This was my answer to Christine:

<I need to start by saying that I definitely do believe that there are
lactiferous sinuses. I believe they are much smaller than cartoon diagrams
led us to believe in the past. I have sometimes described them to pregnant
or newly delivered moms as feeling like "little bee-bees" or "Like little
lumps in tapioca pudding." Never have I felt one much larger than 1/3 to 1/2
the size of a womans (trimmed) little fingernail, even in mothers in full
lactation, when they become much softer after repeated stretching and
relaxing.

My experience has been, through palpation on hundreds of mothers over a 45
year time span, that sinuses occur at different depths posterior to the
nipple. Some mothers have all shallow sinuses, within a half inch of the
base of the nipple.  Other mothers have them further back, perhaps an inch,
or an inch and a half behind the base of the nipple, but most at
approximately the same depth. I believe that is why Lactation consultants
have had to request that pump companies supply different flange sizes,
not simply because of different nipple sizes, but because of different
depths of lactiferous sinuses, which can have little or no connection to the
actual size of the nipple. There are some mothers who have them at multiple
depths, shallow, medium and deep, sometimes in just one breast, but more
often in both.

One time, I actually illustrated this situation in one of my talks by
using two slides, drawn exactly the same, with a diagram of a bouquet of
flowers clutched in a hand, with stems coming out the bottom. As many old
fashioned bouquets are made, there is a lower, outer ring of flowers, then
another layer above the first with a smaller ring of flowers, with yet
another upper layer with just one or two central flowers. I put the second
slide in the tray sideways to illustrate how this could apply to the
nipple-areolar complex. The clutched hand represents the nipple with the
stems in the center, and the flowers represent lactiferous sinuses
at different levels. I believe that some mothers have a full complement of
lobes (15-20) with 7-10 tiny sinuses and some mothers have fewer lobes, with
fewer sinuses, but still make adequate amounts of milk if they nurse often
enough.

The milk ejection reflex is actually the most powerful force in milk
transfer. Vacuum does not really attract or "pull" on anything. It simply
lowers the pressure on the inside of the flange well below atmospheric
pressure. Then, atmospheric pressure on the outside of the breast and
various types of hydraulic pressures inside the breast (interstitial fluid
pressure, blood pressure, intraductal pressure, etc.) try to equalize the
pressure within the flange, because "Nature abhors a vacuum." So while it
feels to the mom like the breast is being "pulled" into the flange, it is
really the breast and specifically all the flesh of the nipple-areolar
complex that is being "pushed" into the flange. So the first action is
really not on milk, but on flesh, as Christine has so astutely observed.


The various components of the tissue, including the sinuses in
range, compress themselves against the inside of the tunnel of the flange,
indirectly moving milk by putting the milk in those few sinuses under a
positive, hydraulic pressure to move the easiest direction it can, usually
outward. Suction acts directly on the milk itself only after it reaches the
surface of the nipple. In the case of a mom with sinuses at multiple levels,
the compression would effect whichever of the anterior ones compressed
themselves sufficiently against the tunnel, while those beyond the tunnel
could actually have some of the flow blocked, because the tunnel entrance
would compress the ducts anterior to the deep sinuses, sometimes tending to
obstruct even the MER pressure.

Here is my suggestion. Have her use the flange that feels the most
comfortable, and use this feedback from clinicians who reported to me that
mothers in NICU get "tons more milk" if they do this sequence:


   1. Do RPS for 1-2 minutes (to stimulate the MER, and to redistribute
   any excess tissue fluid further back out of the nipple-areolar complex. Even
   non-engorged mothers can have tissue fluid moved into the flange while
   pumping, causing the nipple-areolar complex to change measurements per the
   BF Atlas/Wilson-Clay & Hoover. Dairy research also reports this.)
   2. Then do 5-7 minutes of pumping on medium.
   3. Stop and massage from the back of the breast for a minute, to move
   some more milk forward,
   4. Then repeat the entire 3-part sequence as often as needed.
   5. I might also suggest breast compression during the pumping if she
   has some way or some one to hold the flanges in place, or help massage.


I welcome any feedback negative or positive. I sent Christine a copy of the
latest RPS instruction sheet, and am willing to send one to anyone who
wishes, if you contact me privately. I know my clinical impression disagrees
with more highly publicized recent interpretations of ultrasounds and
mechanical milk removal. I can only report what I have observed through my
fingertips, my eyes and my reading of some references in high
school physics, embryology, histology and breast surgery literature. They
have taught me a great deal about the tissues contained in the
nipple-areolar complex and how the accurate focusing of positive
pressure behind the sinuses may utilize Pascal's law and result in effective
milk removal, which was going on manually all over the planet eons
before pumps were invented.


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

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