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6/01 c:/ClFiC/DateDue.p65-p.15

 

A BREAST ASSESSMENT TOOL TO IDENTIFY
INVERTED NIPPLES IN PREGNANT WOMEN

BY

Tamra J. Harris—Ashley

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

2000

To my husband Ted:
. . . for there is nothing greater than
this—— when a husband and wife keep a

household in oneness of mind.

-- Homer, c. 700 B.C.

ACKNOWLEDGMENTS

The rewards of being led down life’s path by the gifts
bestowed from the Almighty God can never be fully expressed
in words. But I am thankful for joining the nursing
profession and the enrichment it brings to one’s life. I
eagerly await what the next level of learning nursing will
bring in my life’s path to come.

Thanks to the committee Chairperson Louise Selanders
and members Kathy Dontije and Kate Lein for their direction
in this project.

To my wonderful children Bekah, Abby, Chelsea, and
Austin: Thanks for your understanding and love throughout
this project and the demands it put on all our lives.

And I am forever grateful for the love, encouragement,
and support of my husband Ted. Without our teamwork,
attaining this goal would not have been possible, and I

love you for your unflagging support.

m

TABLE OF CONTENTS

LIST OF FIGURES ......................................... v
Introduction ............................................ 1
Statement of the Problem ................................ 4
Significance of the Problem ............................. 6
Purpose of the Project .................................. 7
Conceptual Framework .................................... 8
Nursing ............................................ 12
Patient ............................................ 13
Environment ........................................ 13
Social and Psychological ........................... 15
Health ............................................. 16
Review of the Literature ................................ 17
Scope of the Problem ............................... 17
Limitations ........................................ 18
Provider Knowledge and Support ..................... 19
Mechanics of Breastfeeding ......................... 23
Milk Production .................................... 24
Correction of Inverted Nipples ..................... 26

W

Assessment and Support ............................. 30

Prenatal Assessment ........................... 30
Anticipatory Support .......................... 30
Project Description ..................................... 31
Implications for Practice ............................... 34
Implications for Research ............................... 35

APPENDIX A. BREAST ASSESSMENT TOOL FOR INVERTED NIPPLE
ASSESSMENT AND INTERVENTION ................ 39

REFERENCES .............................................. 41

LIST OF FIGURES

Figure l. Nightingale’s Model of Nursing Practice ...... 10

Figure 2. Modified Holistic Patient: Mother with
Inverted Nipples ............................. 11

Figure 3. Nightingale’s Model of Nurse/Mother
Relationship ................................. 13

Figure 4. Cascade of Lactation Failure with Inverted
Nipples. ..................................... 27

Introduction

Professional associations endorse the recent increase
in breastfeeding because of its many benefits to mother,
infant, and society (American Academy of Pediatrics, 1997;
American Dietetics Association, 1997; Dermer, 1995; 0.3.
Department of Health & Human Services, 1990; Cunningham,
Jellife, & Jellife, 1991). Women who nurse their infants
experience decreased incidences of osteoporosis,
premenopausal breast cancer, and cancer of other
reproductive organs (Moore, Zale, & Moramarco, 1998;
Shadigian, Van Bonn, & Cook, 1998). In addition,
lactational amenorrhea reduces the risk of anemia (Adamson
& Williams, 1992).

To the nursing baby, “this living fluid [breast milk]
provides bioactive compounds with specific physiological
functions” (McCamman & Page-Goertz, 1999, p. 3), especially
during the first year of life (Cunningham, Jellife, &
Jellife, 1991). Benefits include protection from
illnesses, decreased gastrointestinal problems, prevention

of diabetes, increased IQ scores, and decreased

2

incidences of childhood diseases (U.S. Department of Health
and Human Services, 1990).

Given the positive outcomes of breastfeeding, it is
important to educate and support mothers during the
prenatal period when they are considering feeding options.
Inverted nipples are a problem that may deter pregnant
women from considering breastfeeding and/or lead to
unsuccessful breastfeeding. Healthy People 2000 (the 1990
promotional program of the U.S. Department of Health and
Human Services) was targeted at increasing breastfeeding
participation to at least 75% of the breastfeeding
population in the early postnatal period. It further
promoted increasing breastfeeding numbers to 50% at six
months. Ryan (1997) stated that in 1995, despite the
Healthy People guidelines, only 59.4% of women initiated
breastfeeding and only 21.6% were still breastfeeding at 6
months. Despite the governmental education and support of
breastfeeding, the statistics did not support the efforts.

The dramatic health benefits to nursing mothers and
breastfed babies have an economic benefit to society. The
American Dietetics Association (1997) states that cost
projections for the difference in morbidity of the newborn
translates into savings of millions of dollars. Medical

expenses for families and companies are significantly

3

reduced in both direct and indirect costs. Fewer absences
of mothers to care for ill infants result in an expense
reduction for workplaces. In addition, families do not
suffer from lost revenues related to missed employment.
Finally, there are savings to medical insurance companies
due to fewer physician visits and pharmacy costs (Adamson &
Williams, 1992).

