Nipple Knowledge Presented by Diana West, BA, IBCLC

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Knipple Knowledge Presented by Diana West, BA, IBCLC

Knipple Knowledge NIPPLE Derived from the Old English word neb, meaning "beak," "nose," or "face"

cÜxáxÇàxw uç Diana West, BA, IBCLC [email protected]

NIPPLE PURPOSE

 “Handle” infant to grasp breast  Point of Sir Astley Cooper (1840) interaction  Almost infinite between breast nipple variations and infant (Montagna, 1974)  “Genetic  Conduit through expression” which milk passes  Look cute

Nipple = Mammal Nipple = Mammal Characteristic Characteristic  Most animals have specialized skin  Total number of nipples = areas to interface with environment maximum litter size (Eastwood, 2007)  Characterized by  Half the total number =  Reduced hair/feathers/scales average litter size  Specific patterns of cell differentiation  Adaptation to changing states  Distinctive keratins to withstand mechanical strain

Nipple Growth and Nipple Growth and Development Development  Fetal  Fetal  4th week gestation:  2-3 months Formation of gestation: Breast symmetrical glandular tissue ectodermal forms near 4th and thickening along 5th ribs, ectodermal embryo’s ventral lines recede lateral sides . This is when  6th week gestation: malformations Milk lines develop (supernumerary nipples/polythelia) occur

Tanner Stages of Nipple Nipple Size and Position Development Can vary between breasts Pregnancy and nursing can increase size, often permanently

Nipple/Areola Pigment Nipple/Areola Pigment Contains melanin  Melanin increases (darkens) during pregnancy to increase resistance to  Protection from ultraviolet rays UV rays and abrasion  Resists abrasion

Nipple/Areola Nipple Tips Pigment and Pain Tips have dense No research has shown clusters of a relationship between nipple sensitivity or pain protrusions and amount of melanin and BUT redheads have crevices melanocortin-1 receptor gene (MC1R) that makes them more sensitive to pain (Delaney, 2010)

Drupelet: The small sections of a Nipple Sides raspberry or blackberry fruit, each containing a seed  Sides have intersecting grooves for Kay Hoover, MS, IBCLC expansion when not erect

Hoover, K. Proposing a new term: drupelet. Clinical Lactation 2013:4(1);36.

Nipple Muscles Nipple Muscles

 Muscles converge toward nipple in  Connective tissue has extensive radial, circular pattern elasticity  Longitudinal muscles most prominent  Particularly near tip and around ducts in center where they meet ducts  Variation in muscle peptides = Variation in leaking

Nipple Muscles Nipple Nerves  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  Location of nerves can vary by women  NOT like sexual erection and by breasts (Sarhadi, 1996)  Same pilomotor reflex that causes  Nerves inside the nipple run along milk goose bumps ducts  Few nerves on nipple side or base

Wax cast of Human Breast Prepared by Sir Astley Cooper (1840) 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)

Nipple Flat Nipples

Variations  Short shank Problematic  NOT retracted, for Latching but no or very little protrusion or Milk  Incidence (Dewey, 2003) Removal  9% Day 1 pp  7% Day 7 pp

Edema (Cotterman, 2004; Miller, 2004) Flat Nipples  Creates traction on areola Typically improve with nursing  Can be caused by: . Excess IV labor fluids  Dose dependent – 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  Adipose tissue (fat) expands and creates tissue stretch traction on areola

Inverted Nipples Inverted Nipples  AKA: tied, invaginated, tethered, 50% congenital non-protractile 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 Other Causes of Inverted Nipples Han & Hong Inverted Nipple Classification System

Nipple is easily pulled out Grade 1 manually, maintains protrusion FLN Nipple can be pulled out Grade 2 manually, but does not maintain Funny Looking Nipple protrusion

Nipple can pulled out manually Grade 3 with difficulty

Other Causes of Other Causes of Inverted Nipples Inverted Nipples  Fat necrosis Cancer  Benign inflammatory  Timing is condition very important  Secondary to: . If it happened . Breast injury or recently and trauma spontaneously: . Surgery or – Could be from biopsy scar tissue in or around lesion or duct . Radiation  Unilateral, even slight, is more suspicious  Common in very large breasts

Other Causes of Inverted Nipple Surgeries Inverted Nipples  Breast abscess  Inverted due to  Duct ectasia adhesions  Plug and inflammation when NOT lactating  Benign

Inverted Nipple Surgeries Positional Modifications for Flat or Inverted Nipples  Inverted due to short ducts  Laid-Back/ Biological Nurturing

