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Knipple Knowledge

Presented by Diana West, BA, IBCLC

Knipple Knowledge

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Diana West, BA, IBCLC

dwestIBCLC@gmail.com

Sir Astley Cooper (1840)
Sir Astley Cooper (1840)

Almost infinite nipple variations

(Montagna, 1974)

“Genetic

expression”

Nipple = Mammal Characteristic

Most animals have specialized skin areas to interface with environment

(Eastwood, 2007)

Characterized by

Reduced hair/feathers/scales

Specific patterns of cell differentiation

Adaptation to changing states

Distinctive keratins to withstand mechanical strain

NIPPLE

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

NIPPLE

PURPOSE

“Handle” infant to grasp breast

Point of interaction between breast and infant

Conduit through which milk passes

Look cute

Nipple = Mammal Characteristic

Total number of nipples = maximum litter size

Half the total number = average litter size

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Nipple Growth and Development

Fetal

4 th week gestation:

Formation of symmetrical ectodermal thickening along embryo’s ventral lateral sides

6 th 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 4 th and 5 th 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

Presented by Diana West, BA, IBCLC

Nipple/Areola Pigment and Pain

No research has shown a relationship between nipple sensitivity or pain and amount of melanin
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
(Delaney, 2010)

Drupelet:

The small sections of a raspberry or blackberry fruit, each containing a seed

Kay Hoover, MS, IBCLC

Hoover, K. Proposing a new term: drupelet. Clinical Lactation 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 Tips

Tips have dense clusters of protrusions and crevices

Nipple Sides

Sides have intersecting grooves for expansion when not erect

Nipple Muscles

Connective tissue has extensive elasticity

Particularly near tip and around ducts

Variation in muscle peptides = Variation in leaking

Knipple Knowledge

Presented by Diana West, BA, IBCLC

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

Wax cast of Human Breast

Prepared by Sir Astley Cooper (1840)

Geddes Ultrasound Study

International Breastfeeding Journal, 2009

Nipple

Nerves

Nipple Nerves  Location of nerves can vary by women a n d b y b
Nipple Nerves  Location of nerves can vary by women a n d b y b

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

the nipple run along milk ducts  Few nerves on nipple side or base Copyright ©

Copyright © 2012 by Diana West, IBCLC

20 of 140

Nipple Ducts

Most ducts branch at 2mm below surface

(Ramsay, 2005)

Closer than previously thought

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

Presented by Diana West, BA, IBCLC

Nipple Variations Problematic for Latching or Milk Removal

Edema

(Cotterman, 2004; Miller, 2004)

Creates traction on areola Can be caused by:

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

Ducts and fibrous tissue stretch

Flat Nipples

Short shank

NOT retracted, but no or very little protrusion

Incidence (Dewey, 2003)

9% Day 1 pp

7% Day 7 pp

Flat Nipples

Typically improve with nursing

Dose dependent

Other Causes of Flat Nipples

Obesity (Jevitt, 2007)

Adipose tissue (fat) expands and creates traction on areola

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Inverted Nipples

AKA: tied, invaginated, tethered, non-protractile

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 Han & Hong Inverted Nipple Classification
Inverted Nipples
Han & Hong Inverted Nipple Classification System
Han & Hong Inverted Nipple Classification System
Han & Hong Inverted Nipple Classification System
Nipple is easily pulled out
Nipple is easily pulled out
Nipple is easily pulled out
Grade 1
Grade 1
Grade 1
manually, maintains protrusion
manually, maintains protrusion
manually, maintains protrusion
Nipple can be pulled out
Nipple can be pulled out
Grade 2
Grade 2
manually, but does not maintain
manually, but does not maintain
protrusion
protrusion
Grade 3
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

Inverted Nipples

50% congenital 50% from trauma, disease, surgery

Other Causes of Inverted Nipples

FLN

Funny Looking Nipple

Other Causes of Inverted Nipples  Fat necrosis  Benign inflammatory condition  Secondary to:
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