In preparing mothers for successful breastfeeding, a
major factor needing thorough assessment is the prenatal
anatomy of nipple inversion (Shadigian et a1, 1998; Walker
& Driscoll, 1989). Nipple inversion is defined as the
inability of the breast nipple to protrude outward from the
breast anytime when stimulated. Although nipple inversion
only affects 10% of the population, it can potentially make
nursing extremely difficult for infants to start a correct
breastfeeding technique (Shadigian et al., 1998). Nipples
with slight inversion will not require interventions in
most cases, but in nipples that are unable to protrude
outward with compression the inverted nipple may and will
benefit from treatment before birth (Mohrbacher & Stock,
1991).

Given the positive outcomes of breastfeeding, it is
important to educate and support mothers during the

prenatal period when they are considering feeding options.

4

Inverted nipples is one problem that may deter pregnant
women from considering breastfeeding and/or lead to
unsuccessful breastfeeding. This paper explores the
prenatal use of a breast anatomy assessment tool for
Advanced Practiced Nurses (APNs) to educate and support
breastfeeding mothers with inverted nipples. In the
primary care setting, APNs have the opportunity and ability
for early assessment of breast abnormalities. Through use
of an assessment tool to evaluate degrees of inversion and
with a decision tree to determine appropriate
interventions, APNs can demonstrate a health—promotion and
problem-prevention approach for women with inverted
nipples.
Statement of the Problem

Nipple inversion is defined as the inability of the
breast nipple to protrude outward from the breast when it
is stimulated. Although only 10% of the population is
affected, inverted nipples can make breastfeeding extremely
difficult (Shadigian et al., 1998). The La Leche League
(1991) claims that treating inverted nipples before
delivery will improve the breastfeeding outcome (Mohrbacher
& Stock, 1991).

DeCoupman (1993) defines inverted nipples as the

inability of nipples to be elastic and be compressed

5

outward from the breast with external manipulation.
Inverted nipples do not normally respond to stimulation or
exposure to cold, and thus do not become erect or protrude
outward (Auerbach & Riordan, 1993; Mohrbacher & Stock,

1991). The La Leche League Answer Book defines inverted

 

nipples as “retracted rather than protrude when the areola
is compressed” (Mohrbacher & Stock, 1991, p. 165). Such
inversion can be unilateral or bilateral, with degrees of
inversion ranging from the nipple being flat with the
breast to completely disguised inside the breast tissue.
It is unclear what causes the inability of the tissue to be
elastic and protrude, but it does appear to have a genetic
component (Auerbach & Riordan, 1993). Breastfeeding aids
(i.e., nipple shields) have been used with success to
correct inverted or flat nipples after an infant’s birth,
especially in the premature population (Meir, Brown, Hurst,
Spatz, Engstrom, Borucki & Krouse, 2000). However,
preventative and promotional approaches can assist pregnant
women to evert the nipple rather than compensating.
Multiple textbooks on lactation (Auerbach & Riordan,
1993; DeCoupman, 1993; Mohrbacher & Stock, 1991) have
discussed in depth the need for assessment and intervention
for inverted nipples, using customized plans based on

suggestions for treatment. The following techniques have

6

been used to promote breastfeeding for mothers with
inverted nipples: Exercises to increase the elastic area
surrounding the breast, use of shells to exert consistent
pressure around the areola, and electric breast pumps
(Auerbach & Riordan, 1993; DeCoupman, 1993). However,
there are no specific guidelines related to degrees of
inversion.

Significance of the Problem

Despite the federal promotional efforts of Healthy
People 2000, breastfeeding trends in the United States are
still far from the target goal of 75 percent (U.S.
Department of Health and Human Services, 1990). Following
a decline in the 19805, the rate increased to 59% by 1995
(Ryan, 1997). Because there is such a significant failure
rate among women with inverted nipples, any improvement in
their success would affect the overall numbers of
breastfeeding women.

A woman's decision to breastfeed can be undermined by
health professionals who lack necessary training and
clinical experience to support her (Newman, 1999). This
lack of support may contribute to the mother's discomfort
and subsequent mismanagement of lactation issues (McCamman
& Page-Goertz, 1999). Up to 96% of women experience nipple

pain that could be prevented by teaching proper positioning

7

and attachment techniques (Cable & Stewart, 1997). For
mothers with inverted nipples, the difficulty of latching
the baby to the breast is compounded by the nipple's
inability to evert.

Purpose of the Project

This scholarly project encourages the use of a breast
assessment tool for inverted nipples in outpatient clinics
delivering care to mothers. Early identification and
education about inverted nipples can guide the mother
toward correct diagnosis, treatment, or referral to a
lactation specialist for early intervention (DeCoupman,
1993).

For this project, an assessment tool was designed as a
guide for those who work in broad-based primary care
settings (Appendix A). Directions for basic interventions
and patient education would be included separately, with
space to document an initial plan and subsequent
reassessment.

Because APNs provide primary care and education to
pregnant women, they are in an excellent position to
implement a tool for nipple assessment. Role
characteristics of APNs demand that they appraise
individuals by collecting subjective and objective data and

assimilate this information into a clinical judgment. In

8

addition, their assessments include social, psychological,
and spiritual dimensions. When combining this process with
a specific assessment tool for inverted nipples, APNs can
provide enhanced health care to a group of patients with
special needs. Thus, by improving outcomes for lactating
women with inverted nipples, APNs can contribute to a
general improvement in numbers of breastfeeding women.
Conceptual Framework

The purpose of a conceptual framework is to define the
functioning of a phenomenon —- in this case, nursing.

Major components within the model describe how the nurse
should conduct the practice of nursing. As with all
models, the goal of nursing is improved health status.

The major concept utilized by Nightingale was
environmental adaptation (Selanders, 1993, 1998). The
framework is a linear model implemented by the nurse in
order to assess the environment, alter the environment, and
assess the resulting outcome. Major concepts of this model
are health and “dys-ease.”

Health is defined as being the best one can be at any
given point in time and is not dependent on any disease
status (Selanders, 1993, 1998). Further health is impacted
by the biological, psychological, social, and spiritual

realms of a holistic individual.

9

Figure 1 describes the client of nursing. The
biological and psychological spheres frequently show
dominance in nursing interaction and therefore are
graphically represented by larger circles. The social
sphere delineates social support systems. The spiritual
influence permeates all aspects of life and therefore is
represented as an encompassing sphere which is permeable to
the environment.

“Dys-ease” is a state in which environmental concerns,
internal or external both, create a condition which is not
optimal for health. In this case, the patient is the
expectant mother with inverted nipples. The environment
(mother) is manipulated by the nurse to aid the mother in
helping herself correct the biological problem (inverted
nipples).

Figure 2 describes the general process of nursing
intervention as outlined by Nightingale. Initially, the
nurse would determine the health status of the client
through observation and collection of both objective and
subjective data. For future use, this information is
entered into the health-care record. The nurse then
identifies specific need for change in the environment and

how this change might occur. Interaction with the client

10

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12

implements the environmental alteration, and this
interaction is documented.
Nursing

Nursing knowledge is achieved through environmental
alteration. Through assessing and manipulating the
environment and utilization of this knowledge, nursing
becomes individualized to specific client situations. The
nursing process is goal-directed and research~driven to aid
patients in improving their condition. According to
Nightingale’s theory, nursing consists of the nurse acting
upon the patient’s environment to facilitate change; the
patient is a recipient of nursing care and not an active
partner (Selanders, 1993).

In the case of inverted nipples and in order to
perform a consistent assessment, a tool should be routinely
utilized. Such a tool will assist those providers lacking
knowledge of breast anatomy in facilitating mothers to
breastfeed successfully. But if a mother does not have
inverted nipples, the tool is still used to educate the
patient about the best way to feed the newborn. For
inverted nipples, the tool also provides the health care
professional with a structured decision-making model
predicted from clinical observations. For instance, degree

of nipple inversion would dictate the level of intervention

13

needed in the plan of care. In both instances of normal or
abnormal nipples, the nurse influences the environment to
achieve successful breastfeeding.
Patient

With Nightingale’s holistic approach, the nurse's role
is one of promoting the breastfeeding environment in a
manner that promotes health of the patient. Figure 3
describes this process. In this instance, the mother with
inverted nipples is the patient. Use of this paradigm
promotes the mother-baby dyad through successful
breastfeeding. In turn, by overcoming the inverted nipple
barrier to nursing the infant, successful breastfeeding
influences the mother’s sense of psychological and
spiritual well-being.

Environment

 

Improving the condition of breast anatomy alters both
external and internal environments, allowing the patient to
cure herself. One external environmental component is
health-care providers. Their outside influences include
the initial identification of the biological problem
(inverted nipples) and subsequent intervention to correct
it. The tool helps nurses classify breast abnormalities
and the decision-tree portion assists them with selecting

appropriate interventions.

14

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15

Once these interventions prove successful, the
internal environment is affected. A mother with inverted
nipples will experience alterations in the nipple anatomy,
resulting in eversion and ability to nurse. Biological
components for alterations in the actual anatomy of the
mother’s breast will influence the mechanical ability of
the newborn to latch correctly and to stimulate milk
production.

Social and Psychological

 

Failure to overcome the biology of inverted nipples
may affect the mother’s ability to feel successful at
achieving the goal of breastfeeding the newborn. The
health care professional's challenge is to support the
mother in her drive to overcome the breast abnormality in
order to support her as the recipient of nursing care in
the treatment of the inverted nipple.

The social barrier is the lack of support from
friends, family, and others who have influence upon the
mother’s life. In particular, the holistic needs of the
family are multidimensional and may affect any or all of
the spheres in the Nightingale model. The nurse may work
with the family, who helps the new mother and child by
positively influencing the outcome of successful

breastfeeding.