Nipple Nudge for Flat or Nipple Shield for Flat or Inverted Nipples 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)

Nipple Shield for Flat or Nipple Shield for Inverted Inverted Nipples or Flat Nipples MUST be Baby MUST applied be latched deeply correctly

Supple Cup for Flat Reverse Pressure Softening or Inverted Nipes (RPS) for Flat Nipples Due to Edema

Pumping to Evert Flat or Other Suction Devices for Inverted Nipples Flat or Inverted Nipples

Avent Niplette (McGeorge, 1994)

Other Suction Devices for Other Suction Devices for Flat or Inverted Nipples Flat or Inverted Nipples

Maternal Concepts Evert-It

Lansinoh LatchAssist

Other Suction Devices for What’s NOT EFFECTIVE for Flat or Inverted Nipples Flat or Inverted Nipples

Modified Syringe  Hoffman’s exercises (Thorley, 1997)  No permanent effect (Alexander,1991; MAIN Trial, 1994)  Breast shells  No permanent effect (Alexander,1991)

Retracted or Dimpled Nipples Retracted or Dimpled Nipples

 Unilateral or bilateral  Interior retains  Sides normal moisture  Center area pulled  Susceptible inward to infection

Nipple Tags Bulbous Areola  May indicate hypoplasia (insufficient glandular tissue)

Can Have Accessory Supernumerary Nipples Breast Tissue  “Polythelia”  Accessory nipple  May or may not include glandular tissue  May or may not include areola  May or may not include hair patch

Supernumerary Nipples Supernumerary Nipples

 Can appear on areola (Abramson, 1975;  Can form Arranz López, 2005; Onesti, 2010) anywhere  Most common location: on milk line along milk just below breast lines

Kajava’s 1915 Supernumerary Supernumerary Nipples Nipple Classification System Classification Description 1 nipple, areola, glandular tissue  0.22-6% Polymastia + 2 + nipple, glandular tissue population – areola 3 + glandular tissue, areola – nipple  Ethnic, 4 + glandular tissue only geographic 5 + nipple, areola, adipose tissue – glandular tissue variance 6 nipple only (most common type) Polythelia + 7 areola only Polythelia areolaris + 8 hair patch only Polythelia pilosa +

Distribution of Supernumerary Nipples Supernumerary Nipples Among Selected Populations Held magical powers Population Prevalence Citation Sign of virility and Caucasian Europeans 0.22% Mathes, 2006 divine powers in men Caucasian Americans 0.6% Kenny, 1997 Sign of a witch in women African Americans 1.6% Rahbar, 1982  To suckle the devil Israelis 2.5% Mimouni, 1983 Arabs 4.7% Jaber, 1988 Japanese 5% Johnson, 1986

Supernumerary Nipples Bifurcated or Double Nipples

 14.5% have kidney and urinary tract  Actually two malformations (Varsano, 1984; Kenney, 1987; Mimouni, nipples 1988; Ferrara, 2009)  “Intra- Areolar Polythelia”  Tend to run in families  May or may (Casey, 1996; Cellini, 1988) not be fused  Incidence of kidney together  Each nipple and urinary tract has own malformations ↑ 30% duct system (Casey, 1996) (Onesti, 2008)

Surgery for Bifurcated or Bifurcated or Double Nipples Double Nipples  Usually hereditary (Abramson, 1975)  Often unilateral  Affected breast may have larger areola (Lopez, 2006)

Very Large Nipples Nipple Reduction (OBD  Oral-Boobular Disproportion)

Very Long Nipples Very Small Nipples

Nipple and Nipple Galactocele Areola Conditions Problematic for Latching or Milk Removal

Nipple Candida (Yeast) Nipple Candida (Yeast) Infection Infection

 Usually C. albicans  May have white  Red skin, shiny crusting  Burning/ stabbing  Pacifier and bottle pain use greatly increases  Can be passed risk (Morrill, 2005) back and forth with nursling

Eczema on Nipple Eczema on Nipple

Usually have a prior history of  Can occur after introduction of solids allergies (Barankin, 2004)  Inflammation creates opportunity for  Can include erythema (redness), staph infection fluid-filled blisters, crusts, fissures,  Common scaling, friable skin  Not contagious (Rago, 1988, Ward, 1997)  NO FLAKING  Burning and itching are common If unilateral, refer to rule out Paget’s Disease (Osther, 1990)

