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Too Swollen to Latch On?
Try Reverse Pressure Softening First

K. Jean Cotterman, RNC, RLC, IBCLC
Dayton OH USA
From: LEAVEN, Vol. 39 No. 2, April-May 2003, pp. 38-40.

Engorgement—when breasts grow larger and heavier with milk, blood, and fluid around two to six days postpartum—can generally be minimized or managed by frequent and unrestricted nursing after birth (at least eight to 12 times in 24 hours) and attention to positioning and latch-on. But when postpartum breasts swell and babies have difficulty latching on, everyone grows anxious about solving the problem quickly. The question becomes “How?”

I have developed in my practice a helpful tool I call Reverse Pressure Softening (RPS). I recommend it as a first alternative to intervening with a breast pump, a nipple shield, or an assortment of other equipment. In RPS, steady, gentle but firm finger pressure is applied to the central areola for one to three minutes, pushing back toward the mother’s chest wall. This simple method of softening the areola helps the nipple extend more deeply into the baby’s mouth, does no harm, works promptly without discomfort, requires no equipment except clean hands, and improves milk transfer.

RPS Triggers the Milk-Ejection Reflex (MER)

Much of what we know about human lactation was first learned from veterinary research. Over half a century ago, that research confirmed for the dairy industry that the most powerful force in milk transfer is the milk-ejection reflex. It was discovered to have two phases, or arcs.

• The neural arc refers to a nerve signal traveling from the breast upward through the spinal cord to the brain, and from there to the pituitary gland, to stimulate the release of oxytocin. (This nerve signal travels quickly. Without a strong stimulus however, distraction or other stressful stimuli may delay the nerve signal. On the other hand, the MER often becomes a conditioned reflex, cued by sights, sounds, smells, etc.)

• The hormonal arc usually happens more slowly, since the oxytocin must be delivered to the breast by the circulatory system. Oxytocin causes myoepithelial cells of both the alveoli and the ducts to begin coordinated contraction (Mepham 1987).

A simple explanation of the MER can empower mothers. I make a special point of making sure the mother understands by saying, “Your breast has its own special way to signal the back of the breast to send milk forward so the baby can reach it more easily.” I try to explain the MER to her husband or other family members, too, to raise awareness of the importance of their support.
Milk expression, using the thumb and fingers, is one of the many good ways to teach mothers to trigger the MER. But during engorgement, hand expression is sometimes difficult, painful, or impossible to accomplish. In contrast, RPS is easily applied and consistently stimulates the neural arc of the MER comfortably and promptly. The hormonal arc soon follows automatically. RPS is effective in stimulating the MER because of the anatomy of the areola. Very little fatty tissue separates the skin and ducts near the base of the nipple (Bricout 1996). Nerve tissue is also concentrated in this same location. The nerves of the breast come together toward this area to encircle each of the individual ducts that travel through the center of the nipple, and emerge at the tip. The sides of the nipple have few nerves (Montagna 1974).

RPS Softens the Areola, Reducing Its Resistance to Elongation by Temporary Redistribution of Tissue Fluid

Edema results from increased accumulation of fluid in the tissues, inefficient lymphatic drainage, or a combination of both (Witte 1997). Fullness of the ducts and alveoli caused by delayed initial feeding or irregular or inadequate removal of milk crowds the breast, slowing lymphatic drainage (M. Newton 1961). Intravenous (IV) fluids given before, during, or after delivery often cause development of excess fluid in tissues throughout the body. This even has the potential to show up as pulmonary (lung) edema, a dangerous complication. The more fluid given, the more likely tissue swelling is to occur (Gonik 1984). In addition, pitocin—used to induce labor—has an antidiuretic effect (Han 1993; Hale 2002). The breast participates in storing retained fluid, sometimes causing pitting edema (a finger, when pressed into the skin, leaves a temporary depression).

By temporarily redistributing edema in the natural direction of lymph drainage toward the axilla (armpit) and chest wall (Bricout 1996; Haagensen 1986), RPS softens the areola. With effective suckling, the areola normally elongates to extend the nipple toward the protection of the soft palate area, allowing the baby’s lower jaw and tongue to reach the ducts beneath the areola and express milk forward through the nipple (Cowie 1974). However, areolar tissue resists elongation (E. Newton 1990) when engorgement expands the breast in a balloon-like fashion, sometimes causing nipples to swell in circumference and/or retract and become more vulnerable to damage.

RPS may often be more effective than pumping at softening the areola of an engorged breast. Breast pumps, from hospital grade to the many poorly engineered pumps commonly available, may be used inappropriately, even in hospitals. This creates the potential to start attracting tissue fluid into the area covered by the flange even before engorgement is obvious. If the vacuum selected is too strong, is used for too long at a time, or is not relieved by regular release at short intervals, it may even result in worsening the situation it is trying to solve. If excess tissue fluid moves into the pump flange area, many observers have noted that a thick, unyielding layer of edema may collect over the areola, preventing compression of the underlying ducts by the baby’s tongue, the fingers, or the pump.

