IBCLC

Nipple Growth and

4th week gestation:

Tanner Stages of Nipple

Copyright 2014 by Diana West, BA, IBCLC

Nipple Growth and

Nipple Size and Position

Presented by Diana West, BA, IBCLC

No research has shown

Tips have dense

The small sections of a

Muscles converge toward nipple in

Copyright 2014 by Diana West, BA, IBCLC

Connective tissue has extensive

Variation in muscle peptides =

Presented by Diana West, BA, IBCLC

Same pilomotor reflex that causes

Location of nerves can vary by women

Wax cast of Human Breast

Geddes Ultrasound Study

Copyright 2014 by Diana West, BA, IBCLC

Presented by Diana West, BA, IBCLC

(Cotterman, 2004; Miller, 2004)

Creates traction on areola

Typically improve with nursing

Excess IV labor fluids

Pitocin (labor or pp)

Photo courtesy Mahala Lactation

Other Causes of Flat Nipples

Ducts and fibrous

Copyright 2014 by Diana West, BA, IBCLC

Adipose tissue (fat) expands and creates

Presented by Diana West, BA, IBCLC

Caused by short ducts or fibrous

Nipple is easily pulled out

Grade 2 manually, but does not maintain

Nipple can pulled out manually

Unilateral, even slight, is more suspicious

Copyright 2014 by Diana West, BA, IBCLC

Presented by Diana West, BA, IBCLC

Inverted Nipple Surgeries

Inverted Nipple Surgeries

Nipple Nudge for Flat or

Positional Modifications for

Nipple Shield for Flat or

Copyright 2014 by Diana West, BA, IBCLC

Presented by Diana West, BA, IBCLC

Nipple Shield for Flat or

Nipple Shield for Inverted

Supple Cup for Flat

Reverse Pressure Softening

Pumping to Evert Flat or

Other Suction Devices for

Copyright 2014 by Diana West, BA, IBCLC

Presented by Diana West, BA, IBCLC

Other Suction Devices for

Other Suction Devices for