I am behind on reading LN due to preoccupation with a new great-granddaughter, now 8 days old, and traveling to see an adult granddaughter who had her "white coat" ceremony at UNC last weekend, the last year before she graduates with her PharmD!!!

However, I wanted to add several thoughts in addition to Jane's excellent answer to Celine's post on persistent areolar edema.

<I searched the archives and didn't find anything about edema this late post partum (baby is 4 weeks) I did, however, read of mothers with NICU babies interrupting pumping after 5-7 min to do RPS and then pumping for another few minutes. Another option that mom considered was to pump for less time but more frequently, but this is difficult to coordinate with course content and note taking.  
 

Mother will try interrupting pumping part way through to do RPS and see how that works. along with using gravity with RPS. Mother will try SNS today, as she is having difficulty with 5 Fr. feeding tube on her own and her mother is unable to help her with it effectively.  She has also been offered donor milk. Mother still has no pain when baby is at breast. >


Barbara Wilson Clay has done measurements of increased nipple-areolar size from edema after pumping performed well beyond the early period. Her report on this can be found in The Breastfeeding Atlas. This has also been researched in dairy goats: Hamann J, Mein GA, Wetzel S, Teat tissue reactions to milking: effects of vacuum level. J Dairy Sci 1993 Apr;76(4): 1040-6. 


Gravity would play some part in the weight of interstitial fluid moving toward the nipple-areolar complex especially if the breast is C cup or beyond. Celine mentioned she was considering gravity as part of the equation to reverse the situation. In addition to gravity, even a small amount of pendulousness will also place the flange area below the heart, in the opposite direction from which natural lymphatic drainage needs to go.


I am finding it fascinating to review the lymphatic system, and I hope to keep reviewing this in more depth. Entrance of fluid into lymphatic capillaries is by physical forces rather than the chemical processes such as osmosis utilized by venous capillaries. Beneath the skin of the areola there is a formation called Sappey's plexus, containing several layers of multiple tiny lymphatic capillaries. Lymphatic vessels have a slight negative (vacuum) pressure inside due to their pumping function. This results in naturally forced entrance of interstitial fluid between the cells in the terminal lymphatic capillaries when even a slight elevation of positive pressure develops in interstitial tissue outside them. 


(Hall JE, Guyton and Hall Textbook of Medical Physiology, 12th edition, 2011, Saunders-Elsevier, p. 187.)


However, when the flange is in place and a vacuum much stronger is centered over this tissue, any positive pressure in interstitial fluid will push toward the area affected by the much larger vacuum, rather than toward the slight natural vacuum of the small lymphatic capillaries.

 
This suggests to me that the vacuum setting in use may also be too high for this particular mother. I will repeat my new mantra: "Vacuum does not pull; other forces push." 


And "fitting a flange" is a matter of controversy in my mind too.  It seems important to me to consider the unseen internal anatomy of the areola, which can often be different for each of an individual mother's breasts, and about which even expert researchers disagree (can't wait to hear Michael Woolridge at ILCA;-). I am musing about pure theory here, because I do not issue pumps, and I know many others have much more experience with pumps and flanges. But I have used fingertip expression on hundreds of mothers, partly to detect what used to be called "the sweet spot", so as to help them identify it. I have found that this often varies slightly with each individual, and in fact, sometimes between the separate nipple-areolar complexes of a single mother. So it seems to me that for the most accurate fit of a flange, identification of this "sweet spot", by the mother or the LC (or nurse), probably also ought to enter into the choice of appropriate flange tunnel size for each separate breast. Or at least it ought to be considered when there seems to be a problem with use of the visually selected routine sizes supplied by manufacturers.


Of course, the size of the nipple certainly has to enter into the "equation", in order to avoid pinching/friction of the nipple. But a vacuum level higher than necessary may be a factor in temporary enlargement of the nipple itself by edema. This often leads to the decision to change to a larger flange size (rather than reducing the vacuum, and reducing the edema with RPS before continuing with the same flange if it is appropriate to the  subareolar ducts of that mother.)  


It is not the "milk that is being pulled" but what portion of the subareolar ductal system that will need to compress itself into the flange tunnel to cause extrusion and propulsion of the milk. This forward movement of the milk results from the laws of hydraulics from compression of the subareolar ducts as they enter into the tunnel. This makes me wonder whether or not perhaps a slightly smaller flange that still admits ductal, but less interstitial tissue, might be considered for a trial.


Rather than being "sucked forward", the milk is being propelled forward by hydraulic forces produced by the pressure on the ducts behind the nipple when they compress themselves against the walls of the flange tunnel. Although the milk seems to be moving toward the direction of the vacuum, the vacuum will have no direct effect on the milk itself until the milk reaches the external openings at the surface of the nipple. 


Increasing the vacuum "to get more milk faster" sometimes seems to be a common "knee-jerk no brainer",  to both professionals and lay people. But this may be potentially self-defeating due to inaccurate understanding of vacuum principles and subareolar anatomy and physiology. Interstitial fluid often pushes forward instead, often crowding and "burying" the ducts. (I think this may enter into the common observation that new pospartum mothers in NICU often stop getting any or as much milk out after the initial few pumpings.)


I would be very interested in finding out just how this particular mother applies RPS and whether (or not) she notices any benefit in her situation. If successful, this might strengthen the case for NICU nurses to understand this aspect better in order to teach new mothers learning to pump.


I confess to having a very active imagination;-) 


K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC     Dayton, OH

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome