Relactation and Induced Lactation (adoptive breastfeeding)
Have you ever thought it possible to breastfeed your baby again, after weaning prematurely or breastfeed your adoptive baby even though you have never been pregnant before?
The processes are called relactation and adoptive breastfeeding.
Relactation is the re-establishing of milk secretion after weaning and adoptive breastfeeding (sometimes called induced lactation) is the induction of lactation in a woman who was not pregnant with the current baby and may involve hormonal preparation (oestrogen and progesterone or progesterone alone - simulating a pregnancy) followed by sudden cessation of the hormones (simulating a birth) and then the commencement of pumping or suckling and a galactagogue that increases prolactin secretion.
For both adoptive breastfeeding and relactation the aim is to bring about (or back) a milk supply and bringing the baby (back) to the breast. These 2 are interconnected endeavours, as the best thing for a milk supply is to have a baby breastfeeding frequently and a baby is more likely to breastfeed or return to the breast if there is plenty of milk there!
Difference between the two: it MAY be easier with relactation to get back to a full milk supply if it was already well established during the first 4-6 weeks postpartum. However moms who did not establish a good milk supply in the beginning and adoptive moms who have never breastfed can also get good results with a little bit more work. With a natural pregnancy the milk making tissues are built during the pregnancy whereas with adoptive breastfeeding (if a mother has never been pregnant or even had menstrual cycle or other hormonal issues) she may need, as mentioned, hormonal preparation.(1) For many adoptive mothers it may be more the about connecting deeply with the new baby than producing large volumes of breastmilk.(2)
Some reasons we have found mothers may wean prematurely: maternal illness, illness of baby, lack of support to breastfeed, lack of knowledge of breastfeeding, breast and/or nipple problems, maternal time commitments, etc.
Some of the reasons why mothers want to relactate: regretting weaning, baby want to continue breastfeeding, baby refuses other milks or food, baby illness, baby allergy to breastmilk substitutes, in times of crisis or emergency, etc.
Some of the reasons a woman may decide to induce lactation: to breastfeed her baby born by a surrogate, to breastfeed a baby she has adopted, to breastfeed a baby whose mother is unable to breastfeed, to breastfeed an abandoned baby, etc.
If a mother is committed to relactating or breastfeeding her adopted baby or her baby born via surrogacy, she can do it. Any amount of breastmilk she is able to provide for her baby is a precious gift. A study done in the early 2000’s evaluated whether mothers with babies less than 6 weeks of age can initiate or establish lactation. Mothers who had either stopped breastfeeding or were not able to initiate breastfeeding received help with establishing lactation at an outpatient clinic. Within 10 days, 91.6% of the mothers established lactation, with 83.4% achieving complete lactation and 8.2% achieving partial lactation.(3)
The following are some factors associated with more success:
A younger baby
If relactating, a shorter gap between weaning and relactating (sometimes called a “lactation gap”)
The willingness of the baby to take the breast
Having assistance from a La Leche League Leader or International Board Certified Lactation Consultant
These factors may influence a mother’s chance at meeting her goals, but each mother/baby pair is different and relactation and adoptive breastfeeding may still be possible even if she doesn’t meet the most “favourable criteria”. A mother may need to decide whether it is important to her to provide as much breastmilk as she can or to have that special relationship, the special closeness and the emotional attachment of breastfeeding. There is no right or wrong way to set goals for relactation.(4) One adopting mother said: “I want to breastfeed. If the baby also gets breastmilk, that’s great”. Although there is little research on relactation, the available studies strongly suggest that, with proper support, most mothers can partially or fully relactate.(5)
To ensure a good milk supply and prevent and manage potential problems it may help to understand how the breasts function. See blog post Questions parents have: What is Fore-milk and Hind-milk? for more information.
So how does one go about relactating or breastfeeding an adoptive baby?
Nr 1: Developing (or re-developing) a milk supply/bringing back the milk and at the same time Nr 1.0: Teaching (or re-teaching) baby to feed at the breast.
Relactation may be a simple project of restarting what one was doing before. If breastfeeding ended because, in spite of “doing everything right,” the mother still didn’t produce enough milk, and/or baby became unwilling to breastfeed, there are more issues to explore. If a mother stopped because of pain, learning more about latch, and exploring the possibility of issues like tongue tie, are worthwhile topics to consider.(6) It may be a good idea to see a La Leche League Leader or International Board Certified Lactation Consultant for more information, support and encouragement.
Let us look at Nr 1: Bring back (developing) the milk supply.
Developing a milk supply requires in part adequate frequent, effective milk removal & stimulation (once there is milk to remove) via baby breastfeeding, hand expression, pumping or a combination of these. The other elements of a good milk supply are sufficient glandular tissue, intact nerve pathways & ducts (anatomy) PLUS adequate hormones & hormone receptors (physiology) discussed in the blog post Why families need help breastfeeding.
