Q. Is it possible to nurse an adopted baby?

A. Even in the absence of lactation, a nursing relationship can be established between an adoptive mother and baby.

Q. Is it possible to lactate in adoptive nursing?

A. With adequate suckling stimulation of the breasts, some lactation can be induced, even in the absence of prior lactation or pregnancy. Amounts may vary from just droplets in some women, to more significant amounts in others. Maternal factors and infant factors affect whether and to what extent breast milk will contribute to the adopted infant's nutrition.

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Methods to Induce Lactation

Q. How is lactation induced in the non-lactating woman?

A. Various techniques have been used to stimulate the breasts. Massage techniques included breast massage, nipple massage, manual expression, back massage, and hot or cold packs on the breasts. Sucking stimulation included use of manual or electric breast pump, suckling a borrowed baby (which is not advisable due to potential cross infection and frustration to the borrowed baby), suckling by the SP (spouse/partner) and of course, suckling by the adopted baby.

The most helpful techniques prior to adoption seem to be manual massage of the breasts and manual expression. This may provide some stimulation, but experience seems to indicate that its advantage may be more that the contact of self-manipulation fosters a familiarity and relaxed feeling towards breast function, as well as to strengthen the psychological factors contributing to the mechanism which triggers lactation. It can also be helpful as a method of correcting flat or inverted nipples and to make nipples supple for nursing.

Many couples noted that assistance from the SP with breast massage and manual expression, as well as suckling by the SP, seemed to create a close bond between them prior to adoption. This is similar to experience described by couples participating in prenatal childbirth classes and exercises in which the SP has an active role in birth preparations and delivery.

Q. Can drugs induce lactation or increase the milk supply?

A. There is no safe drug readily available to specifically induce lactation or build up the milk supply. Some tranquilizers can cause lactation as a side effect in some women. However, determining appropriate dosage and predicting possible effects are so difficult as to make it unadvisable. Such use has not been common since the mid-1970s. It is known that estrogen and progesterone stimulate proliferation (increase in number and size) of the alveoli and ducts of the breasts, as during menstruation and just prior to menses in the menstrual cycle. However, these hormones also may inhibit lactation. A few adoptive-nursing mothers have received estrogen and/or progesterone prior to adoption to stimulate gland and duct development, with use of the hormones stopped at the time of adoption, or greatly reduced in dosage. Most of these women either had infrequent ovulation or hysterectomy, and it may be reasonable to assume that such hormone use could have been helpful in increasing breast tissues which function during lactation. (For a more detailed discussion of hormone replacement therapy HRT, and adoptive nursing, see RPT011 in the Lact-Aid Online Reports)

The fact that the arrival of the adopted baby in most cases is not revealed until a day or two prior to actual placement of the baby can result in a lengthy indeterminate period of hormone use. This increased potential for possible harmful side effects. Most commonly noted side effects of hormone use were nausea, increased weight due to fluid retention, and depression. The anxiety typical of many adoptive applicants seemed to be greatly intensified as a result. This time factor also increases the potential harmful effects of the use of tranquilizers for inducing lactation.

The administration of oxytocin intra-nasally can be helpful in stabilizing the milk-ejection reflex during the initial period of establishing lactation and promoting increased milk yield. Oxytocin triggers the milk-ejection reflex to assure effective emptying of the breasts at each nursing. It may also stimulate the release of prolactin by the anterior pituitary, which is responsible for milk secretion. In large or prolonged dosages, however, it may also have an inhibitory effect on lactation. Recent information received anecdotally indicates nasal oxytocin is no longer available. This information is being further investigated.

More recent drugs:

• Metoclopromide (Reglan) and related drugs– These were developed for digestive disorders, and have been used to increase or induce lactation, with varying degrees of effectiveness. Several women contacted us to report their experiences while using the drugs. They all described severe (suicidal) depression. They also described the astonishment and anger they felt when they learned later that severe depression is a well-documented risk factor associated with the drugs. Further, they all stated that if their prescribing physician had provided proper disclosure, they would have declined to use the drug.
  
