Ginger writes:
<Pumps and pumping are not my strong suit.>
Nor are they mine.
<I have a ton of information for
moms on how to tell if your pump shield is too small. What are some ways to
tell if it is too large? Also has anyone had a mama with the minimum
suction level on the Pump 'n Style being too strong? Would a rental pump
offer a lower setting?>
My thinking is probably mostly theoretical. I waited to see if others with more practical experience would respond, but felt compelled to put in my $.02 worth as usual. I will contribute what insights I believe I have, and hope others add their more specific, experienced knowledge of pumps and/or disagree and explain their rationale.
First, it's important to remember that vacuum does not pull; other forces push. This has been evidence-based for hundreds of years.
Second, if this judgement as to appropriate flange size is to be made within the first 2 weeks after birth, I believe that the type of labor management may often enter into the judgement. IME, even if a mother had IV fluid during the intrapartum period, if a mother is past that time period, any edema from possible overhydration has largely resolved. So it seems to me that if (with mom's permission) you perform fingertip expression and find the location that produces the best flow, the distance of that point from the base of the nipple and the distance between the tips of your finger and thumb would seem (to me) to fairly closely determine the depth and diameter of the desirable pump flange tunnel.
This will allow enough of the subareolar tissue to push forward into the flange to permit the subareolar ducts to compress themselves against the inside of the flange tunnel, forcing the milk to enter the galactophores in the nipple and speed up, because the galactophores are narrower than the subareolar ducts. (60+ year old physics + googling Venturi and Bernoulli principles)
The strength and length of the vacuum session may enter in, (The Breastfeeding Atlas, backed by references from the dairy industry) as Barbara Wilson-Clay actually measured, pumped and remeasured to show that pumping even non-engorged tissue will often result in temporary swelling. This is because some amount of tissue fluid may push forward to help neutralize the vacuum. ("Nature abhors a vacuum.")
It seems to me that any well-manufactured commercial pump's vacuum turned to an appropriate level should not cause pain if tissue is not obviously edematous to begin with, and the flange tunnel is large enough not to pinch the nipple itself nor put skin shear force on the thin skin a the base of the nipple. OTOH, I don't believe there is a legal standard about vacuum and have had moms complain of great pain with cheap pumps manufactured by at least one toy(?) company, which I will not name here.
OTOH, factors that may need to be considered in the first 7-14 days include the possibility of visible, or as yet still invisible tissue edema if
1) a mother has received IV fluids (IME >2000-2500 cc. in any 24 hour period before or after birth) As a
result, she may either be at risk of having, or already have edema in the subareolar area, and/or possibly
the nipple, which may fool the judgement of flange size if it is chosen based on visual nipple diameter.
2) IME, edema is especially likely to happen within 24-48 hours after receiving hours of IV pitocin for induction,
augmentation and/or third stage management, due to the corollary effect of pitocin binding to the ADH
binding sites in the kidney.
3) Edema can make it difficult to express with the fingertips in order to make the judgement I just explained,
and can lead to apparent need to keep increasing the size of flanges in subsequent pumping sessions.
4) Edema that has pushed its way forward in response to the first few pumpings can result in crowding the
subareolar ducts to the point that little or no milk can escape at pumpings for the next day or more. I have
heard that pattern from NICU moms quite often.
5) In these kinds of situations, I see careful reverse pressure softening in an antigravity position as an
important part of moving any edema out of the subareolar tissue temporarily in preparation for effective
fingertip expression in order to make that flange size judgement as explained above.
6) And the mother may benefit by preceding each pumping with RPS, to temporarily move any edema away
from the flange area to1-2 inches further back in the breast , (and in severe cases, perhaps repeat 1-2
times during a 15-20 minute pumping session), until any edema has resolved sufficiently by 7-14 days. (An
added benefit will be to trigger the MER at each of those 5-7 minute intervals.)
I hope I have articulated my ideas clearly enough to illustrate them well, and am looking forward to feedback from those more knowledgeable. Although I do issue hand pumps when indicated, I confess to deferring to those LC's at our sites who are more experienced with issuing the mechanical pumps.
K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC Dayton OH
If that tissue is flexible enough, that portion of the areola/subareola that fits into the flange tunnel is pushed forward into the flange by the other hydrostatic forces within the tissues in the breast (blood pressure, elevated interstitial pressure, and possibly + ambient air pressure, etc. Denver versus LA ???)
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