Dr. Mimi,

I may be late in reading your request. These thoughts occur to me (with
my special interest in reading up on nipple development and anatomy.)

<I have a mom with "bulbous" nipples with very tiny aerola (almost
mushroom
like in appearance).  She is day 2 post partum and had a C-section due to
fetal distress.>

Connective tissue of the nipple and areola can be the radial and circular
muscles of the nipple-areolar complex and/or just plain fibrous
connective tissue. I think a lot depends on which it is in this case.

Also, there is a very rich plexus of lymphatc vessels under the skin in
that area. Due to the surgery/IV's etc., Reverse Pressure Softening (see
archives) of the areola and breast just beyond it during the first 7-10
days may be one helpful component.

If this were my client, I would want to palpate where the milk sinuses
are. I did see one mother (of Nigerian descent) who actually had some
milk sinuses in the (rather bulbous) nipple, as pulsed compression of the
nipple button actually produced continued droplets of milk much as one
might get in compressing another mother's areolar sinuses.

In such a case, it might not be necessary to feel compelled to get as
much tissue in as usual, though the potential for pinching trauma is
still plenty.

Secondly, I think it's definitely to this mom's advantage to have a
careful explanation of the MER, and the fact that the nerves that trigger
it under the nipple and in the chest/breast wall can be stimulated
manually. (I particularly like the Marmet method and LLL puts out an
illustrated sheet demonstrating and explaining it.)

IME it takes about 2-3 full minutes for the stimulus to complete the
neurohormonal arc to the point where milk issues from the tip of the
nipple.

Veterinary references frequently refer to this as the most powerful force
in moving milk from the glandular area forward. I think we need to
cultivate a greater appreciation of that in helping mothers understand
and manage their situations.

In this situation, this would shorten the actual time baby needed to be
laboring with the nipple by 3 minutes each time.

I think this, plus use of Paula Meier's work of effectiveness of a
flexible nipple shield with premies (if you can find a shield large
enough) might be one thing to try.

This is likewise a case of relative imbalance between the size of the
mouth and size of the nipple (oroboobular disproportion) that time and
growth of the infant's mouth may cure.

And by all means remember breast compression as explained by Jack.

Hope this offers some help.

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

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