Theresa Johnson wrote:

< I wonder to this day if maybe she was
"wired" slightly different.  Her nipples were tough
and did exactly the same as your description.  Jean
Cotterman(sp) seems to know the wiring of breasts well
and maybe would have some insight as to the "wiring"
possibilities.

Jean are you out there?>

Yes, I am, and I posted privately to Ann just yesterday. Your description
of your client and the ineffectiveness of RPS for her is helpful for me
to know. I invite such observations from others.

While the posts in the archives recommend that the pressure be held a
full 60 seconds, some situations do seem to respond a little better to a
full 2-3 minutes of reverse pressure. Moist heat before the procedure
helps in some situations.

Thank you for your confidence in my insights. I mainly report what I have
observed and tried to find ways to understand after having seen literally
thousands of breasts over a 40+ year professional time span.

I've observed many women in pregnancy who have "pithy" tissue, reminding
me of a turnip or carrot that's been left in the vegetable drawer too
long. Normal intrapartum events seem to add to this. "Managed" labor
seems to make it worse yet.

Some degree of "water-logging" seems to be natural to some of these
mothers, perhaps because of some difference of the lymphatic drainage.
Some have more of this characteristic, and some have less.

Some seem to have a larger amount of connective tissue in the
nipple-areolar complex that can create some functional retraction of the
nipple. That is, when the areola is compressed, the nipple retracts.
I have had some of these mothers remark that their sister, or mother, or
aunt "has nipples just like mine".

The breast is the only organ in the body that is incompletely developed
at birth. But the embryologic foundation for the proportion and location
of future connective tissue develops from genetic determinants. For
myself, I have concluded that this is the most likely possibility, and
have discarded lots of others such as irradiation, injury, early
mastitis, etc.

I believe this genetic component also applies to the random placement of
milk sinuses, deeper in some mothers than others, requiring different
placement of the fingers for fingertip extrusion of milk or different
size pump flanges. One size does not fit all.

At any rate, such a state of affairs often leads to what someone has
described as "latch-defying nipples" and may contribute to "oroboobular
disproportion".

This presents challenges with no clear set of answers, and draws on all
the skills the HCP's can muster. It also makes me appreciate more the
need to understand and harness the power of the MER in feeding
management.

I have an article by Drake, I believe, with a neat phrase about the
mother's breast needing to conform to the geometry of the baby's mouth.
Some breasts, especially during the postpartum period, don't do this as
well as others.

Unfortunately, for these mothers at least, our present state of knowledge
continues to lead to disagreement in approach to management and
inconsistent information for the mother. It is out of these observations
that my ideas of Reverse Pressure Softening arose, and continue to
develop.

In summary, the end result is often increased sub-areolar tissue
resistance. This is a term I use that describes the relative firmness,
compressibility or extendibility of the internal tissues beneath the
areola, including the milk sinuses deep behind the nipple.

These are the tissues upon which the jaws and tongue of the infant must
be able to fix and operate for efficient suckling. As I see it, the
difficulties may arise from a combination of three main factors:

Anatomical-Inflexible tissue (determined by genetic development and/or
previous tissue damage) in the nipple-areolar complex that has remained
non-elastic throughout pregnancy.

Physiological-Lactogenesis II and relative overdistention of the milk
sinuses, whose walls may become stretched to the limit of their current
capacity.

Iatrogenic-Increased intracellular edema caused by delayed, ineffective
or infrequent early breastfeeding, deliberate intrapartum overhydration,
and/or inappropriate use of vacuum to stimulate or remove milk from the
breast.

It is comforting to realize that the babies don't know the difference.
This mother is the only one the babe has  ever known, and if their mouth
becomes familiar with her and her only, they can often do quite well.
When they don't, time and growth of the baby's mouth will often help
within 6-8 weeks.

In the meantime, interventions for supporting milk production must be
explained and demonstrated carefully so as not to destroy the mother's
confidence or make her feel somehow abnormal.

Ways to provide nutrition to the baby must be individually chosen so that
the partcular parents can manage without discouragement, but still leave
the baby willing to try to latch on to the breast eventually.

There is still much work for us all.

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

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