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 *********************************************** To temporarily stop your subscription: set lactnet nomail To start it again: set lactnet mail (or digest) To unsubscribe: unsubscribe lactnet All commands go to [log in to unmask] The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(R) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html