Theresa Johnson wrote: < I wonder to this day if maybe she was "wired" slightly different. Her nipples were tough and did exactly the same as your description. Jean Cotterman(sp) seems to know the wiring of breasts well and maybe would have some insight as to the "wiring" possibilities. Jean are you out there?> Yes, I am, and I posted privately to Ann just yesterday. Your description of your client and the ineffectiveness of RPS for her is helpful for me to know. I invite such observations from others. While the posts in the archives recommend that the pressure be held a full 60 seconds, some situations do seem to respond a little better to a full 2-3 minutes of reverse pressure. Moist heat before the procedure helps in some situations. Thank you for your confidence in my insights. I mainly report what I have observed and tried to find ways to understand after having seen literally thousands of breasts over a 40+ year professional time span. I've observed many women in pregnancy who have "pithy" tissue, reminding me of a turnip or carrot that's been left in the vegetable drawer too long. Normal intrapartum events seem to add to this. "Managed" labor seems to make it worse yet. Some degree of "water-logging" seems to be natural to some of these mothers, perhaps because of some difference of the lymphatic drainage. Some have more of this characteristic, and some have less. Some seem to have a larger amount of connective tissue in the nipple-areolar complex that can create some functional retraction of the nipple. That is, when the areola is compressed, the nipple retracts. I have had some of these mothers remark that their sister, or mother, or aunt "has nipples just like mine". The breast is the only organ in the body that is incompletely developed at birth. But the embryologic foundation for the proportion and location of future connective tissue develops from genetic determinants. For myself, I have concluded that this is the most likely possibility, and have discarded lots of others such as irradiation, injury, early mastitis, etc. I believe this genetic component also applies to the random placement of milk sinuses, deeper in some mothers than others, requiring different placement of the fingers for fingertip extrusion of milk or different size pump flanges. One size does not fit all. At any rate, such a state of affairs often leads to what someone has described as "latch-defying nipples" and may contribute to "oroboobular disproportion". This presents challenges with no clear set of answers, and draws on all the skills the HCP's can muster. It also makes me appreciate more the need to understand and harness the power of the MER in feeding management. I have an article by Drake, I believe, with a neat phrase about the mother's breast needing to conform to the geometry of the baby's mouth. Some breasts, especially during the postpartum period, don't do this as well as others. Unfortunately, for these mothers at least, our present state of knowledge continues to lead to disagreement in approach to management and inconsistent information for the mother. It is out of these observations that my ideas of Reverse Pressure Softening arose, and continue to develop. In summary, the end result is often increased sub-areolar tissue resistance. This is a term I use that describes the relative firmness, compressibility or extendibility of the internal tissues beneath the areola, including the milk sinuses deep behind the nipple. These are the tissues upon which the jaws and tongue of the infant must be able to fix and operate for efficient suckling. As I see it, the difficulties may arise from a combination of three main factors: Anatomical-Inflexible tissue (determined by genetic development and/or previous tissue damage) in the nipple-areolar complex that has remained non-elastic throughout pregnancy. Physiological-Lactogenesis II and relative overdistention of the milk sinuses, whose walls may become stretched to the limit of their current capacity. Iatrogenic-Increased intracellular edema caused by delayed, ineffective or infrequent early breastfeeding, deliberate intrapartum overhydration, and/or inappropriate use of vacuum to stimulate or remove milk from the breast. It is comforting to realize that the babies don't know the difference. This mother is the only one the babe has ever known, and if their mouth becomes familiar with her and her only, they can often do quite well. When they don't, time and growth of the baby's mouth will often help within 6-8 weeks. In the meantime, interventions for supporting milk production must be explained and demonstrated carefully so as not to destroy the mother's confidence or make her feel somehow abnormal. Ways to provide nutrition to the baby must be individually chosen so that the partcular parents can manage without discouragement, but still leave the baby willing to try to latch on to the breast eventually. There is still much work for us all. Jean ********** K. Jean Cotterman RNC, IBCLC Dayton, Ohio USA *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html