Anne writes:

<I think what Peter Hartman's studies did point out is that what we know
as lactiferous sinuses change through pregnancy and postpartum. >

I think Peter Hartmann is the senior faculty advisor of the PhD program,
but the work seems to be primarily that of Donna Ramsay. That's how their
ultrasound work "fills in the blanks" for me, personally, because of what
my clinical experience has demonstrated to me by palpation. But somehow,
I'm not sure most people in the lactation community are seeing and
hearing it that way, especially those who are not 'hands on'
practitioners. And especially when several people on Peter's team are
actually out and out stating that older ideas of 3 dimensional
nipple-areolar anatomy are flat-out incorrect and that all anatomy books,
etc. etc. should be changed to reflect their conclusions. (In a personal
communication, an Israeli MD who wrote an article on congenital nipple
defects told me that ultrasound is not the most sensitive and appropriate
way to study the anatomy of the nipple-areolar complex.) LLL and leading
BF publications have already changed to reflect the Hartmann team
conclusions, and believe me, any author who tries to use the words
'lactiferous sinuses' in their articles must have good reason, good
references and very careful wording, and even then, fights an uphill
battle. I have had personal experience with this with two of my articles.


<The ultrasound images he showed in his studies, at least the ones I saw,
were of women past the first few days pp, with established milk
supplies.>

This is an important point. Elastic tissue that has been stretched and
unstretched multiple times undergoes changes, making the fibers less
tightly curled and therefore more easily stretched. Under the microscope,
men and children also have lactiferous sinuses, but only those of mature
women have thick elastic tissue in their walls.


<In those first few days pp prior to the mature milk starting to come in,
therefore the smaller volumes, the lactiferous sinuses can be palpated
and are distended with awaiting colostrum for the new baby.>


IME, they are usually tense and tight, except for possibly tandem
nursers, where the suckling would have maintained the "stretchiness" of
the elastic walls.   

< Once the mature milk is coming then these sinuses expand by fullness
and once the milk ejection is over they become smaller again.>

I think it takes several weeks of suckling or pumping to stretch and
unstretch the walls enough times that they can actually expand to their
fullest volume and feel less tense, and that can also be felt on
palpation. Still, they are very small, though, 8mm wide per the reference
quoted in my post 12/9, or about 1/4 to 1/2 the area of a woman's little
fingernail, and a maximum of about the same length, which is much, much
smaller than textbook "cartoon" diagrams have always led us to believe. 
Once again, I think it is the dimensions of the sinuses in the diagrams
that have been at fault in our erroneous understanding. They are what
need to be changed! I cannot go along with the view that sinuses have
gone out of existence, or never even existed in the first place! 

And I agree, they no doubt "unexpand" quite a bit after the height of the
MER, but are nevertheless, afterward still palpable in many, many moms,
and full enough to elicit a few large drops, a trickle or even a "squirt"
if pressure is effectively focused on the posterior end of the sinus. (I,
too, invariably find myself silently "demonstrating" on my won fully
clothed breast while giving phone directions for massage, breast
compression, RPS or Marmet method ;-) Face to face, I use the demo
breast.


<Jean's thoughts on MER coming later once the volume increases are very
interesting and I can see this but maybe only for a few hours pp.  If a
baby has unlimited assess to the mother and breast and the initial
colostrum is withdrawn then MER would be needed to bring more milk down
for future feedings.>


Actually, the way I perceive it during hand expression, once a sinuse is
expressed, without an MER, or before the next one of 4-5 each feeding,
once the rhythmic phases of a suckle empties a very elastic sinus and
then releases pressure on it, gravity and internal 'milk tension' alone
refills the sinuses, which are less resistant than the upper ducts, and
so on, time and time again during suckling, till the duct leading into it
is less and less full, therefore lowering milk tension. The ducts above
the sinuses simply change their cylindrical dimensions as the volume
decreases in the ducts. That, BTW, is partially responsible for the
phenomenon demonstrated in the Hartmann team videos of the fat "going
back up". Between MER's, the cylindrical dimensions narrow again as the
myoepithelial cells relax, allowing the duct walls to return to their
more elongated form, and "oil and water don't mix", e.g. the cream rises
to the ceiling (probably due to specific gravity, but I don't have
figures for this assumption).  Subsequent MER's shift milk from the
alveolar partitions into the ductal spaces and rebuild milk tension in
the ducts again, allowing gravity and milk tension to keep refilling
sinuses between suckles or pumps or expressions.

<I also find the Marmet method the best for hand expressing.  I teach it
to every mother I meet.  I use Jean's RPS on the edematous nipples and
even this process illicit droplet of colostrum on the nipple.  I praise
even slight wetness to a mother that this is her milk and each time she
does this it gets easier to do and more milk comes out.>

Yes, Anne! Let's never think of colostrum as "illicit", and every drop
'elicited' is to be praised;-) (Sorry, couldn't reisit the pun!)

<I would like to see research on use of hand expression in the first 6-24
hours pp with mothers whose babies are unable to feed.  Then to compare
them to the mothers who have been given a pump to bring in their milk
supply.>

A subject for a Master's thesis or PhD dissertation waiting to be
plucked! Maybe even simple enough for a clinical study for one who
understands how to do research considering such variables as amounts of
IV fluids received, etc.! Any takers???

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

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