Relactation and Adoptive Nursing

By Anne Smith, IBCLC

Relactation is the process of rebuilding your milk supply once you have started nursing and then stopped for a period of weeks or months. Induced lactation is the process of building a milk supply in a mother who has either never nursed a baby, or who has nursed years before.

Relacation and induced lactation both take time, patience, dedication, and a lot of work. If you are considering either option, I strongly recommend that you contact an IBCLC (International Board Certified Lactation Consultant) to help you during the process. You can find an IBCLC in your area by contacting ILCA (International Lactation Consultant Association) at 312-541-1710 or by e-mail at ilca@erols.com.

Many mothers start out nursing their baby and end up weaning earlier than they had planned for a variety of reasons -- stress, nipple soreness, returning to work, taking a medication that is incompatible with breastfeeding, etc. Often when time has passed and their circumstances have changed, they regret their decision to wean and want to return to breastfeeding. One of the most common reasons for relactating is the baby's allergic reaction to formula.

The younger the baby, the easier it is to get him to return to nursing and to re-establish your milk supply. After giving birth, estrogen levels drop rapidly, and by three weeks postpartum, prolactin levels have dropped back down to normal levels. It is easiest to relactate if the process is initiated during the first three weeks after birth, but it is certainly possible to do it after that time as well. The most important elements to successful relactation are a mother who is highly motivated and has a good support system, has realistic expectations, and a baby with a good sucking reflex.

Most babies younger than three months can be coaxed back to the breast, especially if their attempts to suckle are promptly rewarded. Babies between three and six months may or may not be willing to nurse, depending on their individual temperaments. Babies older than six months are pretty set in their ways and usually can't be convinced to nurse.

I would start out by seeing if your baby will latch on and suck. You can offer the breast as a pacifer if he is willing to accept it, even before your milk comes in. Using breast massage and switch nursing (alternating between both breasts several times during a feeding) can help increase your milk production.

I would also recommend taking either Reglan (10 mg, 3 times a day) or Domperidone (10 mg 3 times a day, increasing to 20 mg 4 times a day after you have been taking it for a few weeks). Both of these medications increase prolactin production and have minimal side effects, but Domperidone is the safer of the two drugs, and unfortunately, is available in Canada but not the United States. Both medications must be prescribed by a doctor. In most studies of Reglan, major increases of prolactin and significant increases in milk production were observed, but when it was discontinued abruptly, the supply also decreased abruptly. Tapering the dose is recommended, usually by decreasing it by 10 mg per week. Use of Reglan for more than 4 weeks has been associated with depression, but some mothers have taken it for many months with no noticeable side effects. The average amount of time to take the Reglan is 7-14 days, and by that time, hopefully your supply will have built up and your baby will be providing lots of stimulation so that you don't need it anymore. If you prefer, you can relactate without the use of medications, but in most cases, I have found that it speeds up the process and the side effects are minimal.

Breastmilk is produced by sucking stimulation and supply and demand. The more often you nurse or pump, the more milk you will have. Start expressing milk with a hospital grade electric double pump, like the 015 Classic by Medela. These pumps are too expensive to buy, so most moms will rent them. Call 1-800-TELLYOU for a rental station in your area. Try to double pump 8 times a day for 10-15 minutes. Any stimulation at all is beneficial, so don't worry if you can't pump that often. Don't get discouraged by the amount of milk you pump. You are going for stimulation, and it may take a while to see any significant amounts of milk.

Many babies will get frustrated when you put them to the breast initially and little or no milk is coming out, so they won't stay on for long. Using a supplemental feeding system can solve this problem by ensuring that the baby's sucking efforts are rewarded.(SNS by Medela, or Lact-Aid). (I carry the SNS if you can't find it in your area -- the price is $35.00 plus $3.50 shipping). These tube-feeding devices allow you to deliver formula while the baby is nursing at the breast, and your breasts receive stimulation at the same time. Most babies will accept the supplemental feeding systems because they are receiving a steady flow of milk with each suck, much as they would with a bottle. As your milk supply increases, the amount of supplement will level off while your baby continues to gain weight. This means that your supply is filling the gap, and you can gradually reduce the amount of supplement offered. In the meantime, your baby is feeding at the breast and you can enjoy the physical closeness of the nursing relationship, regardless of the amount of breastmilk that he is receiving.

Inducing lactation, which is the process involved in nursing an adopted baby, is more challenging than relactating. You will find that there is a lot of contradictory information out there about inducing lactation. I think that's because there are no exact answers about a "right" or "wrong" way to do it. Relatively few mothers have tried adoptive nursing (many people are surprised to know it's even possible) although the numbers are increasing as the many nutritional and emotional benefits of breastfeeding become more well known. What works for one adoptive mother may not work for another, so a lot of the research has been on a trial and error basis.

