Jane wrote:

<I would say - hand-expression and reverse pressure softening first.  Pumping is for sustained stimulation since most women won't sit there and hand-express for 15 minutes, but hand-expression is much more rewarding.  Remember that pumps remove milk by eliciting let-down and then keeping milk moving forward out of the breast as the alveolar musculature contracts pushing milk through the ducts and out the nipple.  Or as Jean Cotterman says - forces push, vacuum does not pull.  SOOOOO if there are very low volumes and the alveoli don't have much in them, not much is going to come with the instant demand of the pump.  Even with volume and pushing, the pump does not remove all the available milk and it does absolutely NO reverse pressure softening.  The pump flanges that squeeze down on the nipple don't work to do what the baby can do either.  This is why research has shown that pumping PLUS hand-expression gets the best results in building milk volumes - by sustaining stimulation and removal of milk throughout the let-down(s) and by removing small amounts remaining in the ducts right in the areola (that used to be called lactiferous sinuses but really aren't there LOL). >

Thanks, Jane. You have always been one of my most faithful supporters;)


I'll answer in reverse order: 


I once had a chance to ask Dr. Hartmann personally about the research on lactiferous sinues. His exact words were: "We are UNABLE TO DEMONSTRATE (not yelling, just emphasizing) the presence of lactiferous sinuses on ultrasound." (Note that this research starts only at 4 weeks postpartum, after breastfeeding and/or pumping had had a chance to stretch the elastic walls.) Others on his team have made more far-reaching statements that lactiferous sinuses simply do not exist. 


I am willing to admit that they do not exist in the way we were once taught, built solely upon artist's drawings, copied and re-imagined (like Eli Lilly's fanciful illustration with just line drawings of about 8-10 ducts with a glimmering diamond in each sinus) from drawings of other artists, illustrating them, only in the lactation stages, down through the ages/centuries! 


But there are numerous published photos of microscopic views of lactiferous sinuses in the resting breast in the literature of histologists, breast surgeons, even embryologists, who say even boys and girls and men as well as women have them, the main difference being that there is thick elastic tissue surrounding the walls in the resting breasts of adult females. My question is "Why would nature cause such a feature to appear even in embryonic, microscopic views of the yet immature and/or resting breasts of young and older humans of both sexes, then cause them to disappear completely in adult females ONLY (not shouting, emphasizing) during the only active phase of the organ, then reappear in microscopic slides of the resting breast tissues of (at least) menopausal women???? See a microscopic view of some lactiferous sinuses in tissue from a resting breast on a histology slide from the University of Western Australia, at:


http://www.lab.anhb.uwa.edu.au/mb140/big/nip02he.jpg


I wish I had money to pay someone to collect/do histology examination of the subareolar tissues of (unfortunately deceased) women during each trimester of pregnancy and during the first 4 weeks postpartum of both non-nursing and nursing women. I think that the lactiferous sinuses are dynamic (changing size temporarily according to stages of function and use, as do many reproductive organs, both male and female). I think lactiferous sinuses are important in the effective application of the laws of hydrostatic pressure in suckling, hand expression and pumping.


<<I would say - hand-expression and reverse pressure softening first.  Pumping is for sustained stimulation since most women won't sit there and hand-express for 15 minutes, but hand-expression is much more rewarding.  Remember that pumps remove milk by eliciting let-down and then keeping milk moving forward out of the breast as the alveolar musculature contracts pushing milk through the ducts and out the nipple. >


I myself, usually reverse that order, trying RPS first, of course with brief explanation and the mother's permission. It does no harm to do RPS first, and may give faster success. No one has mentioned edema from natural anatomical pendulousness and/or often-present overhydration, which observation really ought to be considered as a part in every postpartum breast assessment, IME. 


Blood work,  measuring colloid osmotic pressure levels on various succeeding postpartum days, compared with the amount of oral fluids in labor plus the amount and timing of previous IV intake, especially IV pitocin (with its antidiuretic side effects), for induction, augmentation and/or third-stage management, seems thus far to be absent from any of the lactation research I am aware of. Many of the standard "golden oldy" references about engorgement make little of no mention of these perinatal management factors, which were little or seldom used 6+ decades ago at least in the town where I practiced, when most such definitions evolved. 


But I recommend that RPS be the first intervention tried on the areola, being done in a laid back position for mothers with a C cup or beyond, for at least 1-5 minutes (or more, if very obviously edematous) the first several times. IME, it will elicit an MER within 60-90 seconds, and will as well reposition any even invisible edema temporarily upward, right at the start. If there is even less than 30% above the normal amount of interstitial fluid (which has not yet made enough edema to "pit" per Guyton's research) RPS will displace any excess tissue fluid which gravity and other forces have attracted downwards toward the subareolar tissues, which is sometimes enough to crowd the subareolar ducts so much they cannot allow milk to pass easily, or at all, through to the nipple and out.


After RPS has triggered the MER and "temporarily normalized" the subareolar distribution of fluids upwards for an inch or so, so that even overfull lactiferous sinuses are temporarily "downsized and the walls relaxed enough" so that direct compression of hand expression (HE) doesn't hurt, then HE is much more easy and productive, as are also short periods of pumping. 


Any edema, even invisible as yet, will begin to push forward by gravity and/or to normalize/equalize pressures near the negative pressure of vacuum focused in the flange tunnel. So once or twice more during the pumping, at about 5-7 minute intervals when the flow slows, take a break for 1-2 minutes of forward massage from the upper breast, then repeat 1 minute application of RPS in a "laid back position" if C-cup or beyond, or very full  This set of "breaks" will once again permit easier, more productive hand expression and/or pumping. Shorter (10-15 minute total) hand expression or pumping times, at more frequent intervals seem to tire mothers' hands less, as well as provide more frequent stimuli for production.


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

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