Imaging Evaluation of the

Human Nipple During Breast-feeding
Wilbur L. Smith, MD; Allen Erenberg, MD; Arthur Nowak, DMD

\s=b\ A new real-time ultrasound tech- had the approval of the Human Research RESULTS
nique was employed to document in vivo Committee. The changes in human nipple dimen¬
the anatomic characteristics of the hu- All infants were studied at the onset of
sions during suck were similar
man nipple during breast-feeding. The feeding and until, by ultrasound visual
study quantifies human nipple defor- monitoring, the milk intake slowed. Feed¬ throughout the study population. The
mation and provides a description of the ing from both breasts was monitored. Im¬ data demonstrate the human nipple to
mechanics of normal sucking derived ages were obtained in the horizontal trans- be highly elastic, elongating during
from 16 normal infants aged 60 to 120 buccal and transverse submental planes active feeding to approximately twice
days. This in vivo imaging technique has (Fig 1). Studies were performed using a its resting length in the horizontal
great potential value in the study of mechanical real-time ultrasound device transbuccal plane (Fig 1). The lateral
feeding dysfunction. with a 5-MHz transducer. Data were re¬ dimension of the nipple as viewed in
(AJDC 1988;142:76-78) corded on three-quarter inch videotape. the horizontal transbuccal plane is
The data were analyzed from a 512- little changed during suck. This ap¬
rPhe ability to adequately sustain oral matrix high-resolution television monitor
using a multiple-head videotape deck with parent lack of lateral nipple compres¬
nutrition is vital to the survival of sion reinforces the concept that the
infants. In human newborns this means single-frame and stop-frame capabilities.
Measurements were made from the display cheeks, owing to a thick layer of fatty
the ability to nurse effectively, an act using a hand caliper. Duplicate measure¬ tissue, act mainly as a passive seal for
entailing a complex interaction between ments performed independently by all of the oral cavity and do not invert to
the milk source and the infant's mouth us documented that the interobserver form a vacuum. This is explained on
and oropharynx. The human nipple is agreement was within 1 mm. an anatomic basis by the large fat
a unique organ that facilitates this Data were collected from each subject in deposit in the neonate's cheeks.
complex process of suckling. each plane through three full suck cycles. The changes in nipple dimensions in
A noninvasive technique for direct When possible, three contiguous sucking the transverse submental plane dem¬
efforts were employed.
visualization of the nipple in the in¬ Horizontal transbuccal measurements onstrate the compressibility of the
fant's mouth has been described.1 This human nipple. At maximal compres¬
depicted a transaxial view of the infant's
study documents the physical behav¬ mouth and the nipple. Measurements ob¬ sion, nipple height is reduced by half
ior of the human nipple during feeding tained in this plane documented nipple owing to compression between tongue
and the ultrasound dynamics of normal elongation expressed as a ratio of length at and palate. It is important to note that
infant feeding. end of suck to full intraoral nipple extension milk ejection occurs after maximal
MATERIALS AND METHODS (Fig 2). Lateral (transverse) compression compression.
of the nipple was similarly recorded as a Single-frame analysis led to some
In vivo breast-feeding was studied in 16 ratio of nondeformed to maximally de¬
term infants aged 60 to 120 days using formed nipple width (Fig 2). The narrowing
high-resolution real-time ultrasound tech¬ and elongation data for the population are
nique. All of these infants were predomi¬ Change in the Dimensions of the
listed in the Table. Human Nipple During Suck*
nantly breast-fed, although several re¬ Submental transverse views (coronal
ceived supplemental bottle feedings. The axis) were obtained and measured in a Mean ( ± SD)
mother's breast-feeding experience was similar fashion (Fig 2). These data are Percentage
variable, with some feeding their first in¬ somewhat more difficult to interpret owing Dimension Changef
fant and some having breast-fed several to the elongation of the nipple during the Horizontal length 208 ±34
Horizontal lateral 73 ± 15
previous infants. Informed consent was measurement cycle. This led to the need to
obtained from the parents, and the protocol estimate nipple position relative to imaging Transverse submental 56 ± 10
plane and may have skewed the measure¬ length
Accepted for publication Aug 13, 1987. ments. The mean and SD for nipple wid¬ Transverse submental 121 ± 15
From the Departments of Radiology (Dr width
Smith) and Pediatrics (Drs Smith and Erenberg), ening and compression are given in the
University of Iowa Hospitals, and the Depart- Table. Each infant's feeding pattern was *As related to presuck (dimension at maximum
ments of Pediatric Dentistry and Pediatrics (Dr observed by stop-frame visual analysis of suck/resting dimension 100). Value mean ±1

Nowak), University of Iowa, Iowa City. SD. Composite data for the human nipple at full
Reprint requests to Department of Radiology,
nipple deformation and changes in the extension and compression are represented as a
C740, GH, University of Iowa Hospitals, Iowa shape and position of the tongue, cheeks, percentage of resting dimensions.
City, IA 52242 (Dr Smith). and palate. tResting is 100%.