In addition, nipples themselves may become hard, swollen, or blistered from pumping, especially if the pump flange is too small. Veterinary research in goats has shown that inappropriate use of negative pressure (suction) changes both the length and thickness of the teat and the teat canal, making them edematous (swollen). The stronger the vacuum, the more severe the edema (Hamann 1993).

RPS Also Reduces Areolar Resistance to Elongation by Temporary Redistribution of Small Amounts of Colostrum/Milk

Areolar resistance to elongation is also reduced by redistributing milk, which allows the walls of the ducts beneath the areola to respond more easily to the baby’s suckling. RPS reduces possible overdistention of these subareolar ducts by temporarily and painlessly (Cotterman 2002) displacing some of the milk back into the contributing ducts. I have observed that the walls of the ducts immediately beneath the areola then respond more efficiently and comfortably to compression by the baby’s lower jaw, which supports the baby’s tongue as it ripples.

Reports of recent ultrasound research in Australia have created widespread speculation about the shape, function, and distribution and even the existence of milk sinuses (Ramsay 2002). These studies suggest that milk is not stored in (sinuses) ducts directly behind the areola. This research was done on breasts during well-established lactation. To date, such research is not available on mothers in late pregnancy or the first few weeks postpartum. Interestingly, microscopic photography of laboratory specimens of subareolar tissue in the resting (non-lactating) breast has clearly illustrated structures officially classified as lactiferous sinuses. Their unique characteristics have been thoroughly described by histologists and surgeons (Montagna 1974; Azzopardi et al. 1979; Haagensen 1986).

We take it for granted that other parts of the reproductive system change their shape, size, and consistency temporarily during various stages of physiologic function. It may be that milk sinuses gradually undergo a transition in elasticity during late pregnancy and early lactation that has thus far been difficult to investigate scientifically. THE BREASTFEEDING ANSWER BOOK, 2003 Revised Edition, states, “Manually locating what we thought were milk sinuses has been an important aspect of successful hand-expression. Mothers were told to find these ‘milk sinuses’ with their fingers and to compress them in order to express their milk more effectively....We know from many years of experience that proper placement of the fingers is important for successful hand-expression of milk. Further research is needed to determine the reason.”

Editor’s Note: For more information about breast anatomy and function, including recent research, see THE BREASTFEEDING ANSWER BOOK, 2003 Revised Edition, pages 15-23.

Applying RPS to Swollen Breasts

Depending on the length of the mother’s fingernails, one of several finger combinations is used to exert steady, gentle but firm positive pressure on the central areola where it joins the nipple, in an inward direction perpendicular (toward) the mother’s chest wall for a period of one to three full minutes. If breasts are large, a hand mirror may be helpful. When swelling is severe, the re-entry of excess tissue fluid to the areolar area may be slower if the mother lies flat on her back. RPS may be repeated more than once if desired, depending on severity of swelling. Ideally, until sufficient resolution of engorgement has occurred, RPS is best done immediately before each attempt to latch the baby on to the breast, or express milk with fingers and thumb, or with a pump, using short trials of minimum vacuum. (See page 39 for a step-by-step guide to RPS.)
While health care providers may perform RPS first for demonstration, mothers often feel more empowered if taught to apply it to themselves. RPS is so simple that many mothers or their helpers can learn by telephone directions. Practitioners have even reported success in using RPS directly on swollen nipples (Johnson and Myr 2002).

Editor’s Note: For more information about engorgement, including other treatment options, see THE BREASTFEEDING ANSWER BOOK, 2003 revised edition, pages 492-496 and 524-525.

The basic mechanisms of RPS to ease latchability of swollen breasts

[Editor's note: illustrations for RPS are available in the engorgement FAQ.]

© 2003 K. Jean Cotterman

While health care providers may perform RPS first for demonstration, mothers often feel more empowered if taught to apply it to themselves. RPS is so simple that many mothers can learn by telephone directions. Practitioners have even reported success in using RPS directly on swollen nipples (Johnson and Myr 2002).

1. A mother with short fingernails can perform RPS with one hand while soothing a fussy baby in the other arm. She grasps her nipple, positions her fingers on the areola near the place for baby’s tongue and lower jaw, with the thumb opposite, and exerts pressure long enough to sing a song or listen to a commercial. Her curved fingers will sink into the central areola, with the knuckles increasing the circumference of the pit around the nipple. See illustration 1.

2. Mothers may also use both hands, positioning the fingers to circle the base of the nipple closely, with short fingernails contacting the sides of the nipple, to form six to eight pits, or dimples (Mohrbacher and Stock 2003). (Even if there is no visible edema, the area will become much more pliable.) See illustration 2.

