Mary Cummins wrote:

<The discussion about distorted nipples/compression stripes (thank you
Barbara Wilson-Clay for your excellent comments)  reminded me of another
latch problem I have seen.  This is the baby who opens wide, latches
well, sucks a few times, stops and then pulls back away from a deep latch
(without coming off the breast) and then starts to suck with a shallow
latch.>

This baby is just 12 hours old. Theoretically not enough time to be
"retreating from an overwhelming MER" at this point, so I think we can
rule that out right away.

I, too, enjoyed the clarity of Barbara's insightful analysis in answer to
Bonnie Jones' well thought out questions. I would like to propose that
there may be yet another poorly recognized factor at work in many cases
such as Mary describes.

Even before any large amount of edema/engorgement has begun to distort
the nipple, even prenatally, some mothers have a certain amount of what I
call "functional retraction of the nipple". Some have a great deal more
than others.

That is, no matter how everted the nipple may appear to the naked eye,
compression of the areola about 3/4 to 1" behind the base of the nipple,
either  by examining fingers, or by baby's jaw, produces an immediated
inward tug on the nipple. This is due to a certain amount of incomplete
development, or insufficient elasticity and/or overdistention of the
ductal tissue directly under/behind the nipple.

The good latch has components of both vacuum forces and compression
forces. The proportion of these two forces varies from baby to baby, and
from one part of a feeding to another.

Some delicate, small mouthed, gently sucking babies apply mostly suction
with a small amount of compression, and less retraction takes place in
susceptible tissues. In addition, a good MER causes the baby to ease up
on both vacuum and compression to accommodate respiration.

Other babies with a larger mouth and stronger jaw muscles are able to
exert comparatively more compression on the areola at the same time they
are exerting strong suction on the nipple,  and a very hungry baby will
continue to try to exert these forces this vigorously until rewarded by
the MER.

However, the stronger the compression that the baby exerts, the stronger
the inward tug there will be of any nipple retraction. Or as an old
German proverb put it "The harder he tries, the behinder he gets." I
think this may be happening in the case Mary describes.

I am visualizing diagrams I saw in a high school physics book that were
describing what resulted from 3 different mechanical forces:  tension,
compression and shear.

Each 2 dimensional diagram started with a line drawing of a square.
Tension was described as a pull on each end, and the diagram became
elongated into a rectangle, and proportionately thinner.

Compression was described as pressure of opposing forces on the opposite
sides, also resulting in a rectangle due to the flattening of the
original square.

The one which made me say "A ha!" was the diagram of shear. This results
when there is simultaneous tension on one plane and compression in the
other. The square assumes the shape of a parallelogram. (Any Webster
dictionary will give you a definition and probably a diagram.)

Thinking geometrically in 3 dimensional terms, if one imagines the nipple
as if it were a cube, our "Nuk look" emerges as the visible portion
shaped by compression forces of the jaws on top and bottom, and the
simultaneous opposing tension forces of vacuum on one end and retraction
on the other.

Since the nipple more closely resembles a cylinder than a cube, Webster
has an even fancier word that might more closely describe the shape:
"rhomboid-ovate". Partially round and partially oval.

Dermatology and wound care literature frequently speak of the effect of
shear forces upon the skin layer. In the case of the nipple, it seems to
me that shear forces are frequently at work not only on the skin and its
blood vessels, contributing to blanching (more compression) or lesions
(more vacuum), but also upon the internal tissue layers of the nipple.

Is it any wonder that poor milk transfer can occur and the nipple can
suffer so much pain and damage , even when the most careful outward
attempts are made to effect a good latch?

That is what continues to interest me in the subject of functional
retraction of the nipple, be it from the characteristics of the
connective tissue or the distortion effect of excess tissue fluid on
protractility.

Please discuss this with your engineering-oriented husbands and friends
and let me know if my reasoning "holds water".

K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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