Thanks, Barbara,

<  retracting nipples which
disappear when baby tries to latch, milk sinuses which are back beyond
the
infant's "reach" and breast tissue which is difficult to compress and
manipulate?>

There has always been much more of this than anyone seems to have
recognized. It finally confronts the mother and the nursery/postpartum
nurses and LC's after the baby is born. I have been in that situation
many times, and thought "There ought to be some way to avoid this."

It presents a real dilemma as to when and how to intervene and invoke
Rule # 1. Your point about weight checks (by the pediatrician in this
case) is an excellent one.

Red flags are obvious prenatally, and that is why I feel so strongly
about prenatal nipple function assessments. I think this is important if
for no other reason than anticipatory guidance about strictly avoiding
rubber nipples and provision for a referral and close follow-up.

I have read that the breast is but an envelope of skin. What that
envelope contains is different at different times in life. Through
nutritional, genetic, hormonal, disease and degenerative processes,
nature  restructures those tissues day in and day out with few outside
clues. Many assume that a breast is a breast is a breast . . . . . . Not
so.

Whether or not anything can be done to improve the tissue resistance some
nipple-areolar complexes exhibit during pregnancy and lactation is really
still in the emperical observation/trial and error stage. I realize it is
not research based.

Before that time arrives, there will have to be figured in the
observations of many other disciplines: plastic surgeons, pathologists on
surgically removed breasts, and unfortunately, post mortem findings;
perhaps radiologists' observations from mammograms and serial ultrasounds
can give us some evidence about whether tissue expansion can be
stimulated with  intensive vacuum preparation.

It is not a subject that lends itself to easy answers.

<  Sometimes the work of feeding
with nipples like this is so increased that babies can't get to hind
milk.
Post-feed pumping continues to protect the milk supply and provide a
source
of expressed milk to use as supplement.>

And this means that someone needs the expertise to recognize this set of
circumstances. It means taking the time to help the parents understand
that their baby is in fact still an exterogestate fetus.

It means likening these interventions to a temporary "pontoon-type"
bridge between pregnancy and the time when the baby is fully capable of
effective milk transfer. And it means reminding them that it's worth it
to the baby, and to them, and that this, too, will pass.

K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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