About one-third of mothers have flat or inverted nipples during pregnancy. This shape makes formation of a teat more challenging as the baby has to have a very large gape to get around all the tissue. Flat nipples are not necessarily inverted. One way to differentiate the two is by performing a pinch test: Pinch the areolar tissue an inch behind the nipple. If the nipple protrudes it is simply flat and not inverted.

Inversions occur when the nipple adheres to the underlying tissue at the base, preventing protrusion and formation of a normal teat. It is usually congenital, but can also occur from previous nursing, surgery, breast cancer, infection, or breast drooping. One or both breasts may be affected. In most cases, drawing out the nipple with massage resolves the problem. But the tethering may be more severe, so that after protruding the nipple, the tissue falls back into inversion. In these cases, fibrosis causes the milk ducts to be retracted into the breast. Truly inverted nipples, which are rare, are permanently adherent and never protrude. These cases usually require surgical correction to stretch or lengthen the milk ducts and allow milk to flow out of the breast (see Fig. 6.1).

Very soft, pendular breasts can be difficult for baby to get his mouth around. There is no specific size or level of softness to look for—just note the size and shape, and flag as a possible diagnostic factor. Large breasts may contain more fat than glandular tissue, and small breasts may be mostly glandular, so size does not determine the milk making capacity. Large areolas or breasts can require a wider gape from the baby.

Hypoplasia, or insufficient glandular tissue (IGT), has been widely discussed in the plastic surgery literature as a tuberous breast. Mothers with IGT have breasts that have less glandular tissue, and therefore less milk-making capacity. Their breasts are small, tubular often asymmetric, and widely spaced on the chest. The areola tends to be large for the breast size. Huggins et al. (2000) found that mothers with hypoplasia demonstrated breast asymmetry, wide intra-mammary spacing, stretch marks that developed during puberty without significant breast growth, low breast growth during pregnancy, and little engorgement during the first week postpartum (see Fig. 6.2). These findings were commonly associated with poor milk production. About 85 % of mothers with hypoplastic breasts produced less than half of the milk required by their baby during the first week. Early identification of women with hypoplasia is important because milk production can be increased with early and frequent breast emptying, even if they don’t develop a full supply (Huggins et al. 2000; Neifert et al. 1985).

Scars typically indicate surgery from implants, breast reduction or lift, biopsies, or cancer treatment. Typical implant scars are under the breast or in the armpit. Breast mass removal scars can be in any location. Breast reduction and breast lift scars tend to be circular, around the areola, and from the lower edge of the areola to the infra-mammary crease, resembling a lollipop. Since breast fat and glandular tissue is interspersed, it is impossible to reduce the breast size without removing some glandular tissue.

Some researchers have found that nipple piercing may damage milk ducts, making it difficult for the baby to transfer milk. It can also disrupt ducts if the nipple is pierced horizontally (Garbin et al. 2009). Removal of the piercing usually corrects the problem, but surgical repair may be necessary.

Engorgement causes the breasts to appear symmetrically firm and edematous. There is vascular congestion, tenderness, erythema and warmth. Sometimes there is an accompanying low-grade fever and flattened nipples due to the swelling. The symptoms are generalized and not localized to one area. Engorgement is often a sign of inefficient emptying, especially from day 3–7, when transitional milk comes in, and during the first few weeks when the baby’s needs and mother’s supply are just beginning to sync.

Approximately 20 % of women of childbearing age experience Raynaud’s phenomenon. It is caused by vasospasm of arterioles, and affects extremities like fingers and toes and nipples (Flavahan 2015; Wu et al. 2012). It can cause very painful stinging or pinching precipitated by cold temperature and compression. It causes blanching of the nipple, followed by erythema and/or cyanosis (Barrett et al. 2013). To accurately diagnose Raynaud’s, in addition to pain, occurrence of symptoms during pregnancy or when not breastfeeding, biphasic or triphasic color changes, and onset with cold temperature must also be present (Anderson et al. 2004). Raynaud’s phenomenon is often confused with damage from a shallow latch or candida infections but does not respond to antifungals. It is usually a diagnosis of exclusion and symptoms resolve with nifedipine.

Inflammation can be generalized or localized, and is not necessarily indicative of infection. Assess for damaged nipples—nipples that are compressed into a lipstick shape, or cracked and bleeding. They may be swollen, erythematous, and tender. They may have scabbing and bruising. Often mothers use creams or other agents to soothe nipple pain, which may help but may also lead to other problems, such as allergic or irritant contact dermatitis (Heller et al. 2012).