16

The psychological barrier is the mother's fear of
failure at nursing. The spiritual need of the mother to
bond with the baby is an integral part of her desire to
accept nursing care to learn how to overcome both the
physiological breast abnormalities as well as the
psychological fear of failure.

Health

This Nightingale model of nursing is based on
experiential observations made in relationship to
individuals and their health status, thereby creating more
positive conditions for the patient to influece the outcome
of successful breastfeeding (Selanders, 1993, 1998). The
nurse helps mothers with inverted nipples by observing the
degree of nipple inversion, documenting the degree of
inversion, and planning nipple alteration.

The tool assists providers, expecially with limited
knowledge of inverted nipples, to make correct evaluations
of the problem and assist the patient to help herself.
Through rehabilitation, activities directly focusing on the
inversion result in the restorative phase of the
difficulty, thus also improving the mother's health
(Selanders, 1998). Feedback is based on the process and
observable outcomes: Does the nipple begin to make

anatomical changes and become evert? If the nipple becomes

l7

evert, the nurse knows the interventions have worked and
the health of her patient has revived; if the nipple does
not evert, reassessment is necessary.

Review of the Literature

Scope of the Problem

 

Misinformation to a mother is at a critical juncture
when she is commencing breastfeeding and can have serious,
negative effects upon her breastfeeding success (Losch,
Dungy, Russell & Dusdieker, 1995). Perhaps the
professionals have sustained the myth that reduced milk
supply cannot be recovered (Elliot, 1996). Or perhaps she
has been told (by both professionals and family/friends)
she will never be able to breastfeed because of her
inverted nipples (Personal Communication, 1998). One survey
of 35 focus groups found that in at least one-third of the
patients seen, the health care professional did not discuss
prenatal feeding plans for the pregnant women (Shadigian et
al., 1998). Another study made the assumption that health
care providers had information about breastfeeding but did
not act on that information, either because it was not in
their scope of practice or they did not feel it was a
necessity (Coreil, Bryant, Westover & Bailey, 1995).

One author suggested providers should enter into

discussion with the patient about the positive physical,

l8

psychological, and sociological effects of breastfeeding in
order to encourage open dialogue, informed decision making,
and anticipatory guidance for the mother (Newman, 1999).
Such discussions would establish the necessary rapport
between mother and health care professional to help
determine any physical abnormalities of the breast which
could have a negative impact upon successful lactation
(Shadigian et al., 1998).

Limitations

 

Literature older than five years consisted primarily
of surveys of small numbers, thus lacking the statistical
power to be generalized. But a significant limitation of
the literature was that breastfeeding assessment and
lactation specialization are relatively new fields.
Historically, pre-World War II mothers nursed their infants
unless there was a medical necessity to stop lactation and
supplement feeding. The bulk of information about
breastfeeding was passed on by mothers and midwives to new
mothers (Aurebach & Riordan, 1993). Scientific and
statistical rationalization was not needed because
breastfeeding was the cultural norm and infants were
thriving on breast milk (Huffman, 1991). In a new era of
scientific inquiry to prove breastfeeding as preferable to

other feeding methods, organizations like La Leche League

l9

and International Board of Lactation Consultants emerged to
reeducate the public on breastfeeding benefits and build a
new body of research information (Auerbach & Riordan,
1993).

There were no specific studies looking at morbidity
and mortality, though one article described “the
detrimental health consequences” of infant formula feeding.
In determining causes of infant deaths, mothers and
researchers began to examine the deceptive advertising that
bottlefeeding was “like breastfeeding”. Formula was
incorrectly mixed or incorrectly formulated at the factory,
causing newborns to experience nutritional deficits and
even death (Palmer, 1991). Such deaths implied a need to
begin new research and also indicated benefits of
breastfeeding demanded greater exploration. But research
inquiries into breastfeeding problems are still very
limited in the literature.

Provider Knowledge and Support

 

Much of the literature showed a distinct lack of
breastfeeding information and support exchanged between
health care providers and patients. Coreil et al. (1995)
used 6 focus groups and 22 in-depth individual interviews
of health department Anglo-American and African-American

clients and professionals. They found that when problems

20

arose, clients were frustrated by conflicting health
education information versus that provided by health-care
professionals. The authors concluded that providers had a
gap in knowledge between promotion of breastfeeding and
support assistance in problem situations. The Coreil study
would suggest if counsel and assistance in the more general
problems of breastfeeding were not adequately addressed,
then the more technical difficulties associated with
inverted nipples might be missed as well (Coreil et al.,
1995).

Anderson and Geden (1990) surveyed 290 nurses in 50
hospitals in a descriptive study focusing on breastfeeding
knowledge of maternal-neonatal nurses. The study had a low
response rate (38%), perhaps implying that those who
participated shared at least some interest in
breastfeeding. Results indicated that nurses had limited
knowledge of breastfeeding basics and were supplying
inaccurate information to patients (i.e., about frequency
of feeds, proper newborn sucking, treatment of plugged
ducts, and mastitis). If respondants to the study were
indeed concerned about breastfeeding knowledge and
nonparticipants were not, then the amount of misinformation
passed on to nursing mothers could be higher than that

found by the authors.