Malignant Tissue on Nipple Paget’s Disease

 Paget’s Disease (Osther, 1990, Jamali, 1996)  Unilateral  Looks like eczema  1-3% of all breast cancers

medicalpicturesinfo.com/breast‐cancer‐pagets/

Nipple S. aureus (Staph) Psoriasis on Nipple Infection Thick, red skin  Common nipple infection with flaky, silver- (Livingstone, 1999) white patches  Can cause impetigo (scales) vulgaris (Islam, 2000)  Daily water and soap cleansing helps Itchy destroy biofilm (staph’s protective Not contagious barrier) (Ryan, 2007)

Nipple S. aureus (Staph) Story of Infection my client… ↑ Risk of mastitis ↑ Risk of abscess

Nipple and Breast Abscess Infection within Nipple

Nipple Squeeze Nipple Vasospasm for Vasospasm  Intermittent ischemia (lack of blood supply)  Can be very painful  Often secondary to trauma  Biphasic or triphasic

Lisa Amir’s Color Chart Nipple Bleb

 Blocked nipple pore  Leading edge of plugged duct PINK / RED YELLOW  Pinpoint pain, may radiate deep in Candida Bacteria breast  TX: BRIGHT RED  Lancing with sterile needle WHITE  Hydrocortisone cream with occlusive Eczema / Vasospasm dressing (plastic wrap) Dermatitis  Massage

Herpes Virus on Nipple Herpes Virus on Nipple

 Discrete lesions at juncture of  Can be transmitted TO baby nipple and areola (Amir, 2004) (Sullivan, 1983)  Can be fatal to baby under 1 month old  Usually herpes simplex type 1  Can be transmitted FROM baby  VERY painful (Sealander, 1989)  Direct breastfeeding on affected breast should be suspended until lesions are healed  Safest to pump and “sacrifice”

Congenital Poland’s Congenital Poland’s Syndrome Syndrome Absent nipple on one side Incidence 1:10,000 - 1:100,000 Absent chest muscle  Chest often concave on affected births side 3x more common in boys than  Usually missing breastbone (sternal) portion of the pectoralis muscle girls Breast tissue missing or hypoplastic Affects right side twice as often  May be missing nipple/areola on absent breast as left

Congenital Poland’s Syndrome Nipple Warts  Nevoid hyperkeratosis of the nipple Usually webbed fingers and areola (NHNA) (cutaneous syndactyly)  Unilateral or bilateral on same side hand  Asymptomatic Severity varies  Unknown etiology, may be related to estogen levels

(Verma, 2011)

Neurofibromatosis After Wart Removal 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 Nipple Piercings or Milk Removal  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 Areola Piercings

 Milk may leak HIGH through openings Potential  No muscle to close for nerve  Potential for damage nerve damage (Garbin, 2009)  Reduced milk ejection  reduced milk production

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 It’s Up to the Baby

Open, connected milk ducts +

Anatomical Fit +

A Determined, Capable Baby

= Nipple Problem Solved!

Enjoyed this Bibliography presentation? Please LIKE Abramson, D. Bilateral intra-areolar polythelia. Arch Surg 1975, 110:1255. THE END Ahmed, O. and Kolhe, P. Comparison of nipple and areolar sensation after breast Diana West at https:// reduction by free nipple graft and inferior pedicle techniques. Br J Plast Surg www.facebook.com/ 2000 Mar; 53:2 126-9. DWestIBCLC Alexander, J., Grant, A., Campbell, M. Randomized controlled trial of breast shells and Hoffman’s exercises for inverted and non-protractile nipples. Br Med J Questions? 1992; 304:1030-2. Amir, L. Test your knowledge. Nipple pain in breastfeeding. Aust Fam Physician. 2004 Jan-Feb;33(1-2):44-5. Thoughts? Armstrong, M, Caliendo C, Roberts AE. Pregnancy, lactation and nipple piercings. AWHONN Lifelines 2006 Jun-Jul;10(3):212-7. Arranz López JL, Elena Sorando E, Garcia Martinez L, Rodriguez Bravo T. Intra- Comments? areolar polythelia with a partly doubled areola without any other malformation of the breast. Dermatology. 2005;211(4):383-4. Balakrishnan T, and Madaree A 2010 Case report: Ectopic nipple on the sole of the foot, an unexplained anomaly J Plast Reconstr Aesthet Surg. Dec; 63(12):2188-90. Barankin B, Gross MS. Nipple and areolar eczema in the breastfeeding woman. J Thank you for helping mothers and Cutan Med Surg. 2004 Mar-Apr;8(2):126-30. Epub 2004 May 3. Baxter, R. Nipple or Areolar Reduction with Simultaneous Breast Augmentation babies breastfeed! Techniques in Cosmetic Surgery. Plast Reconstr Surg Dec 2003; 112(7):1918-21.

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