Mary, you wrote:
<She started with #24mm shields. She changed to #27mm once home after a week of pumping due to breast pain and her nipple being compressed. Her nipple size at the time was large and filling up the #24mm shields. She pumped with the 27's for a week(milk volume has always been great, 4-5oz each session, every 3 hours, with a 4-5 hour stretch one time at night. After a week she increased her shield size to #30mm on her own and then increased to #36mm at week 2 on her own. Upon my assessment, her nipple size was still large and swollen in the 30's and she had an open wound on the base of nipple from rubbing,so I agreed with her increase to 36mm and treatment of the open area. After a week of pumping with these, she still c/o pain with pumping despite using pre-pumping measures of Lansinoh or olive oil on the shield, warm compresses, and massage. Her volume started decreasing and she was experiencing plugs in one breast after about 4 days. Her areola was bruised, and now more breast tissue than just nipple was pulling into the cylinder. the nipple shape was no longer a defined separation from the breast. Even at rest. We re-evaluated shield size and found the #27mm to be the better fit now.>
I am not an expert on breast pumps or breast flanges per se. I do know that many folks do not fully realize that "Vacuum does not pull; other forces push", (in order to try to bring balance between the pressures in the areas adjacent to each other). It sounds as if this mother's interstitial fluids, skin, connective tissues, subarolar lymphatic channels, ducts with anything inside, capillaries and blood therein are all trying to push forward into the flange tunnel because "Nature abhors a vacuum!" How high is the vacuum she is using?? How long at a time is she pumping??
Has she tried stimulating her MER with her fingertips pressing in on the areola (with fingertip expression or RPS) before starting to pump, no matter what brand of pump she is using? Does she use any breast compression during the pumping to help nature push the milk forward? Or take a break every 7 minutes or so to trigger another MER manually, soften the areola, massage some milk forward, before doing another 7 minutes or so of pumping?
Since the baby is well over a month now, any overhydration from birth is gone. But is this mother pendulous?? Gravity seems to attract any edema, which may be more likely to be present in a pendulous breast especially if the nipple-areolar complex is well below the chest wall. And of course, vacuum being applied at the low end of a pendulous breast would increase this tendency. It sounds to me as if much of the need to change flange sizes resulted from more and more crowding of the tissues with interstitial fluid. If she is pendulous, perhaps lying on her side to pump one side at a time till this is resolved might be of some help. Lying on her back and gently massaging upward in the direction of lymphatic drainage several time a day, perhaps before pumping, might also help move the now-chronic swelling away from her nipple-areolar complex. Has she viewed the Stanford film and considered fingertip expression after the early pumping?
She appears to be so dedicated. But "common sense" and advertising sometimes combine to make folks mistakenly conclude that if you want more milk to come out, that "upping the vacuum" sounds like the way to do it.
Hope some of these ideas help.
K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC Dayton OH
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