21

To understand the experience of individual persistence
in breastfeeding, Bottoroff (1992) found the commitment of
a mother to breastfeed her infant was the best indicator of
success when difficulties arose, such as sore nipples,
growth spurts, or engorgement. In this phenomenological
investigation, the everyday experiences of three
breastfeeding mothers were reviewed. Initially, no
assistance seemed available and the mothers felt alone
without help of an experienced person. Their anxiety
increased. But with perseverance and resolve to nurse and
with good family support they were able to continue
breastfeeding. Though the research did not offer nurses a
prescription for effective interventions, similar studies
might offer insights into the need for increased
sensitivity to mothers whose inverted nipples could cause a
difficult lactation experience.

In a national, random survey of 1,920 practicing and
3,115 resident physicians (68% response rate), more than
30% of professionals were able to choose correct advice to
give a mother, but less than 20% had demonstrated
breastfeeding techniques in residency. The authors
concluded that doctors were ill prepared to counsel
breastfeeding mothers (Freed, Clark, Sorenson, Lohr, Cefalo

& Curtis, 1995).

22

Another survey of 464 nurses and doctors (33%
response) predominately in private practice found that only
4% even discussed prenatal topics with the mother. Nurses,
rather than physicians, tended to have more contact with
mothers, with nurses supplying the bulk of information
throughout pregnancy (Lazzaro, Anderson & Auld, 1995).

A problem frequently cited in the literature was the
nonsupportive behaviors and attitudes of physicians when
breastfeeding difficulties arose (Heinig, 1998). Most
frequently, the physician's response was to recommend
commencement of bottle feeding (Dermer, 1995; Newman, 1999;
Raj & Plichta, 1998). Providers did not adequately assess
why difficulties in breastfeeding arose. Nevertheless, one
recent study found that health care providers were the most
influential and trusted sources of information to nursing
mothers, yet many professionals were neither prepared nor
able to be good sources of counsel to their nursing patient
mothers (Coreil et al., 1995).

In short, the literature clearly indicated that, in
general, health care providers lacked appropriate knowledge
and counseling techniques for mothers wishing to
breastfeed. For example, Armstrong (1996) concluded
professionals had contributed to nipple confusion because

of their lack of correct assessment of a breastfeeding

23

infant's attachment at the breast. He proposed confusion
was based in part on peer-reviewed medical journals'
failure to have breastfeeding articles reviewed by
knowledgeable individuals and the inadequacy of short-term
studies. More specifically, while incidences of inverted
nipples are relatively low (10%), this inability of the
health care professional to adequately assess or support a
prenatal breastfeeding plan for this population has a
greater impact on postnatal breastfeeding success (Coreil
et al., 1995).

Mechanics of Breastfeeding

 

Assessing if an infant is correctly feeding is
difficult if health care providers are unable to assess the
newborn for latching difficulties. Most professionals
presume the infant is feeding if contact with the breast is
made (Shrago, & Bocar, 1990). It is only determined later,
by a newborn’s poor feeding and weight loss as well as
intense breast pain reported by the mother, that there may
be a preexisting physiological problem interfering with
successful latching. If the nipple is inverted, it does
not stand out and the infant has nothing to grasp onto
(Walker & Driscol, 1989; Shrago & Bocar, 1990).

Ignorance of breastfeeding technique is also

responsible for lack of proper diagnosis. Traditionally,

24

physicians in office practices have utilized prepackaged
gift sets and readily available consumer publications to
support new parents (Valaitits, Sheeshka & O’Brein, 1997).
These methods, while time efficient, are not effective in
determining causes of difficulties in nursing. This time
factor, while not readily acknowledged, plays a significant
role in the lack of proper physician support in difficult
breastfeeding caused by inverted nipples (Valaitis et al.,
1997).

Milk Production

 

Many difficulties in breastfeeding can be avoided or
successfully addressed with a proper assessment of the
breast structure and its suitability for feeding
(Alexander, Grant & Campbell, 1992). One of the most
common myths relates to the size of the breast and its
ability to produce milk. Because milk production results
from hormonal stimulation of the target breast cell,
studies have shown there is no causal effect between milk
production and the breast size Auerbach & Riodan, 1993;
DeCoopman, 1991). Yet the most common reason for mothers
discontinuing breastfeeding is the assumption that milk
supply is inadequate (Kim, 1997).

Milk production is partly regulated by the hormone

prolactin. Increases in prolactin production occur when

25

the nipple and areola are stimulated during breastfeeding.
But when the nipple is inverted, sufficient stimulation to
produce the hormone level necessary to produce milk does
not occur (Shrago & Bocar, 1990).

The term “milk ejection reflex” accurately describes
the physiologic movement of the milk through and out of the
breast. The lactiferous ductal system connects the alveoli
with nipple openings. Contraction of the myoepithelial
cells causes milk to eject through the ductal transport
system once the myoepithelial cells contract under the
influence of the hormone oxytocin (Shrago & Bocar, 1990).
Oxytocin acts as a messenger asking the brain to secrete
prolactin which, based on secretory amount, tells the milk
cells to produce milk. There is a delicate balance between
correct stimulation of breast tissue to secrete the
hormones and feedback to the secretary milk cell located in
the breast (Auerbach & Riordan, 1993).

Milk production is also affected by mechanical
compression, both external and internal, of the lactiferous
sinuses that lie under the areolar surface. Externally,
the infant’s mouth should cover these sinuses. Internally,
the correct movement of the infant’s tongue on the nipple
provides areolar compression between the infant’s tongue

and palate (Desmarais & Browne, 1992; Shrago & Bocar,

26

1990). Proper tactile stimulation of the nipple and areola
commences the neurohormonal operation of milk production
and milk ejection, a process called lactogenesis (Righard &
Alade, 1990; Walker & Driscol, 1989). Breast abnormalities
can hamper this process.

In the case of inverted nipples, if the nipple cannot
be adequately placed in the mouth, compression of the
lactiferous sinuses cannot occur (Desmarais & Brower, 1992;
Shrago & Bocar, 1990). The inability of the newborn to
draw out the nipple does not stimulate the hormonal
feedback loop and causes a reduction in milk supply. This
also causes increased pressure within the alveoli,
significant because breast milk production occurs in the
breast alveoli which are located distally to the nipples
(Ogle & Alfano, 1987). The result is a cascade of
lactation failure (Figure 4), influenced by pressure of
overfullness or pressure atrophy due to oversupply caused
by the infant’s inability to latch to remove milk.

Correction of Inverted Nipples

 

Breastfeeding aids (i.e., nipple shields covering the
nipple during feeding) have been used successfully to
correct inverted or flat nipples after infant birth. These
devices are constructed of silicone and are placed over the

breast and nipple. Nipple shields are harder and more

27

Invetted Nipples

l

i

lntant Incouettly Latched

l

Inadequate Bleast Stimulation

l

ttoncomptessed Lactitetous Sinus
Impaited Milk Removal

i

Enyotyement
Ptessure Atrophy of Milk Settetoty Cells

3

Diminished Ptolactln Release

i

Atrophy of Milk Glands

i

LAC'I'ATlml FAILURE
Ptematutely Reduced Milk Supply

Figure 4. Cascade of Lactation Failure with
Inverted Nipples.

28

graspable for the infant, facilitating latching at
thebreast (Meir, et al., 2000; Elliot, 1996).

In the past, nipple shields have been discouraged
because of the assumption that they decreased milk
consumption from lack of compression of the lactiferous
sinus. However, one study found the device increased
suction and acted as a mini breast pump, thereby increasing
milk to the infant (Meir et al., 2000). Though this was a
small study of 34 premature infants in which only some of
the mothers had inverted nipples, the implications were
significant: A premature infant is weaker than a full—term
baby, but the authors noted a statistical increase (p=02)
in milk consumption. Thus, using a nipple shield not only
provided more milk, but also created a negative pressure
(similar to a breast pump) to encourage nipple eversion.
However, Elliot (1966) recommended that the mother should
be carefully assessed and assisted by skilled help or a
lactation consultant to insure proper usage of a nipple
shield.

Of studies reflecting outcomes of shield use to
correct latching difficulties, one study (Brigham, 1996)
conducted interviews with 51 clients using ultra light
nipple shields, of which 30% had flat nipples and 16%

inverted to varying degrees. The shields were used until

29

breastfeeding problems were resolved and were no longer
necessary. Of these clients, 86% were satisfied with the
shield and thought its use helped them start and continue
breastfeeding. Limitations to this study were that it was
retrospective and subjective.

Alexander et al. (1992), in a randomized, trial study
of 96 women with inverted nipples, evaluated the use of a
breast “shell” to increase elasticity around the nipple.
These shells were hard, plastic discs with a dome-shaped
cap worn inside the bra to exert outside pressure against
the breast tissue to increase elasticity of connective
tissue around the nipple. Their goal was to stretch the
tissue either through exercises or mechanical manipulation
with the shell and compare the two. There was a negative
correlation between the group using nipple shell and the
group using Hoffman exercises. The women who were
prescribed the shell found the it was uncomfortable to
wear, caused leaking of colostrum, and broke down tissue.
The mothers also found wearing the shells was embarrassing.
Many in this group discontinued nipple-shell use, opting
instead to bottle feed. By comparison, the group
prescribed Hoffman’s exercise program showed a 20% increase
in breastfeeding rates. The results of the study were not

statistically significant; however, the author thought

3O

antenatal use of the shell could be detrimental and, in
fact, reduce chances of successful breastfeeding.

Assessment and Support

 

Prenatal Assessment.

 

One helpful assessment question is to ask the mother
is whether her nipples become naturally everted when in the
cold. Most women will readily be able to respond and may
not feel as uncomfortable at a formal physical examination
from a provider. Placing the thumb on the upper areolar
margin and the index finger on the lower margin assesses
the nipple. It is gently press inward slightly toward the
rib cage. Then the fingers are brought together as if
closing a "C" into an "O" (Johnson & Apkar, 1998). The
normal nipple should stay everted and no resistance should
be felt (Shadigian et a1, 1998).

Anticipatory Support.

 

Healthcare providers need to be proactive not only in
relation to pregnancy but to a plan for infant feeding.
Nipple anomalies can be identified during pregnancy, most
ideally through an assessment conducted at 24 to 28 weeks
gestation. A true inverted nipple can be recognized by the
presence of a ring of circular fibers which restrict the
ability of the nipple to be everted even slightly (Johnson

& Apkar, 1998). The provider should discuss feeding plans

31

with the mother and discuss the need for a nipple
assessment. The examination is relatively simple and can
be used as opportunity to discuss the benefits of
breastfeeding (Shadigian et al., 1998).

Project Description

The Breast Assessment Tool is a vital link for
providers to correctly assess their patients for inverted
nipples prenatally. It provides anticipatory breastfeeding
support for mothers by providing initial education about
breastfeeding, even in mothers without inverted nipples.
The tool would be fully utilized in women with inverted
nipples during the initial prenatal exam for all providers
in primary care clinics.

As described in the Nightingale model of nursing
practice (see Figure 2), assessment is the nurse's initial
step for assisting the mother. Only a small percentage
(10%) of the population is afflicted with inverted nipples,
the research does not reflect consensus on the problem’s
solution. Nevertheless, the initial breast exam for
mothers can be done prenatally as part of a complete health
screening physical. By asking a mother at this visit if
she intends to breastfeed, the health care provider may
begin dialogue with the patient and educate her about her

body. The provider, by inspection, can visually see if the

32

nipples naturally are everted. If they are, then no other
intervention is needed. If the nipples are flush with the
breast, then a simple discussion with the patient can
determine if they evert or “stick out” with exposure to
cold or to touch. If response is no, a more extensive
physical exam and use of a grasp test is warranted.

The assessment tool (Appendix A) gives the provider an
easy way to evaluate breast anatomy and customize a plan of
care. It begins with a breast history of the patient
(i.e., did other family members have inverted breast
nipples) and is followed by breast examination and nipple
grasp test and assessment. Individuals providing care to
pregnant women would use the tool at the initial prenatal
physical exam for mothers demonstrating inverted nipples.
The tool’s format is designed for ease of use, with a quick
check-off format and checklist for interventions. If a
patient shows nipple abnormalities, the tool offers and
intervention plan based upon such assessment, with an
education plan and when to refer for lactation consultant
assistance.

The shaded area of the tool guides the provider by
cueing them with what interventions are appropriate, based
on the assessment of the grasp test. The documentation of

the exam is available on the first page, and the shaded

33

area of the tool is dated when the intervention is
utilized. The primary care provider can then date the
intervention when initiated on the tool's plan grid, then
date further interventions as utilized. Provider comments
document the progress of the nipple eversion as a brief
narrative note below the tool’s plan grid.

For the mother with inverted nipples, the provider
should then schedule regular prenatal visits to evaluate
progress in making the nipples evert and then reevaluate
the plan's success at each regularly-scheduled prenatal
visit. If progress is insufficient, referral to a
lactation consultant is appropriate. Emotional and
environmental needs can also be evaluated in preparation
for the postnatal breastfeeding and intervention
effectiveness. Quite often, mothers are potentially
worried about being successful at the transition to nursing
and caring for a newborn. Guiding a mother through this
developmental experience is especially important. Success
in breastfeeding is one aspect of the mother's need to feel
emotionally secure with her new role as a mother and help
her provide care for her newborn.

The breast assessment tool's effectiveness could be
evaluated after three months of pilot use in primary care

offices in a single county. Individuals providing prenatal

34

care could be acquired from a local health insurance
directory. Personnel would drop off the tool to area
providers’ offices, accompanied with a brief written
explanation as well as a verbal explanation, if time
permits. A telephone follow-up two weeks after initial
contact should be made to answer questions and inquire
about patient progress. An evaluation of the tool would be
a confidential survey mailed to providers three months
after the tool’s initial use. After collecting the number
of patients on which the tool was employed, providers would
be asked if the tool was easy to use. If the tool was
perceived as inadequate or difficult to understand,
providers would be less likely to use it. Further
evaluation of providers’ perceptions of the tool's
effectiveness in supplying information necessary for
accurate assessment of inverted nipples and in comfort of
doing so would be directly related to the level of use by
providers. The amenity would allow for honest evaluation
of the tool, with revisions made, as necessary, before more
widespread use.
Implications for Practice

A breastfeeding assessment tool is an important

intervention for the APN. Correctly assessing the mother

prenatally for inverted nipples should increase the

35

likelihood of successful breastfeeding at 85% from the
Healthy People 2000 goals (U.S. Department of Health and
Human Services, 1990). The tool evaluates degrees of
inverted nipples and prescribes a plan of care to promote
nipple eversion. A grading system makes assessment easier,
so providers can accurately utilize the tool to help
breastfeeding mothers. By the tool's design, any provider
can describe the degree of inversion described on the
tool's first page, and, utilizing the shaded grid, date
when the plan was initiated. It also gives a comprehensive
guide to interventions for the provider and allows for
reassessment of progress and documentation of further
interventions or referrals to a lactation consultant within
the dated grid or narrative note.
Implications for Research