  

   Metoclopramide (Reglan) RE: Side effects reported in the literature include: nausea, diarrhea, headache, dizziness, drowsiness, dry mouth, restlessness or sleeplessness, involuntary movements of eyes, face or limbs; muscle spasms or trembling of hands, personality changes such as depression, and combined with other drugs may cause reactions or impair effectiveness.Dystonic and diskenetic reactions including tardive diskenisia, a Parkinson's like disorder, and can occur with relatively brief therapy at low doses. Dystonia is defined as impairment of muscular tone and dyskinesia is impairment of the power of voluntary movement, in other words, involuntary, irregular muscle contortions. Dystonic effects occur in about 25% of young adults aged 18-30 years of age. Other effects include cardiac dysrhythmias. For more detailed information on Metoclopromide visit the Tardive Dyskinesia Center web site www.tardivedyskinesia.com .

• Fenugreek: This is an herb, which is reported to be high in protein and the B complex of vitamins. It has been used extensively in the Middle East to enhance lactation. It is available as seeds or as capsules, in most health food stores. While individual reports seem favorable, it is important to keep in mind it is anecdotal. We are looking into whether any study of its effectiveness has been conducted.

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Adequacy of Milk Supply

Q. How Long Does It Take For Lactation to Start?

A. With most of the techniques described, onset of lactation varies from one to six weeks, with most occurring after four weeks. Among mothers of the Avery study, who used the Research Model Nursing Supplementer, onset of lactation often occurred in less than two weeks, and in some cases in less than one week. The onset of lactation in this case is defined as the time drops of milk first become evident. Peak volume occurs about 10 to 12 weeks after beginning to breastfeed.

Q. How much breast milk can an adoptive mother provide her baby?

A. In the past, it was believed that a woman already lactating at the time of adoption, and women who had breastfed previously could more easily stimulate an ample milk supply than a non-lactating woman. However, data accumulated since 1969 indicates otherwise. Generally, women lactating into the second year postpartum or later, as in toddler nursing, are not usually able to totally breastfeed a subsequently adopted infant while "tandem nursing" an older non-adopted child. Likewise, women who have breastfed and weaned other infants prior to adopting, in general, do not lactate enough to breastfeed totally without supplements. There have been reports of unusual success, but these are either anecdotal, or mentions in studies with only a few participants, and with essential details omitted or not clearly defined. Also, the duration of time that breastfeeding is unsupplemented, or supplemented with non-liquid foods (solids) is usually not defined or explained. In the Auerbach & Avery study of 240 adoptive nursing women, only 3 reported being able to breastfeed for a period of time without supplements. Based on other data in their questionnaires, it appears that the time period was short, a few weeks at most, then solid foods and/or cup supplements were introduced. Also, it appears that infant weight gain was slow or remained at a plateau during the period of unsupplemented breastfeeding. Of the 240 women, surveyed, however, about two thirds estimated they were providing 50-75% of their babies nutrition as breast milk after some 10 to 12 weeks of nursing.

Q. What if lactation does not occur?

A. A few mothers have adopted babies who loved to nurse. Milk was given by bottle and the feeding followed by nursing at the breast, to the delight of both mother and baby. Two mothers who used the Research Model Nursing Supplementer, and several in the Auerbach/Avery study did not lactate. They used their Lact-Aid Systems to maintain the nursing relationship; so, although not fed by the breast, such babies were certainly nurtured at their mothers' breasts.

Q. What factors affect milk supply in adoptive nursing?

A. There are maternal factors and infant factors related to the adoptive mother's lactation potential.

• Maternal factors include hormonal imbalance affecting number of milk glands, or behavior of milk gland tissue, mammary involution, and frequency of breastfeeding. See below for details.
• Infant factors include a variety of suckling problems, some of which may relate to underlying illness. Babies also grow, and calories requirements increase over time. See below for details.

Nevertheless, even today, some lactation consultants, physicians, and even mothers themselves still present over optimistic opinions on the possibility of attaining a fully adequate milk supply. It appears that they are unaware of, or may disregard known data about fertility disorders, hormonal disorders, and post-lactation mammary involution, and the fact that adopted babies grow, their caloric needs change, and they can exhibit all the same kinds of suckling problems that "homemade" babies may experience.

Fertility and Hormonal Disorders

Many women who adopt have a fertility disorder. Among adoptive women who have given birth and breastfed their "homemade" infants, there have been a significant number who later adopted due to difficulty in becoming pregnant again. These women typically had highly irregular periods, and had difficulty in achieving adequate milk supply for their homemade babies. With the availability of ultrasound and mammography, the opportunity to see inside the breast would likely show that these women have an unusually low amount of glandular development compared to duct development in their breasts, likely due to subtle imbalance in estrogen/progesterone and related fertility hormones.

