Fleur writes and asks our thoughts about care of a mom who had severe childhood burns:
<Does anyone have experience with a mom who has scarring on her breasts from severe burns as a child?>
These are my first thoughts. I remember in the past seeing a mom with such a history, but only during the hospital practices of old, and I cannot remember the details.
< Saw a mom today (PTP) who is currently pumping and bottle feeding (with some formula as supplement) due to numerous issues (mom has low milk supply, PCOS, had C-section under GA, and baby has a PTT and lip-tie!). >
The PTT and lip-tie need to be addressed ASAP with the appropriate care provider, as they, in themselves, can produce pain, nipple damage and poor breast drainage when nothing problematic is present in the mother herself.
My first thought is how many days post-CS is this mom? Edema from IV's needs to be factored in if within the last 10-14 days, such as: what was her IV history intra partum: did she receive any more than an oral-plus-IV total of fluid >2000-2500 cc in any one 24 hours?? Specifically: was this an elective CS, with IV's mainly for blood pressure regulation during general anesthetia and surgery? Or was she induced with numerous hours of IV pitocin before the birth of the placenta? Did she have numerous hours/several days of IV pitocin after the placenta for 3rd stage management?
If edema is present, it will push forward through the intersitial tissue toward the lower pressure in the flange area very early, crowding the subareolar area so much that the compressed milk ducts may soon be unable to conduct much of any milk forward through the galactophores. Once again, I'm operating on my newest "mantra": "Vacuum does not pull; other forces push."
If there is areolar edema, my inclination would be to explain and get her permission to show her how to very gently try RPS in a 3/4 laid back position, if for nothing else than to observe whether it triggered an MER within 1-2 minutes, or if in this situation, with her Reynaud's-like set of symptoms, it might trigger blanching and pain. The results of this would give you important info about whether the burn scarring is going to effect the MER, which is the most powerful force in natural milk transfer.
Then, with her permission, when any edema has been dispersed 1-2 inches deeper backward in the breast, test and see whether gentle finger-tip expression is comfortable and if it might be able to extrude milk to the surface. Actually, this might be the only way to guess-timate whether the burns actually went deep enough to damage the subareolar ductal system. In that case, the subareolar lymphatic system (Sappey's plexus) between the skin layers and the ducts, would have been damaged too, effecting the lymphatic drainage of the areola.
<One of the main issues for this mom however is the fact that it is painful for her to pump, so pumping frequency is lower than it should be.>
Thinking in terms of the above "mantra", the scarred skin itself may well be so taut that there is no elasticity, and it may be experiencing skin-shear type tension from the inner-breast, inner-areolar forces pushing forward seeking to equalize the low-pressure area in the flange (do you see the similarity to the weatherman's report about the physics of barometric pressure shifts/wind velocity/tornadoes, etc. here?).
< She had second and third degree burns from head to waist as a child due to an accident involving a pot of boiling water.>
The word "child" makes me presume this age was before thelarche-(onset of breast growth)-which begins to happen around age 9-10 or so. If so, it may or may not have damaged the immature ductal system before lobules and lobes would have begun to develop during puberty. A good history of her memories of her breast tissue development might help predict some of the current milk-making potential and whether it may or may not respond to galactogogues and/or future pregnancies.
< There is visible scarring/skin changes on both areolas. When pumping with Medela symphony, even with low vacuum, mom is having pain which is mainly localized to the tips of both nipples, and her nipples are white with obvious vasospasm after pumping.>
Without an extremely accurate (impossible-to-get) surgical history, we have absolutely no idea of how many layers of surface or deeper skin/lymphatic/ductal tissue were damaged, including the nerves that come from all parts of the breast forward to pass directly underneath the areolar skin where there is no fatty tissue. This is the normal pathway of the nerves, on their way to the central sub-nipple location, where, in the center of the nipple flesh, they each wind around a separate galactophore all the way to the tip of the nipple.
This makes me think that if women who have areolar incisions for breast surgery have a higher incidence of Reynaud's syndrome of nerve constriction around the arterial capillaries in the nipple and/or areola, that this mother would be at higher risk as well, especially with any outright trauma of the skin that is happening as her inner breast tissue tries to respond to vacuum as above.
I would be wary of further vacuum, and discuss the symptoms of blanching, etc. with her physician, and ask about the possibility of nifedipine. To my dismay, I recently discovered, (after the first two-week course did not relieve much for the mom I was helping), nifedipine may apparently be repeated in two week time periods several times, in time-release doses of 30 mg. , or 60 mg. or 90 mg, twice daily. (I am not certain, but I think this info may be available from a Ruth Lawrence source.) The nifedipine might simply end up as pain relief to ease the blanching, but may or may not prevent the repeated such response of those nerves to direct stimulation.
< Her nipples appear to be very inelastic>
probably mainly scar tissue, having replaced any elastic characteristics of normal skin.
<and they do not expand with pumping.>
understandable, and possibly indicating unexpandable scar tissue in deeper layers.
<She has tried different flange sizes with no improvement.>
Bless her heart. What courage!! I think she deserves so much commendation and support and an immediate switch to a trial of gentle hand management of any milk removal.
<I suspect that there has been damage to the tissue from the burns she suffered as a child and that is what is causing the pain.>
My thoughts exactly, and would better have been at the center of advance prenatal planning, or initial postpartum planning, or at least now, all future planning. If the milk is seen to begin flowing with gentle fingertip expression at some point, I suggest gentle inward and/or forward massage and/or breast compression during feeding, and possibly some breastfeeding starting with an appropriately fitted nipple shield if the Reynaud's-like pain reaction can be completely relieved first. (My recent sad experience with a mother with Reynaud's symptoms makes me more wary for the future.)
I would recommend no pumping per se until manual means can be used in a pain-free way. Vacuum, in the future, if ever, should be very gentle and accompanied by gentle breast compression or massage to move milk forward more easily toward the area of lower pressure within the flange tunnel.
<Has anyone else seen something similar? What was the outcome?>
Anyone who has such cases could help the mom immensely with advance agreed-on, written, ongoing team planning with the mother's simplified physiological education and participation and consent, depending on the prenatal or early postpartum and incremental daily physical exam of the breast and breast changes, with some type of home care follow-up, so that everyone is "on the same page" on every shift and department.
Clinical photography and writing up of any such case for the lactation literature would certainly help the rest of us in caring for any such mothers we may later meet. I'm convinced our profession MUST (yes, I just shouted) avoid simplistic thinking about vacuum forces, just because they (and their advertising) are so "in-our-face" in developed cultures. 500 years of scientific evidence base supports the physics of vacuum, and health professionals, at least, ought to understand its effects, so as to use vacuum wisely and be able to explain it simply to the moms they care for.
Gentle fingertips have been used by nursing mothers all over the world for eons. Guided by a deeper knowledge of the normal microanatomy and neurology of the nipple-areolar complex, we owe it to our moms to "First, do no harm."
K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC Dayton OH
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