Jan,
My short answer: No I think you will find your client does not have
"blind ducts." But I doubt that direct breastfeeding will ever be
possible.
I have experience with one mother who had one nipple that seemed to be
just like what you describe. She said her mother and two aunts had the
same situation, on one side only.
Her situation is one of the ones that launched me on my quest for
knowledge about inverted nipples and from there to embryological
development, and my "invention" of a method of using vacuum preparation
for inverted and retracting nipples.
(It used parts of old-fashioned nipple shields put together, and a
"bicycle horn" pump, used the timing suggested in an old article by
Egnell, and was published in fall 1976 in the Keeping Abreast Journal.)
This was over 25-30 years ago, before anyone put 2+2 together re:
antenatal nipple stim and risk of premature labor. She had had a previous
CS and a perfectly miserable attempt to breastfeed because her MD
"absolutely forbade pumping postpartum".
She was referred to me early, and I was able to follow her with close-up
slides for 3 months before birth and during the postpartum period. After
obtaining permission from her new MD, at 26 weeks g.a.,she began using
the "contraption" at first 3 x/day for 10 minutes each side.
After a week she increased to 15 minutes each side 4x/d. While her
retracting nipple seemed to become a great deal more elastic, the
invaginated nipple never emerged.
By definition, an invaginated nipple is one where what would have been
the surface of the nipple lines a pit.
This apparently happens because the mesenchymal layer (destined to form
the muscle and connective tissue in the nipple and areola plus surround
the ducts and form the septa between lobes) failed to proliferate and
raise it out of its anatomical inversion (mammary pit) in late
pregnancy/newborn period. (This is a normal stage for every fetus and
sounds like a competely different process from what forms the ducts.)
Schwager RG, Smith JW, Fray GF, Goulian D Jr., Inversion of the Human
Female Nipple, With a Simple Method of Treatment, Plastic &
Reconstructive Surgery, Nov. 1974, Vol. 54, No. 5 pp. 564-569.
It has been my experience (4 unpublished case studies with close-up
pictures) that there are many, many varieties of inversion. Even though
they sound very similar, your client may be different from the one I
describe. But here is why I do not believe your client has "blind ducts":
Early in the second trimester, the embryological "bud" begins to sprout
"secondary buds" from its under surface, which then bifurcate or divide
and continue to grow downward as solid cords into the mesenchymal layer.
(In my mind's eye, I am imagining that the future milk sinuses will occur
in maturity at these points of embryological/fetal bifurcation.)
In a separate process (which I am still avidly hunting for more
information on, because I'm not satisfied with the explanations I have
read), later in the second trimester, the internal part of each solid
cord begins to canalize starting at the deep end and rising upward toward
the surface. This process is completed long before what seems to be a
separate process of the formation of the mammary pit.
I am betting your client's sinuses just empty into the pit, and are
buried so deeply that atmospheric pressure cannot force them into the
"vacuum that nature hates" in the pump flange. It might be worth it to
try the largest (glass) shield that Medela makes to see if there is any
difference, however.
My client's milk sinuses were buried so deep in the breast that I was
never able to palpate them, nor express from them. But all the prenatal
pumping (of both sides, with very little loss of colostrum) brought her
milk in quickly with very little engorgement (as predicted in an old
Israeli article), and must have conditioned a terrific MER.
We had her pumping the inverted side and the baby nursing on the slightly
retracted side, and the MER's caused the colostrum to pour forth from the
pit, and the vacuum took it from there.
But my impression at the time, and still is, is that the same process of
proliferation of the mesenchyal layer to form the nipple button and evert
the nipple is also the one which elevates the milk sinuses to a position
within 1-5 cm behind the nipple.
(Yes, from palpating literally thousands of nipple-areolar complexes over
the years, I do believe they exist, but perhaps just not exactly as we
have been trained to imagine them.)
I suggested several options for my client:
Go home nursing on the one side (which was going very satisfactorily) and
pump on the other to save milk for possible p.c. feedings.
If she discovered the one breast was producing all the milk the baby
needed, she could massage in the shower ad lib for relief and
gradually"wind down" production on the side with the inverted nipple.
She chose the latter, due to social complicatons
having to do with a 2 y.o., a sudden illness of her husband, moving in
with her MIL, etc. etc. shortly after birth. At my last contact at 4
months, she was still exclusively breastfeeding on the one side and dried
up on the side with the inverted nipple.
However, since your client has 2 such nipples, I see only two options:
Pumping, with compression/massage, and then bottle, or finger feeding, or
Continuing to pump for stimulation, but use compression while using a
nipple shield, perhaps with an SNS tube or FF tube under it, to feed "at"
but not "from" the breast.
I would even suggest the old fashioned rigid glass and rubber nipple
shield, still available in Canada, because the rigidity of the base makes
it easier to handle, since there would be no nipple filling the latest
silicone style, and it would slip and collapse easily.
Just my $.02 worth.
Jean
***************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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