3. A mother with long fingernails can perform RPS in two stages. First, straighten the index fingers; point them sideways in opposite directions, with the first knuckles touching the top and bottom of the nipple. After several minutes of inward pressure, reposition the first knuckles at the sides of the nipple, pointing fingertips toward the floor and overlapping the pits previously formed. (If a health care provider or partner is performing RPS for her, the fingers will be pointing to the ceiling.) See illustration 3.

4. A mother, health care provider, or other helper may also perform RPS in two stages pressing with the broad sides of the thumbs near the base of the thumbnail, touching the nipple above and below, then on its opposite sides, forming overlapping pits. See illustration 4.

5. A health care provider or other helping person may stand in front of, or slightly behind and beside the mother, and place his or her fingers or thumbs on her own to provide strength and support for her fingers if the swelling is severe (Cotterman 2002). See illustration 5.

References

Azzopardi, J. et. al. “Problems in Breast Pathology” in Major Problems in Pathology, Vol. 11, (London: Saunders Co. Ltd., 1979) 399-400.
Bricout, N. Breast Surgery. Paris, SpringerVerlag France, 1996.
Campbell, S. Breastfeeding engorgement: self-help treatments are available to help. Adv Nurs New Eng, June 10, 2002; 29-30.
Cotterman, K.J. Zone model tool for assessing early nipple discomfort. Part 2: the assessment process. Lactation Currents September 2002; 59.
Cotterman, K.J. Reverse Pressure Softening. www.health-e-learning.com, May 2002.
Cowie, A. T. Overview of the mammary gland. J Invest Derm 1974; 63(1):29.
Gonik, B. and Cotton, D.B. Peripartum colloid osmotic pressure changes: influence of intravenous hydration. Am J Obstet Gynecol 1984; 150 (1):99-100.
Johnson, M. and Myr, R. Conversation with authors, November 2002.
Haagensen, C. D. Diseases of the Breast, 3rd ed. Philadelphia: W. B. Saunders Co Ltd., 1986.
Hale, T.W. Medications and Mothers’ Milk. Amarillo: Pharmasoft, 2002.
Hamann, J. Mein, G.A. and Wetzel, S. Teat tissue reactions to milking: effects of vacuum level. J Dairy Sci 1993; 76(4):1040-46.
Han, J. S. Yoshitaka, M. and Knepper, M.A. Dual actions of vasopressin and oxytocin in regulation of water permeability in terminal collecting duct. Am J Physiol 1993; 265(1):F 26- 34.
Mepham, T. B. Physiology of Lactation. Philadelphia: Open University Press, 1987, p. 141.
Montagna, W. and Macpherson, E. Some neglected aspects of the anatomy of human breasts. J Invest Derm 1974 ; 63(1):1016.
Mohrbacher, N. and Stock, J. BREASTFEEDING ANSWER BOOK, Third Revised Edition. Schaumburg, IL: La Leche League International, 2003, pp. 16-17, 495.
Newton, E. R. “Lactation and Its Disorders,” in The Female Breast and Its Disorders, (Baltimore: Williams and Wilkins, 1990) 45-74.
Newton, M. “Human lactation” in Milk: The Mammary Gland and Its Secretion, Vol. I, (London: Academic Press, 1961) 281-320.
Ramsay, D.T. Kent, J.C. Hartmann, P.E. 2002. Ultrasound imaging of the human lactating breast. PSANZ/FAOPS Conference proceedings, Christchurch NZ, 9-13 March. (Courtesy Cathy Fetherston)
Witte, C. L. and Witte, M.H. On the causation of edema: A lymphologic perspective. Perspectives in Biology and Medicine 1997; 41(1): 86-97.

K. Jean Cotterman RNC,RLC, IBCLC, retired from maternity nursing after 24 years as a registered nurse and Maternity Inservice Clinician in hospital obstetrics, and 20 years in public health as Coordinator of Prenatal Clinics. She was also a Childbirth Education Instructor and Breastfeeding Instructor for four years in Dayton, Ohio, USA, and received her IBCLC certification in 1985. Jean writes that she and her late husband, Eldon, have “…six adult children, age 50 on down…The first three I nursed for five to 10 days, and stopped with severe nipple pain and damage. In 1959, with our fourth child, I received help from a friend who was on the phone counseling committee of the newly formed Dayton, Ohio LLL Group. She helped me and I was able to have a very rewarding nine-month breastfeeding experience. A decade later, I had a second very rewarding breastfeeding experience, that time for over two years! In 1971, we adopted our sixth child. Though still lactating, I was unaware of what we now know about teaching older babies to breastfeed. So (very regretfully), I was back to artificial feeding again, but at least in an entirely different skin to skin way.” Jean currently volunteers as a lactation consultant for WIC for the Montgomery County Combined Health District, Dayton, Ohio, USA.

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