Carole J. wrote:

<a mom with large-ish (between diameter of a
nickel and a quarter) nipples that were hard and
fibrotic. Nipple length was within a good range, well
everted, but the tissues were not compressible and
Baby was unable to latch. Surrounding areola was
soft, breasts still soft 48 hours postbirth (MOB got
lots of IV fluids and was edematous), unable to pump or manually express
any colostrum, not even a drop or two. Is this more common than I
realize? Any experiences, thoughts, or ideas on management of fibrous
nipples would be greatly appreciated!>

Without seeing what you describe, these are some things that come to my
mind. Nipple formation has genetic components, intrauterine exposure to
hormones, and subsequent growth and development patterns which may differ
between mothers.

This applies not only to the nipple but to the placement and depth of the
milk sinuses, which are individual characteristics, sometimes differing
even in the two breasts of the same mother.

The process normally involves some degree of connective tissue and
muscle, as well as other tissues, including a very concentrated
distribution of skin lymphatic capillaries.

I suspect that part of what you saw and palpated may have already have
been effected by early accumulation of excess fluid in the tissue
prenatally, as well as by the IV's, over and above the amount of
connective tissue.

IME, the baby's mouth will have to grow before it can accommodate a large
nipple and reach the areola and milk sinuses with the tongue and jaws.
This phenomenon has been labeled by others as "oroboobular
disproportion".

Comparatively speaking, the situation sounds much like the premie mouth
in relation to a mom with even medium size nipples. At some point, (but
perhaps not at the moment), when the milk is flowing copiously, a shield
may be of value, as per Paula Meier's article on premies in JHL last
year.

Perhaps explaining this will help the mother to remain hopeful and
patient for the time this will take, when milk removal will need to be
accomplished by other means in the interim. Chapter 10 of Dr. Jack's and
Teresa's book might help keep her spirits up.

By the time you receive this reply, you will note further changes in the
nipple areolar area precipitated both by the IV solutions, the use of
vacuum, and the engorgement factors that include lack of milk removal up
to this point. I predict it will get worse before it gets better within
perhaps 10-14 days.

In the archives, on or about 3/28/01 I described a technique called
Reverse Pressure Softening which may be of value during this period.

If I were helping this mom, I would want to palpate to find where the
milk sinuses are located, if possible, and use the Marmet method of
fingertip extraction in preference to the pump till the edema subsides
and/or the milk supply is so copious it leaks easily. Even then, the
largest flanges ought to be considered, so as to allow the milk sinuses
to be compressed.

Teaching the mother about the Milk Ejection Reflex and how to trigger it
manually will be very important, since this is said to be the most
important force in milk transfer.

Remember that Rule # 1 is that the baby must be fed, no matter if Rule #2
(supporting the production)
and Rule #3 (Fix the breastfeeding) end up taking weeks or months to be
accomplished.

Good luck. I know others will have different viewpoints to contribute.

Jean
********************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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