One thing to consider is simply the mother's particular anatomy. Does she have 1) flat nipples?? 2) Any degree of pendulousness?

It is my impression that the galactophores (ducts in the nipple) are usually shorter in a flatter nipple and less likely to "apply the brake" to the colostrum when the mother has a normal Braxton - Hicks contraction. When such a mother is without a bra she might experience an MER and leakage simply from the sheets brushing against the nipples when simply turning over in bed. Even wearing a sleep bra to reduce tactile stimulation works for some of these moms. Since this young mother has been observed to be saturating pads, I assume she is wearing some sort of bra. 

Is she perhaps pendulous? If so, for one thing she would be more likely to have larger "milk lakes" from longer ducts. If any degree of pendulousness were present, and poorly supported if no good bra or binder were available, and she also has flat nipples as well, gravity alone might be sufficient to allow milk to leak easily, perhaps even through capillary attraction. If the nipple is shallow or flat, any slight exit of milk is simply not blocked by longer, narrower galactophores as it is in those present in a 1/4 inch or longer nipple in a breast with internal ducts that don't begin until slightly deeper down: 3/4 to 1+ inches deep below the nipple in many moms. 

Galactophores are lined with squamous epithelial cells. These are flat cells just like those on the outside of the body. These cells are not as stretchable as the deeper columnar cells (which begin abruptly at what histologists refer to as the squamo columnar junction. From there on inward, the remaining ducts in the breast are lined with columnar and/or cuboidal cells: think of them as "capable of changing shape like a marshmallow as needed")

Stop to think how often you have advised a mom who still leaks copiously several weeks after birth simply to apply the pressure of the heel of her hand to the nipple for 1-2 minutes before or at the first hint of an MER to prevent leaking. 

Since this young mother is probably not aware of her Braxton-Hicks contractions, this might not give her the signal to apply pressure. Therefore, especially if she is at all pendulous, if no excellent quality supportive bra can be supplied, I suggest continuing to protect the nipples with fresh standard leakage pads as needed, but apply a gentle but firm old-fashioned breast binder, or even a large towel applied (starting from the waist up to place pins perpendicular where it joins in front. Another possibility might be a well-fitted standard velcro surgical binder applied further up above the waist. Have the mother lie flat on her back and support her breasts with her hands outside the binder while an HCP starts at the bottom and fastens the velcro.

If either or both of these anatomical features is present, I recommend that this might be where to begin in preserving her colostrum and protecting her nipple from entrance/undue proliferation of organisms.

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

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