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Subject:
From:
Kermaline Cotterman <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Mon, 10 Apr 2006 00:25:28 -0400
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Barbara writes:
<I have found this discussion of nipple shield use fascinating, but have a
practical question.  How do those of you in private practice, "try out"
equipment?  For example, if a 24 mm shield was used and found to be an
inappropriate
size, so you go to a 20mm, let's say, do you charge mom for both shields?
 And
what about pump flanges?  It often takes use to come up with correct sizing
as
mom's nipples can change when suction applied, baby or pump.>


In providing at least one answer to this question, I do not intend to
represent myself as an expert on fitting shields or flanges. I have much to
learn about the practical aspects of this. Neither do I want to seem to be
seeking personal attention nor "preaching to the choir." I apologize if my
post seems repetitious or obnoxious to anyone.


However, I want to reinforce an observation on several ways in which nipples
might theoretically seem to change in size and/or shape during the first
7-14 days of the postpartum period, and reiterate the means in which reverse
pressure softening might be used to good advantage in avoiding the issuance
of multiple shield/flange sizes. (In addition, my post yesterday about
checking the placement and depth of lactiferous sinuses before choosing the
original flange or NS size may also be pertinent.)


<Interaction within the nipple-areolar complex.



The term nipple-areolar complex and its acronym (NAC) are frequently used in
breast surgery and radiology to refer to the whole three-dimensional
anatomical unit composed of the nipple, external areola, subareolar and
retroareolar (Appendix 1) tissues 42  Bricout described this unit as the
keystone of the system,  where all  the intraglandular fibrous septa
converge and the absence of any subcutaneous fatty layer at that level  results
in the close adhesion between skin and glandular tissue.27  . . . . . . . .
. .


The physiologic unit of the NAC appears to function as a closely connected
system. Forces acting on any one part of the NAC may cause other parts to
compensate. Engorgement may magnify this potential, temporarily distorting
the shape of the less muscular or less well-everted nipple, making it appear
flatter. The glandular and connective tissue compartments occupying the NAC
may be responsible for two separate compensatory effects, each temporarily
modifiable by RPS.  (1) Temporary shortening of the depth of the nipple
shaft may be due to traction on the galactophores due to tension from the
walls of the distended lactiferous sinuses to which they are attached, and
(2) expansion of the nipple circumference may be coincidental, due to edema
in the connective tissue compartment of the NAC.  Without effective
intervention, the result may be sustained retraction near the level of the
surrounding areola, persisting till swelling is resolved.  . . . . Simple
hand expression 50 just before feeding often helps soften the central
subareolar and retroareolar areas well enough to permit effective latching.
However, when the NAC is more edematous, this is often inadequate, or
impossible. . . . . . . . . . . . When milk and/or edema crowd the space
within the NAC itself, both its ductal and connective tissues may be forced
to re-align to contain the separate volumes of each, and are therefore often
not "free to elongate" to occupy the oral cavity. . . . . . . . . . . . . .
. . .  Veterinary research has demonstrated that this (vacuum) results in
edematous teats, with greater vacuum producing correspondingly more edema.55
Even pumping a non-engorged, lactating breast has been shown to temporarily
increase the measurements of the NAC.24   . . . . . . . . . .



Inappropriate vacuum use might account for many reports of "swollen
areolas". 20,23 Unless vacuum is used with discrimination, 19,20,22 it may
encourage migration of more fluid into the NAC due to elevated interstitial
fluid pressure within surrounding mammary tissue plus atmospheric pressure
upon nearby surfaces. This may attract an extra layer of edema within the
pump flange area that increases the thickness of the superficial areolar
tissue over the sinuses and sometimes the nipple. . . . . . . . consider
teaching RPS first. This repositioning of edema and milk away from the base
of the nipple facilitates teaching hand (fingertip) expression50 as a
second, separate technique that can soften the areola even further . . . . .
. .





 If the edema component of engorgement is especially severe, repetition of
RPS for additional 2-3 minute periods may produce better results. In cases
with severe edema, or if the breast is quite pendulous, the more supine the
mother's position, the less effect gravity will have on the rapid re-entry
of interstitial fluid into the NAC, thereby extending the window of time for
latching. . . . . . . It may also have a gravitational effect in rerouting
dependent edema away from the front of the breast24, thereby encouraging
better lymphatic drainage of both breasts when at rest.  >





(Cotterman KJ, Reverse Pressure Softening: A Simple Tool to Prepare Areola
for Easier Latching During Engorgement, Journal of Human Lactation, May
2004, vol. 20, iss. 2, pp. 227-237.)





Rachel Myr and Martha Johnson have each assured me privately that it is
entirely possible to use RPS directly on the nipple itself if it appears to
be at all enlarged. (Cotterman, KJ, Too swollen to latch on?: try Reverse
Pressure Softening first, *Leaven* Apr. May 2003, pp. 38-40.)





The NAC may become edematous again simply by gravitational force upon a
pendlous breast, but especially with each subsequent episode of pumping, as
explained above. Explanation of the frequent effects of fluid retention and
early teaching of RPS, to be used before every attempt at latching, nipple
shield application and/or pumping, till subareolar or nipple-areolar
distortion is no longer present may be useful in answering some of the
questions Barbara poses.



Jean

******************

K. Jean Cotterman RNC, IBCLC

Dayton, OH USA

             ***********************************************

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