title: Randomised controlled trial of breast shells and Hoffman's exercises for inverted and non-protractile nipples.
abstract: OBJECTIVE
  To determine the value of recommending breast shells or Hoffman's exercises, or both, to pregnant women with inverted or non-protractile nipples who intend to breast feed.
  
  
  METHODS
  Randomised controlled trial with a two treatment by two level factorial design.
  
  
  METHODS
  Antenatal clinics in a district general hospital and the community.
  
  
  METHODS
  96 nulliparous women recruited between 25 and 35 completed weeks in a singleton pregnancy with at least one inverted or non-protractile nipple.
  
  
  METHODS
  Anatomical change of nipples, judged blindly before first breast feeding, and success of breast feeding reported by postal questionnaire six weeks postnatally.
  
  
  RESULTS
  Sustained improvement in nipple anatomy was more common in the untreated groups but the differences were not significant (52% (25/48) shells v 60% (29/48) no shells; difference -8% (95% confidence interval -28% to 11%) and 54% (26/48) exercises v 58% (28/48) no exercises; -4% (-24% to 16%)). 24 (50%) women not recommended shells and 14 (29%) recommended shells (21%; 40% to 2%) were breast feeding six weeks after delivery (p = 0.05), reflecting more women recommended shells both deciding to bottle feed before delivery and discontinuing breast feeding. The same number of women in exercise and no exercise groups were successfully breast feeding (0%; -20% to 20%). 13% of women approached about the trial (and planning to breast feed) did not attempt breast feeding.
  
  
  CONCLUSIONS
  Recommending nipple preparation with breast shells may reduce the chances of successful breast feeding. While there is no clear evidence that the treatments offered are effective antenatal nipple examination should be abandoned.
authors.affiliation: Department of Nursing Studies, University of Southampton, Southampton General Hospital.
authors.forename: J M
authors.initials: JM
authors.lastname: Alexander
authors.forename: A M
authors.initials: AM
authors.lastname: Grant
authors.forename: M J
authors.initials: MJ
authors.lastname: Campbell
mesh_terms: D000293:Adolescent; D000328:Adult; D001942:Breast Feeding; D000013:Congenital Abnormalities / Q000628:therapy; D015444:Exercise; D005260:Female; D006801:Humans; D009558:Nipples / Q000002:abnormalities*; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods*