Anne writes:
<...Do areolas need to be soft to work with a shield?>
I have been reading the discussion with interest and learning a lot. This
post, however, "pushed some buttons" for me that makes me want to articulate
what I think are some important insights about shields.
One, of course, is the fact that the milk ejection reflex is the most
powerful and efficient factor in milk transfer. So whatever else is being
assessed, I think it's important to give the mother a simple explanation of
MER, its importance, and how to trigger it prior to latching with a shield.
As mentioned in my article, this stimulation of the nerves close beneath the
skin of the areola can take place during the correct application of a NS,
particularly if RPS is performed through the shield at the area where the
"bending up" of the shield occurs when partially turned inside out (whether
her fingernails are short or long.) In fact, I think that success in the
correct application of a nipple shield has automatically involved some
degree of reverse pressure compliance of the nipple-areolar complex within
the shield, even before the concept was formulated and described.
My secnd observation, however, involves the concept of lactiferous sinuses.
So if you don't believe in them, just skip to the next post.
I accept the fact that they are not as large or as symmetrically placed as
we have been led to imagine them by past medical diagrams. But because I
have palpated so many, I firmly believe they exist, and that tiny as they
really are, their depth and the focal point of compression in relation to
their placement, plays an important part in the efficiency of milk removal.
This therefore makes a difference in choosing flange sizes and nipple shield
sizes. The depth and placement of the lactiferous sinuses under the areola
needs to be considered as well as, or perhaps moreso than judging totally on
the size of the nipple itself, or the baby's mouth..
In all my years of examining nipples, nipple function and teaching hand
expression etc. I remember seeing only one mother who must have had milk
(sinuses) inside the nipple button itself (mammilla).
I have come to believe that the reason that Meier's research showed that
premies could remove more milk with shields has several aspects.
1) Sufficient time has passed and previous pumping action has allowed edema
to dissipate, the areola to soften, and the walls of the sinuses to become
more elastic and the supply to build up.
2) The premie's mouth is often not yet large enough for the compression of
the jaws and tongue to reach the sinuses or beyond, so
3) when the premie applies vacuum to a properly applied shield over a
pliable areola with a free-flowing milk supply, the sinuses are drawn
forward along with the nipple toward the more rigid "ring" at the base of
the "nipple tunnel" of the shield.
4) At this point, the sinuses become the focal point of compression against
that ring, and the force on or behind the sinuses, from atmospheric pressure
or the baby's suckling efforts, propels or extrudes milk outward to the tip
of the nipple, (as we would extrude toothpaste from the far end of a tube.)
5) only at that point, does the vacuum then "pull" directly on the milk
itself through the hole in the shield.
So yes, I would definitely say that the softer and more pliable the areola,
the more likely the use of a properly applied nipple shield will
result in more efficient milk transfer.
Anne goes on to say:
< I am working with a mom with very inverted nipples, very leathery
inflexible areola tissue and having trouble with any size nipple shield
staying put at all.There is no way it seems to draw the tissue into the
tip. Baby balks like crazy and is totally frustrated as a result till
bottle appears. This woman is in tears from wanting so much to bfeed and I
am at a loss.>
I have had experience with moms with numerous kinds and degrees of nipple
inversion over the years. One explanation for one type of congenital
inversion postulates a lack of appropriate connective tissue formation at
the time of the eversion process around 36-44 weeks. Other types may have
other causes. At any rate, whenever areolar tissue is "leathery and
inflexible" it often has the tendency to hold excess interstitial fluid
postnatally, making it more inflexible yet.
I have used a protocol of carefully timed prenatal vacuum treatment at 37
weeks with at least 6-7 mothers. One "invaginated" nipple never did come
out. Other "umbilicated" nipples eventually stayed out most of the time, the
"stubborn ones" sometimes taking 3 weeks of treatment with a double pump
before they eventually came out long enough for initial latching and
feeding.
I saw another that never "coalesced" into a single nipple, but each side had
a mound of "fissured" projections from which the milk oozed into the pump
flange. That mom chose to EP.
In my experience, it is unrealistic to expect the small vacuum a baby can
exert through a shield postpartum to effect the tissue expansion that
plastic surgeons expect to take at least 2 weeks to achieve. Since the
nipple inversion was not dealt with prenatally so that the degree of
progress could be anticipated and a plan formulated, at this point, I would
recommend that the mother receive a simple, sympathetic explanation of
probable arrested nipple development in her own infancy, lots of skin to
skin contact, a plan for bringing in and maintaining her supply with double
pumping and massage and that at least paced bottle feeding be used for
feeding the baby. Pumping may eventually bring about some eversion if her
anatomy is capable of it. If not, eventually, she may appreciate some
on-line support from EP moms some of whom may have a similar situation.
Such situations are one reason that I was angered by the conclusion reached
in the Main trial that prenatal nipple examination be totally abandoned.
Schwager RG, Smith JW, Fray GF, Goulian D Jr., Inversion of the Human Female
Nipple, With a Simple Method of Treatment, *Plastic & Reconstructive
Surgery, Nov. 1974, Vol. 54, No. 5 pp. 564-569.*
Bennett RG, Hirt M, A History of Tissue Expansion, Concepts, Controversies,
and Complications, *J. Dermatol lSurg Oncol 1993;19:1066-1073.*
Cotterman KJ, Intensive Preparation for Inverted or Retracting
Nipples, *Keeping
Abreast Journal, Oct-Dec. 1976. *pp. 331-333*.*
Gangal HT, Gangal MH, Suction Method for Correcting Flat Nipples or Inverted
Nipples, *Plastic and Reconstructive Surgery, Vol. 61, No 2, *pp. 294-296,
1978.
Kesaree N, Banapurmath CR, Banapurmath S, Shamanur K, Treatment of Inverted
Nipples Using a Disposable Syringe, J Hum Lact 9:(1)27-29, 1993
Knight CH, Peaker M, Development of the mammary gland,* J Reprod Fert *(1982),
65, 521-536
Lavelle FW, Embryology and Abnormal Development of the Breast, in Textbook
of Breast Disease, Ed. by Isaacs JH, Mosby Year Book, St. Louis, 1992. P.
15-20.
Scholten E, A novel correction of inverted nipples during pregnancy *Am J
Obstet Gynecol, *Vol. 181, No. I, July 1999 p. 228-229.
Jean
********
K. Jean Cotterman RNC, IBCLC
Dayton, OH USA
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