Nuala writes:

<I have permission to post. A mother with 4 week old premature triplets who are 
still in the NICU is pumping every 3 hours and had a very good milk supply. She 
over slept one pumping session and her breasts became very engorged. Her right 
breast recovered well, her left breast however did not do so well. She had 
plugged ducts that have been difficult to relieve. Now when she pumps she is 
getting 50 ml from her left breast(was getting over 100ml) with only one let 
down with some spraying. She still has plenty of milk left in her breast but she 
cannot get it out. Her nipple swells into the 30mm flange and seems to impede 
her milk getting out of the ducts.>


Nuala, good observation and description. I believe you are right in that the subareolar ducts are being compressed by crowding by "third space fluids" that have been pushing forward to neutralize the vacuum in the flange tunnel. 


Contrary to our "common sense", several centuries ago it was scientifically proven that vacuum does not pull; other forces push. (Breast pump manufacturers and engineers know this full well, but they never hint at it to us;-) (Wikipedia has some very interesting history of the science, demonstrated @ Magdeburg with metal hemispheres and teams of horses;-)


The nipple swelling is due to interstitial fluid (fluid in the "third space", between the circulatory vessels and the cell walls/duct walls) pushing its way forward to try to neutralize the vacuum inside the flange tunnel. How strong is the vacuum? There is obviously some slight anatomical difference in the nipples and/or the internal anatomy of the subareolar space/duct length/depth behind the two nipples. When fingertip expression is done, do the fingers need to be placed at a slightly deeper or more shallow position from the base of the nipple on the affected side to get the most efficient result?  Perhaps a lower vacuum, and a slightly larger (or smaller?) flange could be tried on the side that swells so that a slightly different length (1/4 to 1/2 inch???) of the subareolar ducts would be able to push themselves forward to compress themselves against the inside of the flange tunnel and drain that breast more efficiently?


I would suggest reverse pressure softening be done, prior to pumping, on the areola of the nipple that swells, with the mother reclining at least 3/4 of the way down on her back with nipple above heart level, so gravity would help "third-space" fluids stay an inch or so upward from the flange area for a while when the mother sits up to pump. If the flow slows and/or the same thing begins to happen after 5-7 minutes of pumping, repeat (lying back again if necessary) several times during pumping as needed. (or have her lie down on her side and pump that one breast singly so that the force of gravity doesn't offer extra help in the forward movement of 3rd space fluid to enter the nipple and/or crowd the subareolar ducts.)


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


In addition, RPS, held for the slow count of 50 (Thanks, Dr. Gail Hertz;-), will always (IME) trigger an MER within the next 30-60 seconds after RPS. (direct neural stimulus + time needed for oxytocin to travel through the circulation to reach the breast.) RPS can also be used directly on the nipple if necessary (thanks Rachel and Martha;-). Always gentle enough so as never to hurt. If you try all this and begin to find that you get that side draining milk freely, some more frequent short pumping sessions on that side might be in order to stimulate it 's "recuperation" of production speed/amount.


<The only way she can relieve it is to lean her breast into a basin of warm water and with massage> 


(Massage adds "another force pushing" to add hydrostatic pressure to help propel the milk forward in the ducts.) 


<she can get more milk out. It sprays from 4 to 5 ducts and her breast softens some though there is 
still  more milk in her breast. The nipple swelling reduces while in the water.> 


A fascinating fact to contemplate is how nature has provided us all the "baby's-mouth-size" circular group of small lymphatic vessels which forms the Sappey plexus under each areola. The slight negative pressure inside lymphatic vessels, (when freed from the competition of the stronger vacuum inside the pump flange), then helps any slightly positive pressure of interstitial fluid in the "third space" to push its way into the "pre-lymphatics" (Hall JE, Guyton and Hall Textbook of Medical Physiology, 12th edition, 2011, Saunders-Elsevier, p. 187) Lymph does not "circulate"; it drains, in one direction, toward the heart. When "third-space" fluid enters any lymphatic vessel, it then becomes technically titled "lymph", most of it passing through lymph nodes for immune functions, eventually draining back bilaterally, just beneath the clavicles, to the only area(s) where lymph re-enters the circulatory vessels. 


Another name that has been applied to these structures is "initial lymphatic capillaries". (Burt J, White G, Lymphedema, A Breast Cancer Patient's Guide to Prevention and Health, 2nd edition, 2005, Hunter House.). This and other excellent lymphedema paper-backs, very readable, reasonable, used or new, are easily available from on-line book sellers. The information presented is accurate, clear and simple enough to be understood both by lay persons needing the information to cooperate with their therapy, as well as by professionals. 


I think that lactation professionals, in particular, need these insights. Much about the lymphatic system, especially that of the breast, has been and continues to be learned by the radiology/surgery/breast cancer treatment community since at least the middle of the 20th century. I have been finding many fascinating and useful insights into the A&P of the lymphatic system which I have diligently searched for and found to be vague, misleading, outright erroneous, outdated, sparse or completely lacking in all the major lactation textbooks.


Please keep us posted on the progress of this highly motivated young mom with triplets and share what you observe so we can gain from your experience and hers.


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

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