Several days ago, Winnie, in a thoughtful mood, asked:

<On a related topic-I firmly believe that everything that our bodies
do has a purpose.  If so, then what is the purpose of the swelling
that accompanies the initial increase in milk production?  I observe
that every mother has at least a little swelling.  In most cases it
doesn't seem to interfere other than giving her some concern when it
goes away and she feels a little softer.  In other cases it can be a
major factor in baby having trouble latching/maintaining latch until
it is resolved.  So other than "making a pest of itself" for those
few days, does it serve any useful function?  If so what?>

I waited to see if anyone else had an answer to offer. Here is my $.02. I
have references for the statements below.

Edema forms when an imbalance occurs between
   1) the amount of fluid leaving the capillaries to produce new tissue
fluid, and
   2) the amount of tissue fluid returned to the central circulation by
the veins and lymphatic system.

So the answer to 'what is the purpose of the swelling that accompanies
the initial increase in milk production?' might be related to three
things:

1) Something is interfering with the lymphatic flow,
2) Tissue fluid is being formed too rapidly, or
3) A combination of both.

50% of the glandular tissue is located in the upper outer quadrant of the
breast. 75% of the lymphatic drainage is through the axillary lymph
nodes, with the lymphatic vessels needing to pass the upper, outer
quadrant of the breast on their way to the axilla.

So if feedings are delayed, interrupted or inefficient, the milk
gradually accumulating inside the glandular/ductal tree often "crowds"
the lymphatic drainage of the breast, causing edema to form due to "back
up" of tissue fluid that should be entering the lymphatic and venous
circulation. (relates to edema cause #1)

(This can grow into a vicious cycle whereby the edema then "buries" the
ducts and delays excellent clearing of the milk from the upper ducts,
also. Gravity, pectoral muscle movement, etc. can also effect lymphatic
flow negatively, or positively.)

Some theoretical solutions: early, very frequent feedings with an
excellent latch, hand triggered MER's if necessary, and breast
compression, especially the UOQ, to help move milk if baby's suckling is
weak or he falls asleep. Or early, frequent efficient fingertip
expression round the clock, and breast compression. Upward and backward
direction of massage if the swelling seems to be edema; forward and
centrally if fullness seems more related to milk.

If pumping is elected, it's important NOT to use maximum vacuum setting,
or long pumping sessions as this interferes with entry of tissue fluid
into lymph vessels, and often attracts fluid from nearby tissues,
resulting in burying the subareolar ducts (sinuses) deep under a thick
layer of edema.

In regard to edema cause #2:
It is normal for something called "colloid osmotic pressure" (COP) to
fall slightly within the first 6 hours after birth. COP measurement is
based on the concentration of protein in the blood stream, and is what
helps to keep fluids inside the blood vessels, (i.e., not escaping out of
the capillaries to form tissue fluid too rapidly)

Bedrest for over 12-18 hours can lower the COP somewhat. Crystalloid
intravenous fluids (like Ringer's lactate) lower COP by diluting the
protein in the blood stream. HCP's are aware that if too much crystalloid
fluid is given, a low COP can bring about pulmonary edema (a medical
emergency).

Research has shown that the larger the volume of such IV fluids given,
the lower the COP tends to fall. It takes 2-5 days for each 1000 cc. to
be cleared from the body by the kidneys, possibly longer if oxytocin
amounts were enough to act as an antidiuretic.

That is why we often see mothers with complications requiring prenatal
IV's, or with managed labors, still having swollen ankles, etc. for up to
10-14 days after birth. This phenomenon is independent of the type of
anesthetic or route of delivery.

The connective tissue of the breasts participates in the storage of this
excess tissue fluid, often distorting the nipple, making the areola too
firm and preventing good latching, leading to interventions of various
kinds.

And cause #3 is a combination of varying degrees of the above factors.

Theoretically then, mothers who move ad lib and assume various upright
positions during labor and give birth without IV's or drugs so as to have
robustly latching babies that feed early and very frequently, should
experience only the increased volume due to milk, without edema.

Or is this too rosy a picture? I rarely see such moms, perhaps because
they don't have problems that warrant a consult in the WIC LC office.

How does this explanation square with the experience and observations of
others?

Jean
****************
K. Jean Cotterman RNC, RLC, IBCLC
Dayton, OH USA

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