<Mom of a 2 month old had a severly damaged left nipple that became infected with staph. Now the nipple is nearly completely healed. Since just before the infection began, that side has been pouring milk.> The explanation for the copious milk supply is obviously the constant loss, which is removing milk thoroughly and frequently, which are the key factors driving supply. As to why it can leak so freely, has anyone used a magnifying glass to inspect all around the base of the nipple where it meets the areola? Sounds as if a fistula into an anteriorly and shallowly placed milk sinus may have formed as a result of whole process involving the severely damaged left nipple, even if it began before the infection was obvious enough to be diagnosed. During the time it was damaged/infected, it was no doubt excruciatingly painful. I have many times seen mothers with such pain, when attempting to latch, reflexively do the fastest thing they can to "unlatch" - they move the baby away quickly while simultaneously placing sharp traction on the breast to pull the nipple out without taking the time to break suction! Severe traction can cause a tear in what seems to be an "Achille's heel" area, the skin just at the junction between the nipple and the areola, just at the base of the nipple. Perhaps the outer skin here is no thinner than on the rest of the areola, but when the baby is hanging on to the nipple button for dear life, this seems to be the area sustaining most torsion and traction, and therefore at risk for tearing. If this particular mother had even one milk sinus in that shallow area, it too may have sustained a microscopic tear. One of Dr. Hartmann's graduate students who did ultrasound studies of actual nursings suggests that sinuses do not seem to be as clearly delineated as the "bicycle-spoke" like diagrams we see in texts. On ultrasound, a sinus seems to appear to be a collecting area where at least two ducts converge. This might mean that at least 2 lobes of that breast would be under constant extra stimulation from the leakage. I was fascinated by a small factoid I read in pathology and surgery literature. Under microscopic exam, histologists find a distinct change in the type of cells deeper inside this junctional area. A single layer of a type called "squamous (flat) epithelium" lines the galactophores inside and leading out of the nipple (and this cell type continues on over the outer skin of the nipple and areola). Abruptly, at the internal junction of the galactophore with the milk sinus, a two layered cell design takes over. (This same pattern continues in the ducts, ductules and alveoli.) The cells of the interior layer are "columnar cells", which I gather, can change their shape somewhat when distended. The exterior layer of cells are "myoepithelial cells", which respond to oxytocin during the MER. Squamous epithelial cells tend to retain their shape and do not stretch as easily as the columnar cells are designed to do. Perhaps this boundary in the cell types explains why there is a certain comparative resistance to leakage from the intact sinuses despite gravity. Here is a copy of an exchange of letters about a mother with a very similar complaint from the Lactnet archives: <To: [log in to unmask] >Subject: Leaking milk >Date: Sat, Nov 25, 2000, 2:59 AM > > <As a result of poor latching and the yeast early on I > developed pretty bad abrasions - well they were more like gouges to be > honest - on both nipples.> > > <It left a "hole" at the > base of my mipple. It looks as though a push pin was stuck in it. The > main > frustration is that whenever I have let down (which seems to be a lot as > I > still nurse frequently during the day and even more at night) I have a > steady stream of milk flow through the hole. It soaks shirts, bed > clothes, > my daughters clothes. It sprays in her face, on the floor... it drives me > crazy. I'm guessing I lose 6-8 ounces a day through it.> > > It sounds to me as if the damage to your nipples was partly a result of > tearing, and was severe enough to go all the way through several layers > of tissue directly into a milk sinus that happens to lie particularly > forward in the breast, closer to the nipple. (Many mothers I have > examined have their milk sinuses further away from the base of the > nipple, perhaps 3/4" to 1 1/2".) > > It seems to have created a fistula to the surface that has no natural > resistance such as the normal ductal pathway through the nipple tissue. > (Each such ductal pathway through the nipple is narrower, hemmed in by > the longitudinal muscles of the nipple and lined with a different kind > of cells which are not as elastic as the sinuses themselves.) > > This sounds like a vicious cycle, as the more milk you lose through the > fistula, the more that breast (or more specifically, the lobe(s) > communicating with the fistula) produces, and the general oversupply > might be making the milk ejection reflex that much stronger. > > This sounds like a very simplistic question, but what happens when you > apply direct pressure to the area when you are not nursing? Can you sense > when you are going to have a MER? Or is it possible, while nursing, to > use a finger tip to press on the duct behind (above) the fistula to slow > down the squirting in your daughter's face and the general milk loss, at > least some feedings when you are awake? > > Have you considered consulting a plastic surgeon for a second opinion? > Not that you could necessarily expect any more support for continued > nursing. > > But some articles about the cosmetic correction of inverted nipples that > I have read in their journals leads me to believe that they are very > knowledgeable about the microanatomy of the nipple-areolar complex. > > Direct vision microsurgery would sound like a better idea than blindly > directed ablation with laser surgery. (Not that I am well-read on either, > but it would be important not to harm other sinuses.) > > Perhaps part of the consultation might be discussion of ductography by a > radiologist by ultrasound or by x-ray to identify whether this is in fact > a fistula, and just exactly where the tributary duct(s) are located. > (Just imagineering here!) > > Perhaps a surgical repair of a fistula and the sinus might be possible? > Or at least a tying off of the duct(s) leading to that particular sinus, > which would lead to involution to the lobe(s) of the breast that were > feeding into it. But it sounds as if you have plenty more lobes doing > more than an adequate job of production. > > Hope these musings might help. > > K. Jean Cotterman RNC, IBCLC > Dayton, Ohio USA Hi, Thanks for your response. Yes the "finger in the dyke" approach does work to some extent in terms of stopping the spray in her face when she pulls off at let down but not for any other situations. I must just continually leak - or at least leak frequently - as it doesn't work well for keeping me dry throughout the day and night. I used to feel the MER strongly but don't as much anymore. Also what seems to happen is if I apply pressure it will work for the "stream" but I'll still leak continually after. That breast is easily engorged so I think your theory on the vicious cycle of milk production is correct. I would be interested in talking with a plastic surgeon but would like to have more info before doing so. I guess that's why I put this question to Dr. newman, just to see if anyone had any similar experiences to relate. I am open to nursing my daughter into her toddler years so I would like to do something if it's possible.> Perhaps e-mailing the mother in the above post might get some ideas from her subsequent experience. Jean **************** K. Jean Cotterman RNC, IBCLC Dayton, Ohio USA *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html