Dear Jean,
I've read this technique with great interest, it sounds very plausible and I
think there are some collegues at this side of the ocean who may want to try it.
Can I use your post (in literal translation) as a basis for an article in the
Dutch Lactation Consultants' journal, with credit to you of course. I think it
will make a fine discussion piece . And I'm sure to try this technique with the
first mom I help with  a ''latch defying breast''.

Thanks in  advance,

Gonneke van Veldhuizen, IBCLC, Maaseik, Belgium
http://www.users.skynet.be/eurolac
[log in to unmask]


> Betsy,
>
> I presume this mom with what you term nipple adhesions is in the early
> postpartum period.
>
> If she (baby) can draw the nipple into a nipple shield with no difficulty
> and (mom) is using the pump before each feeding to draw the nipples out,
> then it seems to me that part of the difficulty is an excess of
> interstitial fluid deep in the nipple-areolar complex, "using up" much of
> the small amount of available stretch.
>
> It is seen so commonly that most HCP's don't even recognize it as edema.
> Even if it does not look obviously edematous to the naked eye, there is
> almost always more interstitial fluid in this area during late pregnancy
> and early postpartum than one might suppose. This is very common in
> engorgement, especially if the mother had IV's in labor (and/or pitocin
> induction). This increases any subareolar tissue resistance to the baby's
> latch.
>
> Technically speaking, I don't think a pump "draws" a nipple out as much
> as it "pushes" edema back toward deeper lymphatics. This temporarily
> displaces the interstitial fluid under the nipple and the areola so that
> the tissue surrounding the nipple can respond to the baby's vacuum and
> carry the nipple inward into the baby's mouth.
> Same principle applies with shells put in place for 20+ minutes before a
> feeding.
>
> I have found the Hoffman technique to be misunderstood (and maligned),
> and so I steer clear of the term now. Instead, I teach the mom what I now
> call "Reverse Pressure Softening".
>
> This is essentially "pitting" the edema out of the area temporarily, and
> consists of two phases. The purpose is to free up as much of the mother's
> elastic potential as possible for the baby to use in latching.
>
> 1) First, pressure is placed on the areola, close to the nipple:
>          * Right next to the base of the nipple, mom (with short
>            fingernails, using both hands) places the tips of her index,
>                middle and ring fingers (bent) on the areola and pushes
>                  straight in toward the ribs for long enough to sing a
> lullabye                (45-60 seconds if actual timing is desired.)
>          * This moves any excess interstitial tissue fluid back toward
>             the lymph capillaries. It may also temporarily push milk back
>              up from the overfull sinuses into the ducts further above ,
> or                 may cause some to come out the nipple.
>          * (A HCP can also do this for the mother to start out, by using
>             both thumbs placed at the base of the nipple and exerting
>             pressure as described above. It will be necessary to move
>             the thumbs 90 degrees around and press a second time to
>             "pit" what the mother can "pit" with 6 fingertips.)
> 2) Finish with deep digital extraction:
>          *Start an inch or 1 1/4 inch from the base of the nipple, using
>            bent fingers. Press firmly back toward the ribs while
>            rhythmically closing the fingertips over the milk sinuses to
>                remove enough to make the deep areolar area very soft.
>          *All this may also elicit MER so the baby gets more in a
>           shorter time. This pitting will last long enough to give the
>           baby a fighting chance to attempt a decent latch. If the
>           second side is used, it is better to soften it just prior to
> latch.
>          * It may often be helpful to locate the area where baby's
>                 chin will nestle and create a depression by massaging
> milk
>            out of the area.
>
> Palpation of the softened side in comparison with the unprepared side can
> demonstrate to the mother just how much tissue resistance has been moved
> out of the way to help the baby. I keep reassuring moms that this
> swelling is temporary, and they can skip this step when the baby can
> latch without problems or nipple trauma.
>
> Jean
> ***********************************
> K. Jean Cotterman RNC, IBCLC
> Dayton, Ohio USA
>
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