Nancy,

Not being able to observe for myself, I can only guess from your
description and from the description of the physician/mother, but I have
some observations to make. In fact, I would like to play the devil's
advocate.

<the proud mother of a two-month-old baby girl. Three weeks ago I
noticed. .>

4-8 weeks is a common time period for moms who are used to feeling full
and feeling a strong let-down to start to fear their milk is somehow
drying up because the regulation of supply settles down to an autocrine
feedback mechanism, from the earlier hormonally driven stimulation and
they don't "feel as full" any more. She descrbes the end result that on
the one side she feels <The left breast was still smaller that the right,
although the asymmetry was not as pronounced as a few days earlier.
After a few more days, however, the symmetry did not return, and I felt
very little let-down on the left>

Let-down happens simultaneously in both breasts, since the same
concentration of oxytocin in the circulatory system is delivered all over
the body, including both breasts. So the fact that she doesn't feel the
familiar sensation in that breast might actually mean that the opposite
breast, where she can feel it, may have a relative oversupply. This in
itself could produce the relative asymmetry and the sensations of a
strong MER in the right breast. In other words, the larger breast, rather
than the smaller breast, could be the "unbalanced" factor in the present
equation.

<I felt that there was little or no milk in my left breast, as my
daughter would begin to nurse and then pull off, screaming,>

When a baby's body language makes it so clear that she is unhappy about
the different sensation she's experiencing, the mother often reacts very
subjectively and assumes it is somehow her own shortcoming that something
has gone "wrong" with the pattern of breastfeeding she and the baby have
come to expect. It is possible the baby was reacting to the somewhat
saltier taste of the milk on the side where the mastitis had been. Also,
if the baby was used to a "gangbuster's let-down" from the other side and
the previously somewhat overly full breasts, then she might react this
way because she was expecting just that kind of MER and didn't get it.

On the other hand, babies often react this way when they get either a
delay in the let-down, or a let-down more powerful than they can handle.
So there are a variety of reasons why babies react in this manner. It may
signify something else entirely than what the mother is interpreting it
to mean.

It is particularly hard for a first-time mother to be objective about
such a subjective experience as rejection by her baby, and easy for her
to project onto the baby what she herself imagines to be the problem. All
the more so, I would think, when she is accustomed to making objective
assessments of other bodies to which her own body chemistry (adrenalin,
serotonin, sleep deprivation (Melatonin???)etc.) is not connected.

It is an entirely new experience to be (so to speak) on "the inside of
the hospital gown"  as I myself have too often discovered. But the more
mature she is, and the more organized, independent and established in a
profession a woman has become, sometimes the more difficult it is for her
as she experiences the adjustments every first time mother faces.
(Dependent teens often "go with the flow" and pretty much go along with
whatever comes along. Not so, independent career women.)

< and I was unable to express any milk as well.>

This was the end of the preceding sentence-it may have been a
self-fulfilling prophecy if subjectively she had concluded in advance
that she had a reduced supply on that side. Of course, it might also have
meant that she was used to an oversupply and ease in expressing, and
found it disconcerting that her experience was no longer what she had
come to expect.

<however, over the next three days I noticed that there was a large (5-6
cm) lump in the upper-outer quadrant of the left breast, and that the
remainder of the breast was very soft and empty-feeling.>

The upper outer quadrant contains over 50% of the glandular tissue, and
75% of the lymphatic drainage must pass through that area to reach the
axillary nodes as lymph makes its way back to the circulation. The
inflammatory process from the mastitis may have been severe enough that
it took a while to subside, even though the antibiotic took care of the
infective agent. The other 50% of the glandular tissue is distributed
less densely because it is spread out in the other 3 quadrants of the
breast.

While the supply might have suffered somewhat from the mastitis and
perhaps less efficient drainage, once again, the mom's interpretation was
based on her subjective reaction to feeling one area dense, and the other
3 areas much less dense by comparison. Milk usually doesn't 'dry up'
anywhere near as quickly as mothers fear/assume it does.

It is also certainly possible that her own genetic development might have
gifted her right breast with the often quoted number of 15-20 lobes, and
the left breast with say 12-15 lobes or so. If so, those alveoli would
just have to be drained oftener to make them produce faster. Not every
alveolus is producing its maximum at ever minute in time, nor are all in
the same stage of secretion. Some are resting while others are further
along in the secretion process. Perhaps it would help to begin every
feeding with the left breast for several days, nursing the right one a
little less thoroughly in the middle of the feeding, leaving more in the
breast to provide some "tamping down" effect, and returning to the left
breast to end the feeding, draining the hind milk more thoroughly.
Perhaps this might put the supply back in balance, though in this new
phase, both breasts might end up feeling less full than the mother
experienced them several weeks earlier.

<It appeared that I had plugged ducts.> Plural? This makes it sound as if
she envisioned all, or most of her ducts in the left breast to be somehow
plugged. If even one duct was plugged, it doesn't sound as if the plug
was anywhere near the front of the breast or it would have hurt to try to
express or feed. A plug further up could also explain the absence of <a
whitehead on my nipple, and stringy milk,  neither of which I saw.>

<when it is at its most full, feels very firm laterally, and empty
medially.>
Again, the UOQ contains the most glandular tissue, and lymphatic
pathways. Each lobe with its attached lobules, drains into a separate
duct toward the front of the breast. There is no "crossover" between the
lobes, so pressure from the area of inflammation is unlikely to have
affected the alveoli in the other lobes much. And the area she is
describing as softer does not seem to be the area where the mastitis
occurred anyway.

I wonder if it would give a more accurate picture of what is going on to
use an electronic scale for test weights before and after nursing from
the less full feeling breast in order to be truly objective. And the same
with the opposite breast. Strongly consider the possibility of oversupply
on that side. Be sure she understands this is a normal time for
transition to autocrine control to alter the way production is stimulated
and/or suppressed. Since she is more scientifically oriented than most
mothers, perhaps she would ultimately like to read the two JHL articles
of Daly, Hartmann,  et al on autocrine control.

Sorry this got so long. It's sort of like Monday morning quarterbacking I
guess:-)

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

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