Presented by Diana West, BA, IBCLC

Other Causes of Inverted Nipples

Breast abscess

Duct ectasia

Plug and

inflammation

when NOT

lactating

Benign

Inverted Nipple Surgeries

Inverted due to short ducts

Nipple Nudge for Flat or Inverted Nipples

Inverted Nipple Surgeries

Inverted due to adhesions

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

Presented by Diana West, BA, IBCLC

Nipple Shield for Flat or Inverted Nipples

MUST be

applied

correctly

Supple Cup for Flat or Inverted Nipes

Pumping to Evert Flat or Inverted Nipples

Nipple Shield for Inverted or Flat Nipples

Baby MUST

be latched

deeply

Reverse Pressure Softening (RPS) for Flat Nipples Due to Edema

Other Suction Devices for Flat or Inverted Nipples

Avent Niplette

(McGeorge, 1994)

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Other Suction Devices for Flat or Inverted Nipples

Maternal Concepts Evert-It

Other Suction Devices for Flat or Inverted Nipples

Modified Syringe

(Thorley, 1997)

Retracted or Dimpled Nipples

Unilateral or bilateral

Sides normal

Center area pulled inward

Other Suction Devices for Flat or Inverted Nipples

Lansinoh LatchAssist

What’s NOT EFFECTIVE for Flat or Inverted Nipples

Hoffman’s exercises

No permanent effect

(Alexander,1991; MAIN Trial, 1994)

Breast shells

No permanent effect

(Alexander,1991)

Retracted or Dimpled Nipples

Interior

retains

moisture

Susceptible

to infection

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Nipple Tags

Supernumerary Nipples

“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

Can appear on areola (Abramson, 1975;

Arranz López, 2005; Onesti, 2010)

Most common location: on milk line just below breast

Bulbous Areola

May

indicate

hypoplasia

(insufficient

glandular

tissue)

Can Have Accessory Breast Tissue

Supernumerary Nipples

Can form anywhere along milk lines

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Kajava’s 1915 Supernumerary Nipple Classification System Classification Description 1 + nipple, areola, glandular
Kajava’s 1915 Supernumerary
Nipple Classification System
Classification
Description
1
+ nipple, areola, glandular tissue
Polymastia
2
+ nipple, glandular tissue
– areola
3
+ glandular tissue, areola
– nipple
4
+ glandular tissue only
5
+ nipple, areola, adipose tissue
– glandular tissue
6
+ nipple only (most common type)
Polythelia
7
+ areola only
Polythelia areolaris
8
+ hair patch only
Polythelia pilosa
Distribution of Supernumerary Nipples Among Selected Populations Population Prevalence Citation Caucasian Europeans
Distribution of
Supernumerary Nipples
Among Selected Populations
Population
Prevalence
Citation
Caucasian Europeans
0.22%
Mathes, 2006
Caucasian Americans
0.6%
Kenny, 1997
African Americans
1.6%
Rahbar, 1982
Israelis
2.5%
Mimouni, 1983
Arabs
4.7%
Jaber, 1988
Japanese
5%
Johnson, 1986

Supernumerary Nipples

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)

Supernumerary Nipples

0.22-6% population

Ethnic,

geographic

variance

Supernumerary Nipples

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

“Intra- Areolar Polythelia”

May or may not be fused together

Each nipple has own duct system

(Onesti, 2008)

Knipple Knowledge

Presented by Diana West, BA, IBCLC

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

Very Large Nipples

(OBD Oral-Boobular Disproportion)

Very Long Nipples

Surgery for Bifurcated or Double Nipples

Nipple Reduction

Very Small Nipples

Knipple Knowledge

Presented by Diana West, BA, IBCLC

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 Paget’s Disease (Osther, 1990)

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Malignant Tissue on Nipple

Paget’s Disease (Osther, 1990, Jamali, 1996)