Among non-adoptive women having problems breastfeeding, in fact, this phenomenon has been well documented. In addition, these women reported few breast changes during their pregnancy, and said they never felt engorgement nor the sensation that their milk was "coming in" postpartum. Some of the women reported that subsequent endocrine testing confirmed such imbalance.

Some women who adopt have pituitary disorders which cause high prolactin levels, which in turn, inhibits ovulation. One might assume incorrectly that these adoptive mothers should produce abundant milk. However, the effect on their estrogen and progesterone balance may negatively effect gland development, and/or cause breasts to act more like "pregnant" breasts than "lactating" breasts. Some women adopt because cystic ovary disease results in PLH, high levels of persistent luteal hormone. Here again, the result is that breasts act more like pregnant breasts. And just as in the general population of nursing mothers, some women have a thyroid deficiency, which has a negative effect on milk supply.

Mammary Involution and Milk Composition

The availability of ultrasound and MRI technology to peer inside the breast has revealed that in the weaning process, milk glands are gradually decreased in number. They are gradually broken down and literally excreted or reabsorbed to restore the breast close to a pre-pregnant state. This "mammary involution" may well be a factor that accounts for the difficulty in achieving a totally sufficient milk supply for an adopted infant. Studies also show that the composition of milk changes from birth and throughout lactation and weaning. In fact, during weaning, as milk ducts break down, some of the material is excreted in the milk provided to the toddler. This has been reported in studies of weaning milk composition. Thus, it may be that the milk volume may increase dramatically when nursing a toddler and a subsequent adopted infant in tandem. The milk composition may be adequately suited to the nutritional needs of a nursing toddler who is receiving other liquids by cup, and eating solid foods in addition to breast milk. However, it may be lacking in some nutrients needed by a younger adopted sibling. For example, several mothers reported they felt certain they were producing abundant milk supply for both babies. However, their younger adopted babies failed to thrive unless provided some supplement. Since the experience was so typical, it is more likely that milk composition was a factor. It is less likely that all the adopted babies had suckling problems causing poor feeding at the breast.

Frequency of Breastfeeding

The number of times in 24 hours that an adopted baby is nursed has a direct impact on ability to lactate to optimum potential. While the "potential" varies from woman to woman, it seems that nursing at least 7-8 times is important for lactation hormones to become dominant over menstrual cycling hormones. Some interesting facts have come from family planning research, and milk composition research. When women reduce the frequency of breastfeeding from 8-10 times a day to less than 6 times a day, menstruation and fertility resume. Also, lactose (sugar), fat, and zinc content of breast milk decreases. On the other hand, sodium (salt), protein, and iron content increase, in direct relationship to the decreases in feeding frequency.

Women inducing lactation have often reported to us that their early lactation secretions are thick, sticky, and rather salty. As lactation increases over time, it becomes thinner and slippery, and becomes sweeter and sweeter in taste. As weaning occurs, they describe how milk becomes salty again as weaning progresses.

Suckling Problems

An infant's suckling may be weak or poorly coordinated, or may involve gum clenching, tongue thrusting, or other aberrant oral disfunction. Underlying illness can cause extremely high caloric requirements. Babies have been diagnosed with severe cardiac disorders, rare respiratory disorders, and cystic fibrosis, for example. Cerebral palsy and related neuro-muscular disorders may result in weak suckling, or the opposite, excessively strong suction, often including gum clenching. Some infants with low weight gain, and repeated otitis media were found to have submucosal cleft of the palate. Depending upon how long some infants were fed by bottle and artificial nipple, they may have habituated to incorrect tongue positioning. They may have learned to tongue thrust, or curl the tongue behind the nipple to divert the flow of liquid, in order to avoid gagging or aspirating. Any of these factors can impair the effectiveness of Baby's suckling the breast. Poor stimulation and inefficient milk removal affects both volume of milk and nutrient content. A weak milk ejection reflex results in reduced fat content of milk. (See About the Adopted Baby for more details.)