Breastmilk production is a function of the pituitary gland. When your breasts receive stimulation, either from the baby or a pump, signals are sent to the pituitary gland to start producing prolaction (the hormone that makes the milk) and oxytocin (the hormone that releases the milk). During pregnancy, breast changes occur over a period of 4-5 months. These changes are, of course, not present in the adoptive mother. Sucking stimulation can cause these changes to occur over a much shorter period of time, but the supply builds very slowly. Because your body doesn't have the benefit of these hormonal changes during pregnancy, much more sucking stimulation is needed to induce lactation than it takes to establish lactation after giving birth. Previous breastfeeding experience (or lack of it) is not a major factor in inducing lactation.

It is important to have realistic expectations. An adoptive mother may or may not ever produce a full milk supply. Most women will produce some milk, some produce a full supply relatively quickly, and some never produce milk at all. The majority of adoptive mothers will not produce enough breastmilk to adequately nourish their baby without supplements. How much you produce depends on many factors, such as the baby (his age, sucking needs, previous feeding experience, and temperament; how frequently and effectively you stimulate your breasts (type of pump used, baby's willingness to suckle, how often you are able to find time to pump/nurse, etc.); your individual response to stimulation, since each mother's body chemistry is unique; and how long you have been nursing or pumping (some mother's supplies build slowly, then level off; some keep increasing for many months or years).

Since nursing involves so much more than just transferring milk from breast to baby, many adoptive mothers find that the act of nursing, with the physical and emotional closeness it brings, is just as important as the amount of milk the baby actually receives. Even if you produce only small amounts of breastmilk, your baby will get significant benefits from both the milk itself and the security and warmth of nursing at the breast.

The following is what I recommend for the mother who has 6 months or more to prepare for her baby's arrival (this plan can be modified for mothers who have less time to prepare):

  1. Start taking birth control pills that contain both estrogen and progesterone continuously, without the usual one week break each month. This simulates the high levels of these hormones that are produced during pregnancy, and stimulates breast development.
  2. Two weeks before the baby's arrival (or immediately afterward if you don't have advance notice), begin taking either Reglan (10 mg, 3 times a day -- call your OB for a prescription) or Domperidone (10 mg 3 times a day, increasing to 20 mg 4 times a day after you have been taking it for a few weeks) See the previous section for more information on these medications.
  3. Two weeks before the anticipated birth of the baby, stop taking the birth control pills and continue taking the Reglan or Domperidone. Start expressing milk with a hospital grade electric double pump, like the 015 Classic by Medela. These pumps are too expensive to buy, so most moms will rent them. (See previous section for more information on how to obtain a Classic pump). Try to double pump for at least 8 times a day, and remember, you're going for stimulation. Don't get discouraged by the amount of milk you're producing, because it may take weeks for you to see results.
  4. Once the baby is born, put him to the breast using a supplemental feeding system (SNS by Medela, or Lact-Aid). These tube-feeding devices allow you to deliver formula while the baby is nursing at the breast, and your breasts receive stimulation at the same time. Most babies will accept the supplemental feeding systems because they are receiving a steady flow of milk with each suck, much as they would with a bottle. Babies older than 3-6 months are often resistant to any feeding method other than a bottles, while younger babies tend to accept the breast more readily. As your milk supply increases, the amount of supplement will level off while your baby continues to gain weight. This means that your supply is filling the gap, and you can gradually reduce the amount of supplement offered. In the meantime, your baby is feeding at the breast and you can enjoy the physical closeness of the nursing relationship, regardless of the amount of breastmilk the baby is receiving.

It is important to monitor the baby's weight gain to ensure that he is receiving enough milk. Since he will most likely need to be supplemented in order to ensure adequate nourishment, using a tube feeding device at most nursing sessions will ensure that he receives the milk he needs and also reduce the time you spend supplementing. Preparing a whole day's supply of formula and feeding equipment can save time and energy. As you replace the formula supplement with your own milk, you need to proceed slowly, decreasing the amount by no more than 25 ml per feeding (a little less than an ounce). Monitor urine and stool output and weight gain for about a week before decreasing the supplement again.

These are general guidelines for inducing lactation. Individual responses will vary. The most important thing to keep in mind is that it is possible to establish a very close and rewarding nursing relationship with your baby, regardless of the amount of milk you produce.

There is a great website for adoptive nursing moms, and you might find some answers there, as well as lots of support. The address is: www.fourfriends.com/abrw/ (ABRW stands for Adoptive Breastfeeding Resource Website).

Anne SmithAnne Smith, IBCLC has breastfed a total of six children (three boys, three girls). She feels that her first hand experience plus her more than twenty years experience of counseling nursing mothers are among her most important credentials. Anne has been a La Leche Leader since 1978 and IBCLC since 1990. As a nursing mother, LLL Leader, and IBCLC, Anne has worked in many areas over the years. She has led support group meetings, taught breastfeeding classes, trained breastfeeding peer counselors to work with low income mothers, worked one-on-one with mothers to solve breastfeeding problems, helped thousands of mothers with breastfeeding questions over the phone, held workshops for health professionals on various breastfeeding topics, taught OB, Pediatric, and Family Practice Residents breastfeeding at Bowman Gray School of Medicine, and run a breast pump rental station with over 100 pumps, scales, and nursing bras for the past eleven years. We invite you to visit Anne's website.

Copyright © Anne Smith. Permission to republish granted to Pregnancy.org, LLC.