Laurie,
You wrote:
< I agree that many moms expereicne
short-lived pain upon latch and until the milk "starts to flow", esp. in
the
early days of bf. I used to think this was the initial "stretching" or
elongating of the nipple/areola into a long teat extending deep into
baby's
mouth. But maybe this is pain due to the relatively "empty" sinuses/low
flow
issues?. . . Any comments on this
latch-on pain?.>
IME, milk sinuses in late pregnancy and the first 2-3+ weeks after birth
are relatively overdistended, not empty. This pain comes from positive
pressure, not negative pressure. If compression takes place over the
middle of the sinus, where the walls are conceivably tighter and thinner,
it is quite painful till such time as the overdistention is overcome. I
also visualize these walls as a richly ennervated site where compression
sends a strong signal to elicit the MER.
It is when the relative overdistention has been relieved that the pain
begins to subside. At almost the same time, the myoepithelial cells in
the walls of the milk sinuses (as well as the milk ducts and the acini)
seem to be able to respond to the oxytocin and milk begins to ooze easily
out through the sinuses. And the less the milk sinuses are stretched
containing milk, the more the elasticity is then available to be drawn
further inward into the baby's mouth.
It is my observation that at least 50-75% of initial latch pain can be
due to this direct compression of overdistended milk sinuses. Pain also
often results if digital extraction or a breast pump (negative pressure
pulling so that the milk sinuses meet resistance from the bend in the
flange) compresses the "belly" of the sinuses.
I have explained this phenomenon as somewhat analogous to someone in a
car with a seat belt on directly over the hips and bladder. As the
bladder fills, if the driver "jams the brakes on hard", the compression
of the seatbelt causes severe pain in the walls of the distended bladder.
I believe this example also explains why the forces correctly applied in
a really good asymmetrical latch do not cause pain. In an this kind of
latch, I visualize the compression of the top jaw stabilizing the areola,
near the distal part of the sinuses (closer to the nipple), not further
in toward the "belly" of the sinus. I see this as simply part of the
leverage providing some resistance to the action of the lower jaw.
On the opposite side of the areola, the lower jaw and tongue are
extending well back to compress beyond the proximal end of a few of the
milk sinuses (closest to the deeper ducts), gently undulating and pulsing
pressure on just the underside.
As I see it, then at no time are both the opposite walls at the most
thinly stretched part of the milk sinuses being compressed
simultaneously. In time, little by little, as the MER begins to move milk
forward, the resistance of the areola lessens and the nipple-areola
complex is pulled more deeply into the mouth, (or the pump), and the
undulating compression reaches more sinuses
Picture in your imagination, a fresh tube of toothpaste, as a generic
model for a full milk sinus . You can get some out by pressing on the
fattest part of the tube.The pressure displaces some forward, and tries
to displace some backward, with great resistance. But you can get the
toothpaste to come out with less work if you support the front of the
tube and start compressing at the thin end.
You can prove this to yourself simply by observing the mother when you
attempt staight digital extraction, as in the Waller testing technique.
(Not the Marmet technique, which is a gentler approach which seems to
place the fingers and thumb so that compression begins at the proximal
end of the sinus rather than over the "belly of the sinus".)
You will often that find direct compression of the fullest part of the
sinuses is painful to the mother. But ask her to tell you when the pain
goes away. If pursued gently and slowly, after 5 or so drops have been
expressed, she will often remark "Oh, now it doesn't hurt any more!"
OTOH, if she finds it too painful, switch to gentle Reverse Pressure
Softening as I described it in previous posts. In addition to
redistributing excess interstitial fluid, this places pressure on the
distal ends of the sinuses and moves some excess milk back up through the
proximal end into the ducts just behind, and triggers the MER.
After 60 seconds of this, then direct digital extraction can usually be
done painlessly. After the tissue resistance in the areola has been
reduced by relieving the overdistention, the application of a pump, or an
attempt by a vigorous baby to latch will elicit little or no pain from
this area.
So yes, I believe you are on the right track when you posit:
< Therefore it should help to "prime" the system by manually starting
the milk flow? >
It's just that I see in my mind's eye, a different set of circumstances
than what you expressed as the cause of the pain. Your initial idea
actually seems to fit better with what I have observed.
If anybody is interested in a technique I have developed for assessment
of nipple-areolar discomfort in the initial week or two of nursing,
please contact me privately and provide me with your snail mail address.
(I am computer-challenged!) I will be glad to send you a diagram of my
model of 4 conceptual zones where pain may be originating, so that
intervention can be targeted more accurately.
Jean
****************************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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