Dolores writes:

<I am a hospital based LC and I have on occassion had moms with flat
nipples, but they are also dense. When I attempt to shape the nipple
(nipple sandwhich) the tissue is dense. This makes it more difficult to get
infant to latch. Can anyone offer suggestions???>

Your experience reminds me of mine years ago on postpartum. I have done a great deal of thinking about this over the years. At first, I thought that "density" must be due to an actual condition of the tissue itself, perhaps genetic, or due to scar tissue or something. Through palpation and further reading, I have completely changed my mind on the matter. I have found that "density" is really determined by the amount of interstitial fluid in the nipple itself, and since you are talking about making a nipple sandwich, more likely in the areola and the tissues deep down under and inside the areola as well. 


Interstitial fluid is not really fluid, but more in the form of a gel, so that it will not move so easily with positional changes. The gel still allows the raw materials, hormones, O2 and fluids to find their way efficiently from the arterial capillaries through the gel to the individual cell membrane of each milk producing cell, and O2, for instance, to even the ductal tissues. 


One of the normal characteristics of interstitial tissue is the ability to store water. I think that must be why the breast has so much interstitial tissue, since it is "close at hand" for constant milk making. Interstitial tissue in any body area which has it as part of the anatomy, can store up to 30% above the normal amount without showing pitting. When pitting is observed, it means the interstitial tissue is storing 30-50% more fluid than the interstitial tissue is normally meant to hold.  (Hall JE, Guyton and Hall Textbook of Medical Physiology, 12th edition, 2011, Saunders-Elsevier.) This can even begin to show in late pregnancy due to conditions that cause the mother to retain fluid, like PIH.


Another factor involved is gravity itself, which can attract fluid downhill to the lower part of the breast (wouldn't you know it: just where the nipple-areolar tissue is located!) when the mother's breast is the least bit pendulous, meaning a C Cup or beyond. 


If you "add up" 
1) the mother's possible prenatal water retention, 

2) the size/ relative pendulousness of her breast, however well supported, and 

3) then figure in whether she receive IV fluids to make for a total oral and IV intake of > 2000-2500 cc. in any one 24 your period (my observation, not yet evidence based by anyone that I know of), then the tendency of interstitial fluid to gather down and forward (and thus toward the nipple areolar complex) increases. 

4) If she had IV pitocin for hours for induction, augmentation or third stage management, (pitocin can occupy binding sites for antidiuretic hormone (ADH) in the kidney), this too will tend to delay excretion of fluids. 

5) All this can be further complicated if any mechanical vacuum has been applied, because vacuum does not pull. Other forces (including weight/pressure of excess interstitial fluids) will push their way toward the vacuum to attempt to neutralize it. "Nature abhors a vacuum."


So lowering the mother's bed position to anywhere from 45 degrees to flat so that her breasts can be easily elevated above her chest wall, will help other interventions to last long enough to help latching measures, such as "making a breast sandwich". If the tissue is "dense" (i.e. noticeably waterlogged), reverse pressure softening of the areola may require perhaps a whole 5-10 minutes (in the anti-gravity position) at least the first few times. (It will also automatically cause an MER whenever it is done.) 


But the interstitial fluid will move painlessly back upwards 2-3 cm. behind the areola when this intervention is applied with steady pressure, firmly but slowly enough to avoid any sensation of pain. This will then temporarily free the tissue's capacity for "shaping" or responding to latching measures. The gravity part is essential to figure in because the tissue fluid can return to the front of the breast fairly quickly before latching can take place if the mother's breast is pendulous and dependent. 


This means that biological nursing in a "laid back" position might be especially helpful for this mom for 7-10 days till swelling leaves.  In the case you describe, I would suggest the HCP offer to demonstrate the effects of RPS first, and then, mom can use her sense of touch to compare the two areolas, and be taught the most convenient way for her to do RPS herself each time just before latching (or pumping) for the next 7+ days till no longer needed for latching. A second alternative for anticipatory guidance of moms between feedings is a demonstration breast. Even a pediatrician (or an obstetrician !!!!) might use that on rounds, if they but realized the importance of teaching the mom this intervention early, even prenatally;-)


kellymom.com/bf/concerns/mother/rev_pressure_soft_cotterman/


The "flatness" of the nipple itself, if the mom's nipples were not flat before or during the first part of her pregnancy, may be due to filling of the surrounding tissues with interstitial fluid so that the area becomes distorted, if not quite yet able to be pitted. Also the filling of the ducts just 1-3 cms. beneath the nipple may soon tend to tug inward on the nipple. The walls of the full ducts can try to "borrow some stretch" or "tug inward" on the ducts in the nipple itself, which are lined with a different kind of cells just like our outer skin. The effect seems to be to retract the nipple itself inward towards flat, or even temporary retraction that mimics nipple inversion. 


(Many body tissues "borrow stretch" from each other, such as when our elbow or knee bends, or skin from the baby boy's scrotum can be seen as "borrowed" if he has an erection before he is about to wet his diaper, etc.)


If you wish any further information/articles on RPS, you can contact me off list.


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

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