Nikki asks about references about the "pinch test".

Dr. Harold Waller was the medical "champion" of breastfeeding shortly before the mid-20th century in the UK. Research at that time consisted mainly of clinical observation and reporting what seemed to work and what didn't seem to work, and trying to reason why this might be so. He got a lot of things more right than anyone else of his day seemed to be getting them, to read about the following he had among the midwives and the honors he received among the pediatricians and obstetricians alike. I have one of his original books somewhere in my stacks.

I googled "Dr. Waller nipple protractlity test" and brought up: Alexander JM, Grant AM, Campbell MJ,
 "Randomised controlled trial of breast shelis and Hoffman's exercises for inverted and non-protractile nipples"


<If the nipple was not inverted the woman was asked to check for non-protractility using a "pinch test," based on the procedure described by Waller.4 The woman placed her thumb and forefinger on either side of the nipple just beyond its base, pinching them together to imitate the action of a baby's jaw while feeding. Nipples that did not protrude at
least half a centimetre above the areola on pinching were considered non-protractile.>

I remember in 1975 in the AJN a test was described by Mary Jane Otte that was similar, except the examiner would grasp the nipple with the thumb and forefinger of one hand while compressing opposite sides of the areola with the same digits of the other hand, and observing and actually palpating whether the nipple retracted back out of the examiners grasp. There is a one-page "sample" of the article online without the picture that is described as showing the "pinch test", but I remember very clearly that her version was as above. She mentioned Dr. Waller, Dr. Hoffman and Dr. Applebaum in her article:

<Correcting Inverted Nipples: An Aid to Breast Feeding www.jstor.org/stable/3423290Similar
by MJ Otte - 1975 - Cited by 6 - Related articles
alleviate the problem. MARY JANE OTTE ... breast feeding, prefers another solution to the inverted ... AMERICAN JOURNAL OF NURSING. 454. MARCH 1975 >

This article came out at about the precise time I had become intensely interested in the problem of inverted nipples. Jimmy Lynn Avery published my article on correction of inverted nipples in her short-lived journal: Keeping Abreast Journal 1(1):46 48 Jan/March 1976.

All of this interest has led me over the years to read deeply on the microscopic anatomy of the nipple-areolar complex. I have collected several illustrated case studies on inverted nipples, as yet not written up. I have made my share of misjudgements, and trespassed my share of psychological boundaries in the process, but when perinatal medicine was just beginning the process of "labor management" and more and more mothers began receiving multiple bottles (before plastic bags for intravenous fluids came into use) of IV fluids, the "new" differences in the breasts in the early postpartum period were one of the the obvious things I noticed. Temporary flattening and even retraction of the nipples was not uncommon. My continued interest in the subject of nipple protractility led me to try the Hoffman technique on postpartum mothers with that kind of early swelling that I had never noticed in mothers before, back in the days when mothers were NPO in labor and got no IV fluids except in the most dire emergencies. 

I gradually noticed that some babies who always nursed in the same position actually "pitted" the edema in the areas where their jaws were compressing. When nipples seemed flat or retracted during the postpartum period in the 4-5 day stay common for vaginally delivered mothers at that time, I found that using the complete two part technique that Hoffman had described caused pain. But if I very slowly used just the first half of his technique, there was no pain, and the baby then had an easier time getting what I called "a good grasp" of the nipple.  As the lone night duty nurse on the "normal postpartum floor" 5 nights a week, after passing a few pills and taking some occasioanal blood pressures, I had had plenty of time to help breastfeeding mothers. One mother after another, having no solutions offered by anyone else, was more than willing to let me try my best in the middle of the night, to help her baby grasp her nipple. All these experiences helped me gain the insights that eventually led me to the development of reverse pressure softening and my articles in Leaven in 2003 and JHL in 2004. 

The anatomy of the nipple and the areola are intimately connected from the time of their embryological development, and slow development of nipple inversion is normal at one stage near the end of the second trimester. Subsequent eversion apparently is still taking place even during the newborn period, and the Dubowitz-Ballard score for judging gestational age uses breast/nipple development as one of its criteria. 

When even small amounts of fluid collect in the interstitial tissues of the postpartum areola, this effects the ability of the areola to change shape to respond to the physiological forces of suckling to advance the nipple forward deeper into the baby's mouth. In pendulous breasts, this fluid can begin to collect during late pregnancy simply from the effect of gravity itself on the lowest part of the breast, which includes the sub-areolar tissues and the nipple. This process can become all the more obvious, eventually developing what I have labeled "Pre-L-2 edema" in mothers who received >2000-2500 cc of fluid in any one 24 hour period during intrapartum care, especially if pitocin is used for hours for induction, augmentation or third stage management (due to it's antidiuretic action.) This phenomenon definitely needs formal research, as at present it is based only on empirical observations. I have plenty of references and suggestions for anyone interested in doing such research, and would be glad to share them. Please pass the word to those looking for research subjects.

Since many professionals and lay people alike do not realize that "Vacuum does not pull, other forces push", the injudicious use of breast pumps during this time period allows even more interstitial fluid to move into the subareolar area, and often, even the nipple area. This action is added to that of gravity in the case of the pendulous breast. The solution is definitely not to turn the vacuum up higher, but sadly, this is exactly what many people "reason" that they need to do, too often complicating matters even further.

Lynn asks:

<I do have a semi-related question from a mom which I was unable to answer: When a mom has pencil-eraser nipples postpartum, which never go back to flat and smooth like they used to pre-pregnancy (ie they always protrude
rather firmly), will there be a point post-weaning, where they will go back to flat?  The mom's nipples even show through a padded bra and this has led to some awkwardness in professional settings.  High school, I know, but
there it is :P>

My only answer is that I once cared for a mother whose nipples were so large it was almost impossible for her baby (her 5th) to get the whole nipple past his lips. According to her, apparently her nipples had become larger with each new pregnancy/breastfeeding experience. I have no idea why it happened in her case, and I had no reason to disbelieve her, for the nipples were very large, though the breasts were not especially so. (I did not go so far as to delve into her sexual history.) I haven't seen this in any other mother, or at least no one has reported it. I suspect it may be dependent upon a particular mother's individual anatomical and genetic traits, so that some mothers may have different experiences from others. If this mother you describe were willing to consent to anonymous medical photography now and later, this might make for an interesting case history from which others could learn.

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





 

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