Barbara wrote:

<Something about the baby's early oral exper. may have made him/her
aversive.
Or he/she is injured (sore throat).  Or is somewhat early and unready to
feed and CAN'T MAKE THE BREAST WORK  (my emphasis, not shouting).  Babies
have to be able to create
adequate levels of positive and negative pressure to breastfeed.  They
have
to be able to seal off the oral chamber with a tight lip seal around the
breast.  They have to be able to pull the nipple to twice its resting
length
to the junction of the hard and soft palate.  They have to be able to
lift
their lower jaw and compress the nipple in half between the tongue and
the
hard/soft palate. Some newborns who are early or who are injured can do
this.  Some cannot.>

Excellent post, Barbara. Very thought provoking. I would like to suggest
just one substitution (in two places) to create what I feel is a more
accurate understanding, and I do that to add what I consider to be an
important dimension to the total assessment in such situations.

When the word "nipple" is used, many professionals and non-professionals
alike, take that to mean that one is referring just to the mammilla, or
the raised "button" of the outer central portion of the breast.

They believe that the statement quoted means that it is the mammilla
itself that literally stretches to twice it's resting length. To me, this
creates an imprecise impression.

My sense is that the mammilla alone, even if the muscular, ductal and
connective tissue that makes up the anatomy of this "button" can be
thinned and elongated somewhat, is not truly capable of "stretching to
twice it's length."

The "tip of the new lipstick" shape we have all seen seems to be what
occurs when the mammilla, or "nipple button" is the main tissue that is
exposed to forces sufficient to elongate it.

It is more precisely the entire nipple/areolar complex that must be
reshaped into a cone so that part of the areola and sub-areola plus the
mammilla achieve the length that is twice (or more) the height of the
resting mamilla.

In so doing, the lactiferous sinuses are ideally brought into range of
the tongue and jaw, and that is the crucial point. If we can facilitate
that efficient juxtaposition of the two anatomies, we end up with
leverage that results in better milk transfer.

Pursuing my interest in reasons for functional retraction and inversion
of nipples, I have become an advocate of nipple function tests over the
years. I have palpated many sets of lactiferous sinuses.

The sensitivity of my fingers was no doubt groomed by my experience in
L&D, palpating funduses and relative effacement and dilatation of
cervices.

But this is certainly not a prerequisite for learning. I recommend
palpation of the subareolar area to assess maternal factors that can
inhibit milk transfer, especially in the case of a compromised baby. This
is one more way to help the baby (and the mother) MAKE THE BREAST WORK.

I have seen only a very, very few nipples (perhaps one or two sets) which
contain the lactiferous sinuses in the mammilla itself, although I have
seen numerous diagrams and explanations in medical literature depicting
them there.

Roughly 25% of the mothers I have examined have some shallow sinuses
within the first 1/2" to 3/4" from the base of the nipple, plus more,
deeper inside the sub-areolar tissue.

In my imagination, I can see the anatomy of such a mother responding to a
nipple shield like the situation described, delivering more milk for a
compromised baby than the bare nipple alone.

The suction the baby is able to generate allows the areola to enter into
the shield deeply enough so that the shallow sinuses can compress
themselves against the firm, ring-shaped bend of the shield. This
compensates for the compression the baby is unable to muster.

What of the other mothers? Hopefully, the MER will be triggered, at
least. Regardless of where the sinuses are, the nerves for triggering the
MER extend through the subareolar area.

(I'm not convinced that we all fully appreciate the MER as the most
important force in moving milk.) I visualize this as partially
responsible for the pooling of milk in the tip of the shield.

By my estimate, about 50-60% of mothers have their shallowest sinuses
located at 1" to 1-1/4" behind and beneath the base of the nipple, with
others perhaps deeper.

The remaining 15-25% have their shallowest sinuses starting at 1 1/2 to
2" or perhaps more, behind and beneath the base of the nipple. It is
mothers with this distribution that may obtain better pumping results
with a larger flange.

This can seem like a mis-match situation when the baby has a small mouth.
Even when the size of the mammilla is compatible with the baby's mouth,
inability to stroke the deep sinuses leads to a relative "oroboobular
disproportion", a phrase coined by Deanne Francis.

I use the term "subareolar tissue resistance" to refer to a quality of
resiliency or "engagement" of the mother's subareolar tissues in this
interactive event of milk removal. This term applies whether her tissues
are interacting with the baby's oral forces, strategically placed
fingertips or the pump.

Subareolar tissue resistance that exceeds the capabilities of the baby's
oral efficiency interferes with efficient milk removal. Assessing this
other half of the equation is not always given as much attention as
assessing the infant's oral capabilities.

The effort required of the examining fingers to compress the sinuses
parallels the comparative effort that the baby's jaw would have to make.

I envision at least 3 separate different components making up this
subareolar tissue resistance.

First, there is the mother's individual tissue characteristics. There are
varying degrees and distribution of suppleness and elasticity.

Worst case scenario, is the areola with the "latch-defying", "pithy",
abundant connective tissue that feels like a turnip or a carrot kept
overlong in the vegetable drawer. The tissue feels that way even when
non-pregnant. There is not much immmediate that can be done about this
factor except to reduce the other two.

Second, there is interstitial fluid, sometimes less than the 30% needed
to qualify for the term edema, but contributing its share to subareolar
tissue resistance. This is capable of shielding or burying the
lactiferous sinuses, distancing them from attempts to compress them.

Too often, someone seeking to be helpful, will begin with the pump.
However, vacuum can draw more interstitial fluid into the nippleareolar
complex, burying the sinuses beneath even more edema and making
compression of the sinuses even more difficult.

This is where I find what I call "Reverse Pressure Softening" technique
helpful in temporarily displacing fluid to more distant areas, thereby
reducing subareolar tissue resistance long enough for latching.

And thirdly, there is relative distention of lactiferous sinuses, which
can offer considerable resistance when overly distended. This is present
in many mothers well before birth, but certainly within 48 hours after.

Here too, Reverse Pressure Softening is helpful in comfortably pushing
some milk back up into the ducts temporarily. The sinuses then have more
flexibility to respond to compression, without pain for the mother or
resistance to the baby's mouth.

Thank you Jan Barger, for allowing me to explain RPS in detail in the
summer BSC newsletter.

I would enjoy feedback from others who find any of these insights
helpful.

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

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