If a baby isn’t taking the breast, or is doing so infrequently, the use a pump to stimulate the milk supply is essential since milk supply seems to be calibrated based on how well the breasts are drained.(7) Mothers should try and drain their breasts frequently. (Since milk is made continuously a mother can never really “empty” her breasts and that’s why we talk about “draining”).(8) Double pumping provides more stimulation than pumping one side at a time.(9) A mothers should aim to pump at least 8–10 times in 24 hours (including at least once at night) massaging before and/or during pumping finishing with hands-on expression. A descriptive video on maximizing milk production with hands-on expressing can be found here: https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html.
Galactogogues (or lactogogues) are medications or other substances believed to assist initiation, maintenance, or augmentation of the rate of maternal milk synthesis. Human milk production is a complex physiologic process involving physical and emotional factors and the interaction of multiple hormones, the most important of which is believed to be prolactin.(10) One should caution against inappropriately recommended galactogogues prior to emphasizing the primary means of increasing the overall rate of milk synthesis (frequent feeding and regular draining of the breasts).
There are both herbal supplements and prescription medications which increase milk supply. Some herbs are particularly helpful with glandular and hormonal causes of low milk supply. Currently available pharmaceutical galactogogues are all dopamine antagonists and will increase prolactin levels via this mechanism.(11) Herbal remedies have been used throughout history to enhance milk supply. Some herbs mentioned as galactogogues include fenugreek, goat’s rue, milk thistle (Silybum marianum), oats, dandelion, millet, seaweed, anise, basil, blessed thistle, fennel seeds, marshmallow, and many others. Although beer is used in some cultures, alcohol may actually reduce milk production. A barley component of beer (even non-alcoholic beer) can increase prolactin secretion, but there are ‘‘no systematic studies’’ and ‘‘there is no hard evidence for causal effect.’’(12,13) Mothers wanting to make use of a galactogogues should contact their Health Care Provider for a prescription since La Leche League Leaders or International Board Certified Lactation Consultants are not allowed to prescribe any medication be it natural or pharmacological.
SO galactagogues may be helpful to speed up milk supply but are not magic bullets. They provide building blocks for milk production and effective removal of milk is still essential since (as mentioned) milk supply seem to be calibrated based on how well the breasts are drained.(14)
If the baby is willing to breastfeed, and doing to effectively then feeding frequently is the single most effective thing a mother can do to build her supply. She should aim for at least 10-12 feedings every 24 hours. Feeding on both sides and feeding long enough to drain each breast well if baby is willing. Using a supplemental nursing system (SNS – more about this below) allows a baby to receive supplements at the breast while simultaneously stimulating a mother’s milk production and also reduces the need to feed baby via another method after a breastfeed.
Nr 1.0: Bring baby (back) to the breast.
Teaching (or re-teaching) a baby to feed at the breast starts with as much skin-to-skin contact and holding as possible an important step back to the breast.(15) A study by Svensson et al showed skin-to-skin contact during breastfeeding seemed to immediately enhance maternal positive feelings and shorten the time it takes to resolve severe latch-on problems in the infants who started to latch. They said an underlying mechanism may be that skin-to-skin contact with the mother may calm infants with earlier strong reaction to “hands on latch intervention” and relieve the stress which may have blocked the infant’s inborn biological program to find the breast and latch on.(16)
Research is increasingly pointing toward the importance of baby’s innate feeding instincts in the establishment and re-establishment of breastfeeding.(17) Biological Nurturing, or Laid-Back Breastfeeding, involves reclining to breastfeed. Mothers should ensure a deep latch. A deep latch will allow the baby to receive the most milk and will keep the mother comfortable. Mothers should ask for help from a La Leche League Leader or International Board Certified Lactation Consultant if getting a deep latch poses a challenge.
Mothers can also use breast compression while feeding baby. This squeezing the breast while baby is breastfeeding keeps baby engaged at the breast. It is particularly effective if a baby is sleepy at the breast.(18)
If a baby is reluctant to attempt suckling one can try to use the same strategies as one would with any baby that refuses the breast. Using a nipple shield may help with a baby who has only ever been bottle fed. Seek help from a La Leche League Leader or International Board Certified Lactation Consultant for assistance in using and weaning baby from a nipple shield.
Using a tube feeding device at the breast for supplements will encourage the baby to stay at the breast suckling for longer since they get a greater flow and it avoids the need to use alternative feeding methods. There are two basic types of supplementary nursing systems (SNS). Seek help from La Leche League Leader or International Board Certified Lactation Consultant for assistance in using a SNS.