Changing Caloric Requirements of Infants

It is important to remember that during the entire period of working to induce and enhance milk volume, Baby is growing. Thus, caloric requirements increase over time! This one factor is perhaps one of the most important to keep in mind when developing goals in adoptive nursing. Whether the adopted baby is newborn, a month old, or 3, 4, or 6 months old at the time of adoption, caloric needs will constantly be changing. Milk supply begins as droplets, and volume increases gradually over time. How much it increases is affected by all the maternal and infant factors described. Peak volume for most adoptive moms occurs after 10 to 12 weeks of nursing. And, as for non-adopted babies, solid foods should be introduced at age appropriate times. In the Auerbach and Avery Study, most mothers introduced solids when babies were about 4 1/2 months old. For a mom adopting an older infant, solids may already be part of Baby's diet.

A reasonable goal in nursing an older adopted infant (3 months ) would be to establish a nursing relationship, with liquid supplement provided via a supplementer, and some nutrition from solids. Any breast milk that might result would be a fringe benefit of the nursing relationship. At some point, it might be reasonable to try to displace the supplementer with cup feeding at an age appropriate time, for babies willing to nurse the breast without the supplementer. A mom adopting a younger infant (newborn to 3 months) might have an edge in terms of providing more nutrition as breast milk, this is assuming all other maternal and infant factors are ideal. At an appropriate time, she would make the transition to mixed nutrition for her baby. The rare moms who establish significant milk supply might be able to "totally breastfeed" if babies remained newborn in terms of their caloric needs. The fact for most is that they just cannot close the gap to catch up to their older, bigger adopted babies' needs.

Q. What are typical results in building milk supply?

A. Unfortunately for women contemplating nursing an adopted baby, there are no "typical" results in building milk supply. Most of the 240 adoptive mothers participating in the Auerbach/Avery study estimated that they were able to supply between 50-75% of their babies' needs after the initial period of building up the milk supply (10 to 12 weeks of nursing). This was estimated by comparing the actual amount of supplement provided with the average intake of bottle-fed infants of similar age and size. Although there have been occasional remarkable exceptions, most adoptive-nursing mothers must supplement formula by bottle, or Lact-Aid®, until the introduction of solids and/or a cup, regardless of the methods used to induce lactation, and regardless of when lactation began, before or after adoption. There are some "typical" patterns in how lactation progresses, which related to fluctuating hormone levels of the menstrual cycle. "Typically", women who were decreasing supplements find that for 2-3 days prior to a menstrual period, the amount of supplement used remains constant (stops decreasing), or they need to provide extra amounts of supplement. About 2 days after menses begins (flow may be normal or spotty), milk supply resumes increasing and supplement begins decreasing, until another "premenstrual plateau" occurs. There are 24-hour variations in milk volume related to changes in prolactin hormones, with volume being higher in the morning hours and lower in late afternoon and evening. (See Managing Supplements for more details.)

Note: At the time of the study, no other commercially manufactured devices were available. Thus, among women who used supplementers, Lact-Aid® System was the device they used. Comparable results with supplementers manufactured by others, and homemade supplemental devices have not been achieved, and reports are only anecdotal. There has not been an in depth study conducted since the Auerbach/Avery study. Several recent reports on women who received drugs to induce lactation have included small numbers of study participants. Also, how long women were able to exclusively breastfeed with no supplements is not clearly stated. We recently received a report suggesting that women who were in a recent study of induced lactation did eliminate formula supplements. However, researchers allegedly did not report that the mothers were providing their infants other foods in addition to breast milk, i.e., use of solids and/or other liquified foods in addition to the breastfeeding. This is being investigated further and will be presented in an update.

Q. What are the physiological effects of induced lactation?

A. Among adoptive-nursing mothers surveyed, many women reported a variety of experiences related to menstruation, and patterns of lactation versus supplementation, appetite and weight changes, and breast changes.

Menstrual Patterns

Many women reported marked effects of induced lactation on the menstrual cycle, sufficient to be of concern for those couples practicing rhythm contraception. Often, complete cycles were skipped, or menses was diminished to almost unnoticeable spotting. Menses tended to occur at longer intervals, with flow diminished and of shorter duration. A few mothers noticed no changes in their usual menstrual patterns. Lactation amenorhea has been most frequently associated with use of the Lact-Aid® System. Women, who tried other devices and then switched, reported that they experienced their normal menstrual patterns with the other device/s. After switching to Lact-Aid® System, they experienced the changes described, including lactation amenorhea.

Lactation versus Supplementation Patterns

In regard to milk supply, many mothers noted a brief, premenstrual plateau or marked decrease in milk supply, or less stable milk-ejection reflex, which lasted 1-3 days, just prior to the onset of menstruation. Lactation would then increase significantly within 2-3 days after the onset of menses, with continuing progress until 1-3 days prior to the next menses. Menses could be normal, very light, or just spotting on a single day. This is likely due to high premenstrual hormone levels, which cause milk glands to enter a proliferative phase of activity instead of secretory phase. In other words, they behave like pregnant breasts, adding more milk glands during proliferation, and "pay less attention" to their job of lactating!

This need to increase supplements can be disappointing for uninformed women who may be feeling stress anyway from the high level of premenstrual hormones. Women who did not have this information have actually burst into tears of frustration when they called for help, thinking they were losing their milk supply after working so hard to establish it. Their relief on learning the facts was intense. Consequently, this information is included as part of Lact-Aid® System instructions. For lactation consultants and health professionals, this information is an essential component of preparatory guidance, to help mothers know what to expect and how to recognize natural sequence of events versus true problems. An informed mother should know the need to increase supplements for a few days is only temporary. In actuality, more milk glands are being developed by the action of the premenstrual hormones and the prolactin her baby's suckling stimulates. A helpful analogy to describe the progress of induced lactation is "milk supply grows in steps; four steps forward and half a step backward." Progress truly is being made, despite occasional needs for extra supplement.

Appetite and Weight Changes

Some mothers experienced a sharp increase in appetite during the initial onset of lactation and build up of the milk supply. Some mothers experienced a sudden weight gain (about 7-12 pounds) the first month of nursing, which is likely due to increased fluid retention. This is probably because oxytocin secreted during lactation has fluid retentive properties. It is thought this effect is to help assure adequate fluid for the breasts to produce milk.

Breast Changes

While a few mothers noticed no breast changes, many described increased firmness and fullness of the breasts, and more protuberant or elongated nipples. Over tie, the glands of Montgomery around the areolas appeared more prominent for most. No mothers reported any marked drooping or loss of esthetic appeal of the breasts during nursing, or after weaning, although some mentioned the breasts seemed softer. A few mothers experienced leaking on occasion from the opposite breast during nursing. Some mothers also experienced milk-ejection and leaking during sexual relations, and felt that the experience tended to enhance the sexual relationship, because the partner/spouse SP regarded it as a sign of full sexual responsiveness.

These physiological effects are not unique to adoptive-nursing, except for the marked effect of the menses upon milk supply. Ovulation and menstruation may be inhibited somewhat in "normal" lactation. In fact, lactation amenorhea is a key factor in natural family planning methods. Interestingly, many women nursing their homemade babies experience a pre-menstrual interval when babies want to "nurse, nurse, nurse" or seem to "fuss a lot" as if they aren't getting quite enough milk. Breast changes are similar in both situations, with the exception that in adoptive-nursing, the marked increase of breast size typical in pregnancy does not occur.

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About the Adopted Baby

Q. Does the age of the adopted baby affect nursing success?

A. Ideally, the adopted baby should be as young as possible, as the nursing reflexes are stronger in the younger baby. Bottles given to a baby in the hospital or foster home can change the sucking action of the mouth and jaw so that nursing is not as efficient or as vigorous as the baby who has had very few, or no bottles. Rooting behavior is also diminished in time by use of bottles. Improper suckling caused by artificial nipples can impair an infant's ability to correctly suckle the breast. Thus, nipple confusion (fussing, gum clenching, tongue thrusting, and losing grip of the nipple) is often perceived as breast rejection.

Q. Can an older baby be taught to nurse the breast?

A. Adopted babies from newborn up to 18 months and older have been very successfully taught to nurse. Most nursing babies in the 1971 Avery survey were under one month, though several over three months participated in successful nursing relationships. Most nursing failures with babies under 3 months resulted from excessive bottle supplements which caused nipple confusion, while those mothers who used the Research Model Nursing Supplementer appropriately (for almost all feedings) were nearly all successful in establishing and maintaining nursing relationships. Nursing of the older baby (over 3 months) is obviously more for the enjoyment of the relationship than for possible benefits of the breast milk (except when milk allergy is apparent). Mothers are advised to regard any amount of breast milk produced as a "delightful fringe benefit" of the relationship established. By making the introduction to the breast a gradual and pleasant experience for the baby with the Lact-Aid® system, many babies over 4 months old, and others older, up to 18 months old have participated in nursing relationships. In the early 1970s, there were a high number of Korean and Vietnamese adoptive infants, most of whom were 4 to 6 months old.