Implications for further research on this topic are
vast. The tool is designed in steps, so it could be used
to note the prevalence of the problem and degrees of
inversion by using an explorative-descriptive study design.
By first documenting through the grasp test the occurrence
and degree of nipple inversion, numbers on grasp degrees of
inversion can be identified. Prevalence of each occurrence
can than be described in preparation for the next research

step. Research could then evaluate the success of the

36

intervention in relation to the degree of inversion by
using qualitative and unstructured data methods to do a
content analysis and constant comparison. Patients with
grasp levels would then be evaluated for the intervention's
effectiveness. Each grasp test degree of inversion could
be paired to look at interventions in relationship to
problem occurrences and outcome of nursing experience. The
level-one research would provide descriptive processes or
phenomena to the mother with inverted nipples.

The psychological impact on the mother's attitudes
about nipple inversion, with respect to interventions used
and outcomes of breastfeeding the infant, could also be
addressed. However, these interventions have not at this
time been evaluated for actual outcomes of individual
interventions that the tool could later provide for
research projects using a descriptive-correlation design.
The tool could initially look at one specific problem in
breastfeeding and then identify other problems related to
breastfeeding. One example is to identify how many mothers
with Grasp 3 experience nipple pain, tissue breakdown, and
redness. Another issue is what effect this has on the
duration of the breastfeeding experience. Once other
problems related to breastfeeding are identified, further

research can be undertaken to look at effective means to

37

help the mother. Actual numbers of occurrences of certain
problems and success of interventions could be evaluated.

The educational implications for providers delivering
healthcare to pregnant mothers from this tool are
considerable. First, it educates the provider that this is
a problem for some pregnant mothers, which can lead to
breastfeeding difficulties. Secondly, the tool’s step—by-
step design guides the provider through the assessment,
plan, evaluation, and reevaluation process. Thirdly, it
provides a guide when referral to a lactation specialist is
warranted.

The tool could also be incorporated into existing
documents, such as American College of Obstetrics and
Gynecology prenatal forms. Currently, the forms do not
mention the breast except as a planned way of feeding. The
literature has repeatedly stated that talking with the
mother during prenatal visits about the mother's plans for
infant feeding successfully increases breastfeeding
numbers. By giving health care providers the information
they need in utilizing an assessment tool, the grid then
provides the information to educate mothers while assessing
potential problems.

In summary, the breast assessment tool can be an

effective means for the APN to assess the need for prenatal

38

intervention for mothers with inverted nipples. The tool
is in a format that would allow further analysis of the
effectiveness of interventions by evaluating the actual
numbers of mothers diagnosed. A more specific plan for
additional assistance to a mother with inverted nipples
could then be developed and refined. The end goal of
assisting the mother with inverted nipples can benefit the
provider in delivering care to the mother and newborn. The
breast assessment tool would be an effective method of
treating inverted nipples in pregnant women who are

choosing to breastfeed.

APPENDIX A

INVERTED NIPPLE ASSESSMENT AND INTERVENTION

APPENDIX A

Inverted Nipple Assessment and Intervention

Name: Date of Birth: / I
Expected Due Date: I I First Baby: Yes I No Nursed Before: Yes I No

SUBJECTIVE
Concerns about breastfeeding:
Fanily difficulties with breastfeeding: Yes / No
Other problems:

 

 

 

 

OBJECTIVE
Size: A B C D Symmetricd: Yes/ No Nipples in Midline: Yes/ No
Consistency of tissue:

 

@ @

Left Right

 

LEFT RIGHT

 

Grasp Test: 1. Everts with compression
Full nipple exposure
2. Everts with compression
Tip of nipple exposed
3. Everts with compression
Nipple flush with tissue
4. No eversion slit for nipple opening

 

 

 

 

 

 

 

Assessment: Grasp 1. Norma response
Grasp 2. Potentid for problems. Intervention needed.
Gram 3. Abnormal, nongraspable. Prenatal intervention needed.
Grasp 4. Abnom'ral, severely nongraspable. Prenatal intervention needed.

PLAN See attached table.

39

Inverted Nipple Assessment and Intervention Plan

40

ASSESSMENT OF NIPPLES FROM TOOL

 

Interventions

Gresp1

Gmspz

Grasp3

Grasp4

 

Educate in basic breastfeeding
positions and techniques

 

Discuss potential laching
difficrlties

 

Discuss psychological and
spiritual needs

 

Reinforce that newborns adjust
to motmrs nipple anatomy

 

No rubber nipples initidly

 

Refer if latching problems to
lactation consuttant or
experienced provider

 

 

 

 

 

NOTES:

 

 

 

 

 

 

 

 

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