Dianne,

I think I have this one more post opportunity for today. Various kinds of breast massage are practiced in various areas of the world. The Oketani method is famed in Japan. I have heard of its wide popular use in other far east areas. Breast massage is very prevalent in Russia and the new eastern block nations near there. Maya Bolman has been learning a lot and contributing a great deal during her trips to that area. I hope Maya weighs in on this discussion too. 


I am becoming more and more fascinated with the potential of our profession to gain from insights commonly taught to patients being treated by lymphatic drainage practitioners.


All fluids enter the breast, resting, or lactating, through the arterial system. Fluids leave the LACTATING breast in two separate directions:


1.) Anteriorly and centrally, as milk, through one exit area, the nipple-areolar complex. (We all have seen the traffic jams that can occur there.)


2.) Posteriorly and upward through the axilla and substernal areas, 90% normally re-entering venous capillaries directly as well as 10% (normally) entering lymphatic capillaries and thence through lymphatic vessels with valves and a system of nodes. After processing lymphatic fluid for "waste removal" and antibody production purposes, (Love SM, Lindsey K, Williams M, Dr. Susan Love’s Breast Book, 4th edition, 2005. Da Capo Press. pp. 3-26.), the continuing lymphatic vessels will be dumping their recycled fluid back into the subclavian veins beneath the clavicals shortly before the veins enter the right atrium. (The lymphatic system is capable of increasing it's fluid absorption capacity to 50%. (Hall JE, Guyton and Hall Textbook of Medical Physiology, 12th edition, 2011, Saunders-Elsevier.)


I think the LC community ought to be investigating that with the help of lymphatic drainage experts, or at least through the instruction books they have written for the lay public afflicted with lymphedema.  I found extremelely helpful: "Lymphedema: A Breast Cancer Patient’s Guide to Prevention and Healing",  Jeannie Burt, Gwen White, 2005. Also, "Lymphedema: Understanding and Managing Lymphedema After Cancer Treatment", 2006, American Cancer Society Health Promotions, Atlanta GA 


Googling "lymphedema paper backs" will get you oodles of inexpensive, easily available paperback books written for the layperson with information which I believe everyone in our profession ought to start learning much more about. There will always be mothers with major complications that require life-saving IV therapy, even if we were to convince all obstetricians and anesthesiologist of today that current levels of IV administration often throw major roadblocks into the initiation of lactation itself, and especially into the early learning curves of the breastfeeding mother and baby.


I observed that breast binders,  carefully applied for limited times (I applied many, many in the middle of the night on postpartum as a student) had their place in comforting mothers in the late 1940's, '50's and beyond. Also any external pressure on the lymphatic vessels, such as short periods of deliberate deep , or pectoral (and other) muscle contraction and external pressure assists the entry of fluids into the lymphatic capillaries (which are very, very different from circulatory capillaries). Pressure from skeletal and breathing muscles also help trigger contractions of the lymphangions which propel lymph forward. 


Lymph does not circulate, as has been carelessly worded in some highly respected lactation texts. Lymph drains, in one general direction only, from the interstitial tissues towards the major veins in the subclavian area leading directly to the heart. It behooves us all to review, at least the simplified versions of the A & P of the lymphatic system given to laypersons to help them manage their own lymphedema care. We could begin to routinely give this "do no harm" level of info to mothers before they left the hospital.


Generally speaking, forward massage might seem mainly to facilitate milk movement forward.


Contrary to that, woule be short periods of gentle upward and posteriorly directed massage, to help slowly clear edema. Lymphatic souces recommend it as no heavier than the weight of a U S. nickel. I find it has worked best in an obviously laid back position (with the breast elevated on to the chest wall, (manually or with pillows, slings, significant others ??) as much as is comfortable) helping to give comfort and clear edema faster in most moms I have tried it on. The main direction would best be especially toward the armpit, where 75% of the breast lymphatic drainage lies, tending to help lymphatic drainage of excess interstitial fluid. I have found this to be helpful in many mothers with extremely pendulous breasts (EE to HH, II, etc.). 


In severely edematous mothers, maybe in moms with smaller breasts where swelling extends to the clavicular area, starting there may be best, following directions in the lymphedema books quoted. They recommend  "clearing" the forward lymphatics in the clavicle area first, by gentle circular motion with flat fingers, just like advised in monthly "looking for lumps" breast exams, which most moms have already heard of. The site of circular motion is gradually moved to the outer upper parts of the breast, the axillary areas, and then further and further toward the major swelling areas and lastly the areolar area, moving these fluids into the paths previously cleared by the earlier massage.


Hope this helps.


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

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