Valuable feedback from these and other mothers, as well as from lactation consultants has been compiled into helpful instructions on teaching older and reluctant infants to nurse at the breast. The pamphlet, "Helpful Hints for Using Your Lact-Aid Nursing Trainer™ System is included in every Lact-Aid® System. The full text will also be available to you online soon. Watch "Updates and Revisions" for announcements of availability.

Q. Can the adopted baby have problems that affect breastfeeding?

A. Just as in breastfeeding homemade babies, adopted babies can have suckling problems such as weak or poorly coordinated suckling, cleft lip/palate, Down Syndrome and other facial anomalies, cerebral palsy and dystrophic disorders. Some infants may have communicable infection such as hepatitis B, herpes, and aids, which would make it inadvisable to breastfeed. Some infants may have an illness resulting in weak suckling. Infants have been diagnosed with cystic fibrosis, rare lung disorder and cardiac problems, all of which required very high calorie intake as well. Ear infection and thrush can make suckling painful for Baby. Sinus problems can make breathing difficult during suckling. All these situations require specialized support and guidance from the infant's physician as well as the lactation consultant.

Q. How do you get a baby to nurse if the mother is not lactating, or has very little milk at the time of adoption?

A. A few babies enjoy suckling enough to cooperate to nurse even the dry breast for an extended period of time. However, most will refuse to nurse a dry or empty breast after a moment or two. The repeated frustration experienced by a hungry baby can condition the baby to finally reject the'breast completely. Adoptive-nursing mothers have used many techniques to coax a baby to nurse dry or inadequately producing breasts.

• Flavoring the breast by applying honey or syrup to the nippless.  Honey should not be used as it can cause botulism in infants.  Medicine droppers have been used to drip milk, formula, or sugar water onto the nipples, or inserting it into the infant's mouth along with the nipple of the breast.
• Avoiding artificial nipples. Feeding only with a cup, spoon, or dropper, and avoiding use of pacifiers, so that an infant will seek to satisfy sucking needs at the breast.
• Starving out. This was reported in some cases to maintain a constant hunger state in order to force more frequent and prolonged nursing. This was done by offering highly diluted formula to keep baby hungry. In some cases it was intended to make baby hungry. In other cases, it was accidental, as a result of efforts to decrease or eliminate supplements as lactation increased. In the latter situation, babies were simply offered less and less over a period of time, usually offering a specific amount less each feeding, or gradually eliminating supplements at one feeding, then another, and so on.
• Either of these methods are dangerous practices, which have on occasion resulted in severe starvation of the babies involved, and are not advisable in any circumstance. People involved in the cases that were reported included not only the adoptive mothers, but their lactation advisors and even some physicians.

It had been assumed by the mother, her ob-gyn, her lactation consultant, and her breastfeeding acquantances that since lactation was successfully initiated, the milk supply would increase as rapidly as it does among non-adoptive mothers following childbirth. They also had assumed that if babies become hungry, they will cry to signal that they need to be fed. It was the pediatrician in the case described who explained starvation physiology. He described how gradual underfeeding produces a placid condition. Starved babies do very little crying, and even if they may be willing to suckle, and suckling time may be prolonged, their suckling is weak and inefficient. Also, in gradual starvation, babies may not look underfed until a critical point is reached. That is because kidneys continue to output normal volumes of liquid, and it is only when the kidneys begin drawing fluids from body tissues that dehydration signs suddenly become visually evident.

Nursing Supplementers. A method that has proved to be both successful and mutually enjoyable for teaching a baby to nurse at the breast is the Lact-Aid® Nursing Trainer™ System. This is a unique device designed to supplement the nursing infant at the breast. It consists of a pre-sterilized disposable bag to contain appropriate supplement. It has a special closure, from which extends a length of very soft, clear, very fine flexible tubing. The device is worn discreetly under clothing, suspended between the breasts by means of an adjustable Neck Strap.

As Baby suckles the tip of the tube and the nipple of the breast simultaneously, the flow of supplement acts as a natural incentive stimulus to suckle. The actual suckling behavior is not distinguishable in any way from the typical nursing baby. This provides the breasts with highly effective stimulation to induce lactation and increase the milk supply.

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Managing Supplemental Feeding

Q.How is a baby fed adequately if the mother is not lactating or milk supply is not adequate?

