Barbara wrote:

<  I spend a lot of time
thinking about the relative sizes of things, which is a consequence of
fooling around with nipple shields. We know there have been problems with
the one-size-fits-all with shields because nipples are different sizes in
diameter, and babies have slightly different "lengths" to their palates
(from front to back).  Pump flanges have the same problems because of the
variability in women's anatomy.>

Barbara, (and anyone else so inclined), for the sake of your very
scientific approach which can end up teaching us all when you share it,
the next time you have a mother for whom you decide that a larger flange
would be beneficial, please go this extra

"Survey and map" the locations of her most easily accessed milk sinuses
as well as the other measurements you are recording as you develop your
insights into better nipple shield design.

We have all seen various kinds of generic diagrams that may lead us to
think of the placement of the milk sinuses quite close to the nipple and
arranged rather like the spokes in a bicycle wheel. I perceive the
placement differently.

I think of various kinds of bouquets of flowers that you might hold in
your hand.  In some, there are more flowers in the lower, larger outer
layer arranged irregularly, some in front, some behind, but more or less
circularly. Then, there are some slightly taller, in a smaller circle,
with a few even taller ones in the center, deep inside and above the
circumference of the outer flowers.

Then again, there are other shapes of bouquets, with a few small flowers
close to the hand, and taller ones in a larger circle, perhaps with the
center ones the same height, so that the top of the bouquet is flat, like
a "nosegay".

Now, tilt your hand 90 degrees to the side and imagine your closed hand
as the nipple, with the stems passing through it as the nipple pores. The
milk sinuses are often arranged like the flowers in some sort of bouquet.

Some may be nearer the surface and arranged more or less circularly and
shallowly under the areola, anywhere from about 1/2 to 3/4" from the base
of the nipple.  (I have seen at least one mom who seemed to have sinuses
inside the nipple itself. close to the base.)

More commonly (IME), they can be found buried a little more deeply, at a
radius of about 1 or 1 1/4 ", sometimes even 1 1/2" from the base of the
nipple, whatever its diameter.

There are often a smaller number of others, buried centrally and even
more deeply, and hard to palpate without pain if the outer sinuses are
full.

To "map" her milk sinuses, (just for the sake of science,remember),
locate the area inside or perhaps closer to the edge of the areola where
you can express milk most easily by #1) pressing backward toward the
chest wall, then #2)maintaining that back pressure and simultaneously
compressing your fingertips together.

Mark that location in 4 quadrants with an innocuous marking medium
(lipstick? washable ink?) and then use your engineer's circle to measure
it and calculate the diameter. (After you "map" a few moms, you will soon
find yourself doing it mentally, without marks.)

Depending on the "indentability" and the elasticity of the subareolar
tissue and/or that part of the breast just beyond the areola, this may or
may not correspond to the exact diameter of the flange you choose. But I
am guessing that if you test 2 or 3 different size flanges, a flange
diameter equal to or slightly larger than the diameter you found on your
"milk sinus map" will nearly always remove milk more efficiently than one
smaller.

I visualize this happening because it will be applying pressure to both
the deepest end of the majority of the milk sinuses, but also, bringing
some pressure to bear on any even deeper sinuses. I will be anxious to
hear someone's results, on way or another.

K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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