Phyllis writes: 
"Jean: Thinking of possible sharp edges from cut silicone> 
I wouldn't be concerned. This is not analogous to cutting off a nipple
shield. The part I had suggested cutting off is the extension of the
nipple itself. Unless the mother has a rather large nipple, the diameter
of the common rubber/silicone nipple is big enough that the cut part just
3/16 inch high would not really touch the side of the mother's nipple.
(See the photograph in the JHL article) 
It simply allows the color of the nipple to be visualized, to be on the
safe side, in case one feared occluding circulation. It also actually 
permits one to see the nipple "rise" or "evert" as the fluids are
eventually "pitted" backward into the subareolar area. Actually,
depending on the circumference of mom's nipple the process would probably
work just as well without bothering to cut off the top. The idea is to
provide that continous circular base to spread the pressure evenly and
protect the areola from fingernails.  
I did suggest in my article, for mothers of babies in NICU, using RPS
<prior to or as part of the application of a soft silicone nipple
shield.> That works just fine to exert pressure right through the
circular ridge, if a mother has already been issued one (large enough for
her nipple) and charged for it for another reason. I think it would be
wasteful to give one out simply for the purpose of RPS alone.
<would it work to use the inner ring from a breast shell, without the
shell itself? I'm thinking of the piece with the smaller hole intended to
bring out inverted nipples. Instead of wearing it on the breast inside
the bra, just use the inner ring as a RPS device. What do you think> 
Actually, when the breast shell works as advertised, I think it's on the
same principle of pitting edema, because of the slight constant reverse
pressure from the bra against the shell against the areola. Not near as
much as from RPS itself, but if the mother had already been charged for
them, it would be worth a try, using just the inner part, not the whole
shield. 
The curvature is slightly different, and I definitely don't think it
would work as well by pressing on the whole shell because the leverage is
less efficient to exert the needed pressure right at the base of mom's
nipple. There is much stronger leverage when the fingers are pressing
directly close to the opening. If anyone tries it and finds it works as
well I'd like to know. 
I had even thought of inverting the inner part to get a reverse
curvature, but that definitely wouldn't work because there would then be
that fairly sharp circular edge ridge that would be painful and
potentially damaging if pressure were exerted. 
I also thought of the glass part of the old fashioned two piece nipple
shield, but that too, is the wrong angle. It needs to be flat for 3/8 of
an inch or so. (A garden hose washer or a flat metal washer, or even the
Medela plastic nipple circumference ruler have even crossed my mind!)
I confess that the idea of simply cutting off an ordinary garden variety
rubber/silicone nipple occurred to me because it's so often "right there
handy" and I wanted to discourage the invention of one more "gizmo" that
would have to be stocked, charged for, and/or someone being sent to the
drugstore for! Plus it gave me a grin to think that the "free" nipples in
the hospital provided by the AIM companies could be used to facilitate
latching;-) (and thereby discourage supplementing;-)

Jean
************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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