Unilateral

Looks like eczema

1-3% of all breast cancers

Psoriasis on Nipple

Thick, red skin with flaky, silver- white patches (scales)

(Islam, 2000)

Itchy Not contagious

Nipple S. aureus (Staph) Infection

Risk of mastitis Risk of abscess

Paget’s Disease

medicalpicturesinfo.com/breastcancer pagets /

Nipple S. aureus (Staph) Infection

Common nipple infection

(Livingstone, 1999)

Can cause impetigo vulgaris

Daily water and soap cleansing helps destroy biofilm (staph’s protective

barrier) (Ryan, 2007)

Story of my client…

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Nipple and Breast Abscess

Nipple Vasospasm

Intermittent ischemia (lack of blood supply)

Can be very painful

Often secondary to trauma

Biphasic or triphasic

Lisa Amir’s Color Chart PINK / RED Candida YELLOW Bacteria BRIGHT RED WHITE Eczema /
Lisa Amir’s Color Chart
PINK / RED
Candida
YELLOW
Bacteria
BRIGHT RED
WHITE
Eczema /
Vasospasm
Dermatitis

Infection within Nipple

Nipple Squeeze for 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

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Herpes Virus on Nipple

Discrete lesions at juncture of nipple and areola (Amir, 2004)

Usually herpes simplex type 1

VERY painful

Congenital Poland s 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 Poland s Syndrome

Usually webbed fingers (cutaneous syndactyly) on same side hand Severity varies

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 Poland s 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)

Knipple Knowledge

Presented by Diana West, BA, IBCLC

After Wart Removal

(Verma, 2011)

Nipple Procedures Problematic for Latching or Milk Removal

Nipple Procedures Problematic for Latching or Milk Removal

Nipple Piercings

Milk may leak through openings

No muscle to close

Potential for

nerve damage

(Garbin, 2009)

Reduced milk

ejection

reduced milk

production

Neurofibromatosis

Type I

Also known as von Recklinghausen disease

Genetically-inherited disorder

Nerve tissue grows benign tumors (neurofibromas)

May compressing nerves and other tissues

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

Areola Piercings

HIGH

Potential

for nerve

damage

Knipple Knowledge

Presented by Diana West, BA, IBCLC

Breast Tattoos

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

THE END

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Nipple/Areola Injuries

It’s Up to the Baby

Open, connected milk ducts +

Anatomical Fit +

A Determined, Capable Baby

= Nipple Problem Solved!

Bibliography

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Knipple Knowledge

Presented by Diana West, BA, IBCLC

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McGeorge, D. The "Niplette": an instrument for the non-surgical correction of inverted nipples. Br J Plast Surg 1994 Jan; 47(1):46-9. Mills D, Gordon EJ, Casano A, Lahti SM, Nguyen T, Preston A, Tondre J, Wu K, Yanase T, Chan H, Chia D, Esfandiari M, Himmel T,Love SM. The physiology of the normal human breast: an exploratory study. J Physiol Biochem. 2011

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Mimouni F. Association of supernumerary nipples and renal anomalies. Am J Dis Child. 1988 Jun;142(6):591-2. Mimouni F, Merlob P, Reisner SH. Occurrence of supernumerary nipples in newborns. Am J Dis Child. 1983 Oct;137(10):952-3.

Sadove R, Clayman MA. Surgical procedure for reversal of nipple piercing. Aesthetic Plast Surg. 2008 May;32(3):563-5. Epub 2008 Apr 4. Sanuki J, Fukuma E, Uchida Y. Morphologic study of nipple-areola complex in 600 breasts. Aesthetic Plast Surg. 2009 May;33(3):295-7. Epub 2008 Jul 15. Sarhadi, M., Shaw Dunn, J., Lee, F., Soutar, D. An anatomical study of the nerve

supply of the breast, including the nipple and areola. Br J Pl Surg 1996;49:156-

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Knipple Knowledge

Presented by Diana West, BA, IBCLC

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