The breasts should be evaluated for hard, tender cords limited to one area of the breast, which can indicate plugged ducts. Also, note any milk blebs, which are blister-like collections of milk at the end of a duct, and indicate a blocked duct. They can occur on one or both breasts. Blocked ducts cause stasis of milk flow and therefore can lead to decreased milk supply. Repeated or prolonged blockage can lead to infection.

The bones of the neonatal skull are not connected at the sutures. This is so that the skull can grow to accommodate the growth of the infant’s brain, and so that the bones of the skull can overlap to fit through the birth canal. After birth, the bones of the skull do not always return to their natural positions. The shape of the head can also indicate birth trauma, such as hematoma by vacuum or forceps delivery (see Osetopathic Cranial Academy website).

Babies born by C-section do not travel through the birth canal and therefore are not subjected to those types of injuries. However, in utero, the skull can mold into a certain position and shape. In those cases, travel through the birth canal can free the skull bones, so babies born by C-section do not have that benefit.

The size and position of the jaw are important because it will impact not only feeding, but also breathing and facial symmetry. The anatomy of newborns is different from that of adults. At 6 weeks gestation, the mandible begins to ossify. At birth, it is relatively retrognathic to the maxilla so it appears small, but it is really just set back. All babies are born with varying degrees of retrognathia, called physiologic jaw retraction. Movement of the muscles of mastication and swallowing movement of the tongue provide the stimulus for forward movement of the mandible over time, as the neonate grows. While there are no measurements for variants of “normal” retrognathia, there are measurements for what is considered pathologic retrognathia, found in some syndromes, such as Pierre Robin.

One objective assessment of retrognathia has been studied through intrauterine ultrasound. Rotten et al. (2002) describe retrognathia using the “inferior facial angle, defined on a mid-sagittal view, by the crossing of: (1) the line orthogonal to the vertical part of the forehead at the level of the synostosis of the nasal bones (reference line); (2) the line joining the tip of the mentum and the anterior border of the more protruding lip (profile line).” The mean value of the inferior facial angle was 65.5°. Consequently, an inferior facial angle value below 49.2° defined retrognathism. Palit et al. (2008) describe the frontal naso-mental angle having a mean of 146.74° in neonates.

It is important to differentiate between retrognathia and micrognathia. In micrognathia, the jaw is not merely set back, it is smaller, as in Pierre Robin Sequence and Stickler syndrome. Micrognathia can be assessed through the calculation of the mandible width/maxilla width ratio on axial views obtained at the alveolar level. Mandible and maxilla widths should be measured 10 mm posteriorly to the anterior osteous border. A mandible width/maxilla width ratio < 0.785 defines micrognathism (Rotten et al. 2002). Baudon et al. (2002) showed that babies with Pierre Robin sequence have dysfunction in motor organization of the tongue, pharynx and esophagus during feeding. Micrognathia does not self correct and must be addressed separately by appropriate specialists.

But even babies who fall under the “normal” category of retrognathia can have exaggerated retrognathia that can impact the baby’s gape and therefore affect nursing. No studies have addressed this phenomenon, although it is clinically apparent and obvious even by subjective evaluation. Babies with exaggerated retrognathia have limited ability to open wide enough for a sufficient gape. Also, Luz et al. (2006) found an association between non-nutritive sucking habits (sucking without milk transfer) and short duration of breastfeeding. They also noted that babies with retrognathia display more non-nutritive sucking (they do not transfer milk efficiently) (see Fig. 6.3).

Mandibular asymmetry can also impact nursing. Wall and Glass (2006) noted that mandibular asymmetry is an early indicator of torticollis, which will be discussed in a later section.

At 6 weeks gestation, the palatal shelves meet and fuse in the midline. The palate is shaped by the swallowing movement of the tongue, and by the downward and forward movement of the mandible. The shape of the palate can be noted most easily by direct visualization, and allowing the baby to suck on your finger (Fig. 6.4). Because the palate must be filled in order to stimulate the suck reflex (Glass and Wolf 1992), the shape of the palate determines how much breast is necessary for successful breastfeeding. A flat palate is easier to fill. A high and arched palate means there is more room in the mouth to fill. If the baby has a high palate and that space isn’t filled with sufficient breast tissue, the baby will be more likely to take in air with nursing, or fail to suck entirely. Also, higher palates are farther away from the tongue. Even if the tongue is not tethered by an anterior frenulum, it may still not able to reach high enough to compress the breast against a high, arched palate. For all these reasons, babies with high palates are more likely to have an inefficient latch.