A. The same techniques described have been used for feeding, as well as coaxing the baby to nurse. Also used for feeding were the following: rubber bulb syringe with a tube attached and held in position by hand, hypodermic syringe with tube attached, and plastic bottle with narrow spout such as used in hair tinting application. Of the various methods described, the Lact-Aid® system is the only one that does not interfere with the normal infant behavior typical of nursing. As there is no exposure to artificial nipples and suckling effort is rewarded, there is no frustration or negative conditioning to cause rejection of the breast. The compact design of the device makes it possible to provide up to 4.5 ounces of supplement at the breast quite discreetly by even the small-breasted woman. Nursing can be spontaneous as unsupplemented nursing by attaching the device to the Neck Strap prior to each subsequent feeding, by which time the cool supplement will be body temperature.

Q. How can you tell milk supply is increasing and how do you decrease supplements?

A. Breasts will feel fuller and firmer. Baby's stool will become softer. Milk curds in the stool will appear less like cottage cheese and have a smaller grainy texture. Stool color will be lighter. Weight gain will be appropriate. Baby may settle into a pattern of going longer between morning feedings, but nurses more frequently in the afternoons. Baby may be satisfied to nurse the first 1-2 feedings of the day with no supplement, or if using Lact-Aid® System, will leave some supplement in the nursing bag after feedings.

To decrease supplements when these signs are present, do the following:

1. Watch Baby's swallowing pattern closely. Notice if Baby has a beginning interval of evenly paced swallows. This will be followed by a period of rapid swallowing. During this interval, the Lact-Aid® nursing bag will stop flattening. This is because a milk ejection reflex MER has occurred, and Baby is swallowing mostly breast milk. Thus there is very little suction on the Lact-Aid® Nursing Tube. After a few minutes, swallowing will become much, much slower. Baby has obtained most of the available breast milk on the first breast and is now drinking mostly supplement from the tube.
2. This is the signal to switch sides to the other breast, where the MER has made breast milk readily available. Baby will begin rapid swallowing. The frequent "expressing", (open/close movement of tongue and jaw) will likely stimulate another MER. When swallows slow down again….
3. Switch back to the first breast. Do this several times to take advantage of multiple MERs that will likely occur, and minimize the amount of formula supplement taken.
4. Notice which feedings Baby is leaving supplement in the bag. Or
5. If Baby still takes the entire supplement, but begins waiting longer between feedings to nurse, you will know at which feedings you are producing the most milk.
6. Concentrate on those 1 or 2 feedings to begin nursing first, without the Lact-Aid® System. Nurse both breasts and switch sides until Baby lets you know more supplement is needed. Then follow with the Lact-Aid® System to finish the breastfeeding. In this way you can, over time, graduate from some or most supplemented feedings.

Q. Can supplemental feedings ever be eliminated?

A. Peak milk production is achieved by the adoptive-nursing mother occurs on the average at 12 weeks after onset of lactation. At that point, the adopted baby may be nursing half or most feedings without supplements, or requiring small amounts, or large amounts of supplement at each feeding. Upon the introduction of solids, supplementary milk or formula can be significantly reduced. Care must be taken to assure adequate liquids if milk supply is quite low, however, by using a Lact-Aid® System. It is important to keep in mind the individual mother's lactation potential, taking into account any fertility or hormonal factors and any infant factors. Some adoptive mothers are also women who work outside the home and must return to work after their adoption leave. So, for them, milk supply issues should be of less importance than guidance in maintaining the nursing relationship. Keep in mind that women nursing their homemade babies, will be giving their infants mixed sources of nutrition, when solid foods, and liquids by cup are introduced at appropriate stages in their infants' development. For adoptive nursing mothers, a similar goal is far more realistic to work towards, than some arbitrary number of weeks or months of unsupplemented breastfeeding.

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Preparing to breastfeed

Q. How should an adoptive mother prepare for nursing?

A. A comparison of successful and unsuccessful adoptive-nursing mothers indicates that the following practices contribute greatly to the successful establishment and maintenance of the adoptive-nursing relationship:

