Maria writes:
<It is sad when you know you could have helped someone yet they didn't ask
for your help. But frankly, how can we expect these new parents to trust us
or anyone since they often feel they've been dooped!  When the reality of
what happens to them vs what they thought or were told was going to happen,
doesn't jive, they are scared and skiddish.  Here they spent money on
pre-natal classes, books, pumps and whatever else ,all to find that their
delivery didn't go as planned, the care given inadequate, everyone they
encountered gave them contradictory information etc. so ultimately they can
trust no one but themselves and they wing-it alone....some do OK, most
don't!>

Yes I agree. I still remember all too vividly, that set of emotions at 5-10
days with my first 3 children, half a century ago. What a painful blow it
was to the hopeful, trusting ego of a confident, enthusiastic, perhaps
conceited young OB nurse! That seared-in memory is part of why, with
subsequent children, I "humbled myself" to seek help from the then newly
formed LLL, resolved to learn more, and how to do better what I continue to
do to this day. From past experience working in a hospital, childbirth
education and more recently working with WIC mothers in days 2-10 and
beyond, the main maternal things that stand out in my mind today are:

   1. when moms get a total volume of IV fluid > than the normal oral
   fluid/food intake in 24 hours i.e.>1500-2000 cc/24 hrs.
   2. unwitting application (without adequate anticipatory and follow-up
   guidance) of a very expensive vacuum device to a breast whose edema is
   destined to get worse and remain, in the first 4-7 or more days because of
   the totals of crystalloid IV fluids administered, and
   3. when "one or two smallest (24-27 mm.) size pump flanges are provided
   to fit all", too often resulting poor yield, pain and eventual giving up.


Routine crystalloid intravenous infusions, in labor management, emergency,
anesthetic or many normal OB situations, are not going to go away, at least
in most developed countries. That is something that health professionals
need to accept as a fact of 21st century life and learn to anticipate,
assess potential for edema and provide anticipatory guidance and follow-up
for. There is much yet to be researched in this area, but that is different
subject from that of this post.


I would like to see a discussion among experts on pumping (I am not one of
them, so I want to learn from those who are) about choosing the appropriate
size tunnel on a pump flange. I think some of the manufacturers, DME
providers, and hospital folk, especially in NICU, need some serious
feedback. Insurance companies have a definite stake in this too. Too many
taxpayer and/or insurance financed pumps end up on E-bay.


What my clinical experience and extensive reading in several disciplines
tell me about the anatomy of the nipple-areolar complex convinces me that
neither the circumference of the nipple around its shaft nor its base should
be the determining factor in the size of pump flange needed for comfortable
and efficient pumping. In my mind the "sweet spot" enters into the equation.



In my admittedly limited experience in issuing pumps, it seems to me that
initial fingertip expression (by mom or LC with permission) is the best way
I have found to identify the "sweet spot". I wonder if hospital personnel or
WIC personnel or others who issue pump flanges agree, or do they just
"eyeball" and "hope", or just plain "not eyeball" and "presume on average"
that the flange provided will succeed? Or as in direct purchase by parents
sight unseen, (both flanges and nipple-areolar complex), are some being set
up for failure by various pump manufacturers' cost decisions?


Vacuum does not pull. It may look like it and feel like it, but according to
the laws of physics, that's not so. Since nature abhors a vacuum, other
forces push, trying to equalize pressures. And atmospheric pressure on the
outside of the breast plus skin tightness, blood pressure, interstitial
fluid pressure, plus hydrostatic pressure of the awaiting milk plus MER (and
perhaps breast compression) are some of the factors that help push the flesh
of the nipple-areolar complex into the flange (or the baby's mouth) toward
the vacuum to equalize and balance the pressures. Too small a tunnel on a
flange, despite strength of any vacuum level, may resist part of this
forward pressure. This thereby may allow too much compensatory stress on
blood vessels, skin and connective tissue, and sometimes even create
backward hydraulic pressure (Pascal's law) in the ducts resisting some of
the force of the MER, by not freely admitting enough of the flesh of the
deeper retroareolar tissues.


As I see it, enough of the areola must be pliable enough to be able to be
pushed into the flange tunnel by those positive pressure forces. This needs
to result in allowing 1-2 cm (or more) of the subareolar and retroareolar
ducts (whatever we may prefer to label them) to compress themselves against
the walls of the tunnel as they enter it. This is necessary  to focus enough
pressure at the appropriate region in the subareolar ducts deeper behind the
nipple, to create sufficient forward hydraulic pressure to force the
milk through the total nipple-areolar complex forward to the tip of the
nipple. At that moment in time, and at that point only, will the milk itself
then be in direct contact with vacuum forces to allow it to move beyond the
flange into the bottle, to equalize the 2 pressures.


This description of the picture in my mind's eye may sound overly
complicated to many experienced and successful folks in the lactation and
larger health care communities. Maybe they've had enough success that
they've never given it much thought. Perhaps the engineers among us, or
among our significant others might shed some light. OTOH, I think the pump
engineers might understand it all too well if they had first
hand, ("hands on") tactile  understanding of the microscopic (not simply
ultrasound) anatomy of the nipple areolar complex in many varying and
different mothers, as many in the lactation community do.


What I consider to be incomplete information or outright misinformation
provided to the lactation/health care community and parents seriously
disturbs me. I guess I feel the need for feedback from others who closely
and thoughtfully observe where "the rubber meets the road". Am I "all wet"?
Should I just "stop harping" about my seemingly "peculiar" perceptions
of the dynamic anatomy and physiology of the nipple-areolar complex,
especially in the first two weeks postpartum?


I strongly believe that research in other disciplines, such as histology,
plastic surgery and breast surgery, needs to be considered by those with
formal research capabilities, and some of it replicated (ultrasonically as
well as forensically) on the breast in late pregnancy and early
lactation. Lactnet seems the perfect place to elicit some thoughtful
insights from the abundant expertise around the world. I look forward to
learning from you about possible ways to approach this goal. Or not;-)


Jean


K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC
Dayton OH


 "Since my youth, O God you have taught me, and to this day I declare your
marvelous deeds. Even when I am old and gray, do not forsake me, O God, till
I declare your power to the next generation, your might to all who are to
come."                      Psalm 71, vs.17-18

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