Marianne writes:

<**I have been wondering about this concept again last weekend during GOLD.
One of the presentations was about the importance of vacuum. It made me feel

uncomfortable, because (as others have said): it is not really surprising
that someone working with sponsorship from a pump company would draw the
conclusion that vacuum is important...>


I have purposely been "sitting out" this discussion to see what others would
say. Just call me the devil's advocate, more or less. I have been asking
"Why" ever since I can remember back at age 3-4 or so. I have frustrated
many authority figures in my life;-)


First, vacuum does not PULL. it may look like it's pulling and feel like
it's pulling, but that is not what is happening. (Just as there is no such
thing as "dark"-only relative absence of light, and no such thing as"cold",
only relative absence of heat.)


What has been named "vacuum" denotes a condition within a confined area
where the pressure has been reduced below (relative absence of) atmospheric
pressure. And as the maxim goes, Nature abhors a vacuum! So, other forces
PUSH in order to equalize the pressures. This means hydraulic
pressure, blood pressure in the nipple, the skin, the ducts, the MER,
interstitial fluid pressure if the breast is in the process of developing
edema, etc, is pushing the flesh of the nipple and the areola (and any freer
flowing interstitial fluid) forward into the nipple shield or the flange
tunnel.


I admit there are times I have handed out a nipple shield as a last resort
at a WIC consult, which always occurs at 3 or more days postpartum and way
beyond sometimes. I cannot say I have become expert at it, especially
teaching the mother how to apply it. If just "put up against" the mom's
nipple and areola, which is what they seem to do, it often seems to curl
back onto the baby's lip/s and/or slip. No doubt this is what a mom does
when she uses one she bought at a store.


I have heard about Linda Pohl's method of folding it back partway inside
out, and I am trying to learn to remember to do that. What I cannot buy is
that "the vacuum pulls the nipple inside the shield". There are holes in
the tip of the shield, so there cannot be a true vacuum.  It must be some
other physical force that seems to make this work as well as many say it
does if done that way. Is that how it is always taught by everyone?? Perhaps
the diameter of the inside of the nipple portion of the shield changes as it
is unfolded again,to "clamp on and tug on the nipple to keep it "trapped" in
the forward portion of the shield??  I also vaguely remember reading
somewhere about even taping the shield to mom so that it doesn't curl back
onto the baby's lips and/or slide. Would that at least make it a little
easier for the mother to manage?? Or would the discomfort of the adhesive
tape coming off not be worth the effort?? I have also read of using EBM or a
bit of Lansinoh or something to moisten it so it adheres better. Any
opinions on this?? Please enlighten me, because I want to learn to do it
better for those few moms for whom I conclude it's a temporary "last resort"
till other issues can be resolved.


My next thought is that in the hospital, even when moms have had as little
as 1500 cc. of IV fluid in a period of less than 24 hours, IME there is
likely to be building up some "subareolar tissue resistance" from pre-L2
edema that is not sufficient enough to be "pittable", that is, still less
than 30% above normal hydration. Is anyone routinely teaching the moms to do
RPS before latching attempts, and especially before trying a shield? Or if
it is possible to hand express first, is that being done before appyling the
shield??? Because I strongly believe it is the pliability of the areola that
is the crucial factor in allowing the areola and its underlying ducts (the
"sweet spot" we always used to call lactiferous sinuses) to push forward to
respond to the baby's efforts. To say nothing of stimulating the MER before
the baby attempts to use the shield.


So you see, I do not believe that the shield is just to fit the nipple
into.  As to shield size, I have to admit that our WIC LC office doesn't
always have the variety of sizes I would like to use. Much depends on the
size of the mother's nipple, but also on the size of the baby's mouth. And
unfortunately, they are sometimes "mutually exclusive", or there is
"oroboobular disproportion" as Diane from Utah used to say..And other times,
in desperation, mom has been using a pump, and if there is edema fluid
enough to push forward into the nipple-areolar tissues as river waters do in
a flood, then the size of the mothers nipple and areola becomes
swollen temporarily as a result. So maybe that enters into why some feel a
16 mm. shield works early, and a few days later, someone decides that a 24
mm. is needed. Isn't that almost the size of a US quarter???


My colleagues and I are of the stong opinion that the nipple and breast
dealt with in the hospital on DOL 1 and 2 is usually not the same size and
pliability we observe on DOL 3-6 and possibly beyond. We know the hospital
staff did their best with what they perceived, and that they have no crystal
ball, so it's not surprising that the instructions tried and possibly
successful in the hospital do not alway continue to work well in the days
following discharge. Thus, knowledgeable lactation follow-up is crucial for
some moms and babies, and nice for all of them.


If I remember the gist of Paula Meier's study, the premies (who would have
smaller mouths unable to bypass the nipple to get to the areola) got more
milk with the shield than by trying to latch directly. On the few shields I
have had the opportunity to observe closely in action, it's my impression
that the baby is not in any way "latching" on to the breast itself, but that
the firm base circle performs the same function as the tunnel on a properly
fitting flange of a pump. In addition, the firm round circle at the junction
between the base of the shield creates extra hydraulic pressure on the
underlying ducts by allowing the areola to compress itself against that firm
circle while the nipple is advanced into the tip.  I'm operating on memories
of Pascal's Law from my own ancient high school physics and some brushup
reading on lots of this. Will some physicists help me out here?? Where is
that Lactnetter from South America???


Furthermore, no matter how often the word "soft" is used, the nipple portion
of the shield does not seem soft by my definition. To add fuel to the fire,
will some Lactnetters from the far east tell me whether the old fashioned
glass and rubber nipple shields are still available there, possibly from
Pigeon?? I remember seeing visible milk transfer when we used them 4-5
decades ago. Nipple confusion?? Forget it, the babies had all had 3 feedings
of 5% Glucose water in their second twelve hours of life before they were
allowed to go to breast for the first time at 24 hours for 3 minutes on one
side each feeding every 4 hours, then got supplemented, etc. etc.


But my point is, once the milk was plentiful and flowing well the baby had
no problem "latching" on to he long rubber nipple and applying suction so
that the mother and her caregivers could see through the glass flange the
milk pushing forward toward the baby's mouth. It was reassuring to the
mothers. I think this was before mothers began getting IV's in our hospital
except in the direst of emergencies. I remember someone researched these
compared with "soft" shields, but I would like the citation, because I am
wondering what years the research was done and whether it was done on
mothers who had had IV's or not. Frankly, I would like to be able to buy a
couple of those old type shields and ask some savvy mothers to evaluate them
after being taught RPS. I personally don't think they were all that bad for
temporary use. No flames please! I'm just reporting what I saw happening in
the '50's or so!


Remember, I'm just playing the devil's advocate, more or less;-)


K. JeanCotterman RNC-E, IBCLC
WIC Volunteer
Dayton OH

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