I like Jean's toothpaste tube analogy, and agree that the size of the pump
flange is prob. more important than we have realized. I spend a lot of time
thinking about the relative sizes of things, which is a consequence of
fooling around with nipple shields. We know there have been problems with
the one-size-fits-all with shields because nipples are different sizes in
diameter, and babies have slightly different "lengths" to their palates
(from front to back). Pump flanges have the same problems because of the
variability in women's anatomy.
I saw a woman yesterday with smallish, 38 week gestational age twins; one
about 5 lb, the other about 6 lbs. Mom had nipples which were between 22
and 24 mm in diameter and about 1.2 cm eversion at rest. I say "between"
when describing the nipple diameter, because I first measured them (using an
engineer's circle template) right after pumping with a standard size flange.
They were very swollen, and she was only getting about 28 ml from each
breast. After about half an hour, the nipples decreased in size several mm.
The 9 day old babies had never latched before in spite of them having nice,
normal reflexes and oral anatomy. I got them on in side lying, but clearly
they are currently mis-matched in terms of size of their mouths vs her
nipples. Test weights revealed no milk transfer at all.
Fit problems like this don't concern me much, because growth takes care of
them. You following the 1-2-3 rules: Feed the babies, protect the milk
supply, and keep something happening at breast. However, if I don;t get
this mother on a larger pump flange, I suspect that rule 2 may not be
followed closely enough to really protect her lactation capacity. I
visualize it as "crimping the hose".
Just for those who may never have handled a fit problem before, my protocol
involves generous feeding of the babies however parents desire. In this
case, with twins, the parents opted for bottles. There isn't a lot of risk
of nipple confusion with such huge nipples so long as milk transfer remains
good. These nipples compete well with bottle teats because they are so very
big and firm. These twins are to spend a lot of skin-to-skin time with mom
cuddling and nuzzling to keep rule 3 happening. As babies grow, they should
transition nicely. Mom has been given lots of positive suggestion about how
"none of this is a big deal so long as you keep pumping like crazy, along
with some manual expression." However, my big challenge is to quickly get
some larger flanges to her. I was driving my husband's car due to a flat
tire, and didn't have my handy in-trunk basket of larger flanges. It never
fails that you need something the one time you don't have it!
Access to equipment which accomodates variations in female anatomy is
something I am grateful for because it allows me to be of better service to
the women who have more challenging bfg. circumstances.
I want to also say that I am continually grateful to all the people who use
Lactnet as a forum for education, to share interesting cases, and to provoke
serious theoretical and ethical discussion in our new discipline. I am also
very grateful to Kathleen Auerbach and Kathleen Bruce, the founders, and to
the current list mothers who help bring this interesting resource to us each
day. Happy New Years to all.
PS I'm REAL grateful this computer is still working today on 1-1-2000!!!!
Barbara Wilson-Clay, BSEd, IBCLC
Austin Lactation Associates, Austin, Texas
http://www.jump.net/~bwc/lactnews.html
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