Downloaded From: by a University of Texas at Dallas User on 02/06/2017

- Width Full Extension Width at Compression 100% =of Presuck Width D 100% = Widening Width Before Suck Width Uncompressed During Compression Fig 1. and hyoid. peared to rely less on undulant motion of the tongue and more on an up and down pistonlike movement of the man¬ dible.—Frame from real-time ultrasound study showing nipple (arrows) within oral cavity. Günther3 per¬ formed indirect measurements of the infant's mouth and the feeding moth- Downloaded From: http://jamanetwork.ashx?url=/data/journals/peds/13172/ by a University of Texas at Dallas User on 02/06/2017 . COMMENT Previous attempts at in vivo imaging of the human nipple in the oral cavity have been limited. and interrupted dashed lines. new observations on the oral sucking Fig 2. In contrast to other de¬ This is horizontal view with infant's lips on right side of illustration.7 1 Length Full Extension Height Full Suck x 100% = % Lengthening C 100% = Maximum Compression Length Before Suck Height Rest . dashed lines.6 C B 0. Solid lines indicate nipple fully extended and compressed. mechanism. Dark material beyond scriptions. plane in which submental images were obtained. Horizontal Submental A Palate 2X 0. This suggests that the jaw actually creates a negative pressure by enlarg¬ ing the oral cavity to induce milk ejection. Milk ejection actually occurred later than maximal nipple deformation and coincided with the downstroke of the tongue and jaw. nipple at rest. This mechanism differs from previous descriptions and must be con¬ firmed by simultaneous pressure mea¬ surements.—Composite drawing of human nipple deformation in horizontal and submental 2 most of our infants ap¬ tip of nipple is milk. tongue.

jaw. the oral cavity. The method of imaging is Owing to the single-plane limitation. Gabriel Marshak. gravity. was limited to the lateral caudally. and the infant's mouth.156:379\x=req-\ gravity. The use of ionizing radiation that we suggest for milk ejection is This investigation was supported in part by a prohibited widespread application of somewhat different from that of Ar. those seen in our submental views. MD. Kemp FH: A correlation be- They believed that milk expression into the ducts but that actual stimulus tween suckling pressure and the movements of the tongue.48:261\x=req-\ occurred owing to compression of the for release is a vacuum phenomenon 272. Ardran GM. MD.ashx?url=/data/journals/peds/13172/ by a University of Texas at Dallas User on 02/06/2017 . MD. MD. PhD.1:575-578. MD. The undulant tongue Lancet 1955. Their study. in Other AMA Journals ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Myringoplasty in the Pediatrie Population Dov Ophir.113:1294-1300) Autosomal Recessive Progressive High-Frequency Sensorineural Deafness in Childhood Cor Cremers. Nowak A: Physi- nipple. their technique among normal infants. nipple one to two frames (0. Single-frame analysis To our knowledge. Rec 1958. Because ultra¬ plane and predominantly examined Single-frame analysis documented sound is noninvasive. Hans-Arne Hansson. nipple compression may draw milk 2. dran and Kemp2 who believed that The same authors also studied animal milk expression is caused by compres¬ References breast-feeding using a barium-coated sion of the nipple between the palate 1. PhD (Arch Otolaryngol Head Neck Surg 1987. 4.113:1319-1324) Downloaded From: http://jamanetwork. Radiology 1985. this study rep¬ of the areola and nipple occurs. Gunther M: Instinct and the nursing couple. the technique the interaction of the components of that the milk was ejected from the can be used to obtain data on a large the infant's oral cavity during sucking. Our data suggest rather that 381. ographic techniques. Smith WL. enlarging the oropharynx.113:1288-1290) Nasal Mucosal Changes in Children With Frequent Infections Björn Petruson. and hyoid then move normal interaction of the human nipple nipples.4 Their results document move¬ and the tongue with assistance from ology of sucking in the normal term infant using ments of the oral cavity similar to real-time ultrasound. maximal nipple elongation.03 s) after population. mation.70:808. Columbus. Based on extrinsic to the infant and the infant's they did not quantitate nipple defor¬ these observations the mechanism feeding is therefore physiologic. er's nipple and implied that elongation nutrient intake. Ohio. Ben ter Haar. the mouth. MD (Arch Otolar¬ yngol Head Neck Surg 1987. grant from Ross Laboratories. The posterior portion of As such it provides a baseline for the which employed human and artificial the tongue. Moshe Porat (Paretsky). Acta Paediatr Scand 1959. Ardran of our data suggests that the infant resents the first in vivo ultrasound and Kemp2 have studied the behavior uses the lips and cheeks to form a seal quantitation of the behavior of the of the infant's mouth using Vet ing mechanisms are well adapted for expression than previously suspected. Peter van Rijn. Cowie AT. and then draws the nipple deep into human nipple during breast-feeding. nipple between tongue and palate and caused by the rapid enlargement of 3. MD (Arch Otolaryngol Head Neck Surg 1987. Erenberg A. MD. Kemp FH: Further observations The human nipple and infant suck¬ motions may have less to do with milk on the teat sinus of the goat during suckling.