One type of SNS is a bottle or bag filled with expressed breastmilk, banked breastmilk or artificial infant milk that is worn around the neck or clipped to clothing or hidden in a shirt pocket. Thin tubes leading from the bottle or bag attach to both breasts. The baby then breastfeeds from the breast normally. As mentioned this is an excellent way to supplement the baby's feedings until the mother is able to bring in/up her milk supply.
Commercial supplementary nursing systems (SNS)
The other type of SNS is an alternate homemade feeding tube device. To make a homemade SNS one will need an ordinary feeding or storage bottle, a Nr 5 French feeding tube (nasogastric tube) available from hospital pharmacies or Lactation Consultant and a 20ml syringe for flushing and cleaning the tube. A small hole can be made in the storage bottle cap and the tubing “threaded” upwards through it. A tight fit for the tube through the storage container cap will reduce spillage. The plastic end (an open/close valve) on the feeding tube sits in the milk at the bottom of the bottle (make sure the valve is open!). Piercing a second hole in the cap allows air into the container so the baby doesn’t need to suck harder as the container empties. Some mothers find it works well without the extra hole. The free rounded end of the tube should lie alongside mother’s nipple and be taken into the baby’s mouth when baby begins to suck. Mothers find it useful to tape the tube to their breast. Jack Newman, a Canadian paediatrician and breastfeeding expert says the tube only needs to be over the baby’s gums to work properly.(19)
Homemade supplementary nursing systems (SNS) with tube hanging in bottle
Homemade supplementary nursing systems (SNS) with tube attached to syringe
More resources on relactation and adoptive breastfeeding can be found at http://kellymom.com/ages/adopt-relactate/relactation-resources/.
Mothers wanting to relactate or breastfeed their adopted baby can chat to a La Leche League Leader** or International Board Certified Lactation Consultant* for more information, support and encouragement.
*IBCLCs (International Board Certified Lactation Consultants) have passed a rigorous examination that demonstrates their ability to provide competent, comprehensive lactation and breastfeeding care. IBCLCs may have different areas of expertise, so you might have to seek further help if you needs are not met. Facebook: Lactation Consultants (ibclc) South Africa or on Facebook: Breastfeeding Clinic.
**A La Leche League Leader is a mother who has successfully breastfed her own child for at least a year, and has been trained by La Leche League International in helping other mothers breastfeed. La Leche League Leaders are excellent in answering breastfeeding questions over the phone, and they are a perfect resource for older-baby breastfeeding question. Find a LLLL here: http://www.llli.org/southafrica.html or on Facebook: groups/lalecheleaguesouthafrica.
1. The Protocols for Induced Lactation: A Guide for Maximizing Breastmilk Production by Lenore Goldfarb, B. Comm, B. Sc., LE and Jack Newman, MD, FRCPC (based on the Original Induced Lactation Protocol conceived and published by Jack Newman, MD): http://www.asklenore.info/breastfeeding/induced_lactation/gn_protocols.shtml
2. The Womanly Art of Breastfeeding. La Leche League International, 2010
3. Judith Lauwers, Counseling the Nursing Mother, 2015, Jones & Bartlett Publishers.
5. Judith Lauwers, Counseling the Nursing Mother, 2015, Jones & Bartlett Publishers.
7. Daly SEJ, Kent JC, Owens RA, Hartmann PE. Frequency and degree of milk removal and the short-term control of human milk synthesis. Exp Physiol 1996; 81:861–75.
8. Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeeds and fat content of breast milk throughout the day. Pediatrics 2006; 117:e387–95.
9. J Hum Lact. 1996 Sep;12(3):193-9. The effect of sequential and simultaneous breast pumping on milk volume and prolactin levels: a pilot study. Hill PD, Aldag JC, Chatterton RT.
10. ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting the Rate of Maternal Milk Secretion
11. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession, 6th ed. Elsevier Mosby, Philadelphia, 2005.
12. Koletzko B, Lehner F. Beer and breastfeeding. Adv Exp Med Biol 2000;478:23–28.
13. Mennella JA, Beauchamp GK. Beer, breast feeding, and folklore. Dev Psychobiol 1993;26:459–466.
14. Daly SEJ, Kent JC, Owens RA, Hartmann PE. Frequency and degree of milk removal and the short-term control of human milk synthesis. Exp Physiol 1996; 81:861–75.
15. The Womanly Art of Breastfeeding. La Leche League International, 2010.
16. Svensson et al. Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: a randomized trial. International Breastfeeding Journal 2013, 8:1
17. Colson, S. (2010b). What happens to breastfeeding when mothers lie back? Clinical Lactation, 1(1), 11–14.