1. Learn about breastfeeding in general by reading, and associate with happily nursing mothers. Contact a nursing mothers support group or lactation consultant for guidance.
2. Learn about adoptive-nursing by reading, and network with other adoptive-nursing mothers.
3. Perform some kind of breast and nipple manipulation for at least one month prior to adoption if at all possible. This should be done a few times daily as when changing clothes and bathing, in a relaxed, casual manner in order to avoid undue emphasis on lactation per se. Experience indicates that at least one month of such preparation helps mothers become emotionally attuned to the giving, touching, intimacy of nursing. Studies of prolactin secretion compared infant suckling, self stimulation of the breasts, suckling by a spouse/partner SP, and breast pumping. Next to baby, self stimulation by massage or stroking scored next highest. Breast pumps scored the lowest.
4. In the Auerbach/Avery study of 240 adoptive mothers, women who used no breast pumping at all, did as well in terms of milk supply as women who pumped faithfully prior to receiving their adopted baby. Breast pumping seems to be of more importance and value for women breastfeeding their homemade babies in adverse situations and while working. Today, there are new types of breast pumps with alternating suction levels, double pumping of both breasts simultaneously, and soft milk collection funnels. There is, however, very little data available on their advantages for adoptive nursing. We are currently providing known data, and encourage mothers who choose to try pumping to keep us informed of their experiences.
5. Share breastfeeding and adoptive-nursing information with the spouse/partner SP, who in turn should provide encouragement and support, and even assistance with breast preparation, if possible.

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Making the Decision

Q. Should a mother try to nurse an adopted baby?

A. The following conditions represent in general the attitudes, motivation, and preparations of those mothers who were successful in establishing and maintaining an enjoyable nursing relationship. The mother who contemplates adoptive-nursing with similar attitudes and motivation may certainly be well advised to proceed in efforts to nurse, if:

• she has a firm belief in the value of the close mother-child relationship inherent in nursing;
• she has educated herself and her SP as fully as possible regarding both breastfeeding and adoptive-nursing;
• she has the full support and encouragement of her SP (In the initial Avery survey, almost every mother failed whose SP was indifferent or opposed to adoptive-nursing).
• she has sufficient self-confidence and determination to overcome possible negative response from friends, relatives, or other persons;
• she will have time to provide unrestricted nursing on demand; (This has since been revised to nursing at least 7-8 times per 24 hours. However, nursing/working moms and busy, highly active lifestyle moms have had happy nursing experience nursing less frequently. In adoptive nursing, milk is not the important issue as much as being able to establish and maintain a happy nursing relationship that benefits the entire family.)
• she will avoid use of bottles when company calls or when away from home with the baby; (When bottles are needed, we recommend an orthodontic nipple, to minimize nipple confusion.)
• and ideally, if she has the warm support of a physician favorable toward breastfeeding. (Wonderful, but not totally necessary. Many unsupportive physicians have received a lovely education on breastfeeding by the examples of their adoptive nursing moms who chose to stay in their practices!)
• Finally, keep in mind that women have had positive experience despite the fact that they did not meet all of these criteria! The decision to try or not is, after all, up to the individual mother.

 Q. Should a mother be discouraged from trying adoptive nursing?

A. The following conditions represent in general the attitudes, motivation, and preparation of those mothers who failed in establishing and maintaining an enjoyable nursing relationship. In the past, we thought that the mother having similar attitudes and motivation should probably seek other ways to create a close relationship with her adopted baby than through nursing, if:

• she has focused her interest in nursing primarily on the nutritional benefits of breast milk, and/or upon lactation as a measure of feminine function, with little concern or recognition of the beneficial emotional aspects;
• she has not availed herself of the information available regarding adoptive-nursing or breastfeeding; (It is never to late to learn. Some mothers put their babies to breast just to comfort the baby, and later found out about "adoptive nursing", then wanted to know more!)
• she has a spouse/partner who is overtly opposed or indifferent to her nursing efforts; (Some women did what they thought was best, and had a positive nursing experience!)
• she has had difficulties in nursing "home made" (non-adopted) offspring prior to adoption; (Some women did amazingly well nursing adopted babies, however! Just as in nursing mothers in general, many women who did not "successfully" nurse prior babies, subsequently had wonderful breastfeeding experiences due to good information and support!)
• and she has an extremely active social life which will impose frequent bottle feedings and will neither alter such social activities, nor learn discreet methods of nursing in order to assure the maintenance of the nursing relationship. (Here again, every family is unique, and there have been some who ended up having very positive breastfeeding experiences, nursing only a few times a day! Babies seem to be amazingly adaptable!)

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IN CONCLUSION

While there is ample evidence as to the nutritional and health advantages of breast milk, nursing is much more than a feeding technique in fact and by definition. Just as "cup feeding", or "spoon feeding", or "bottle feeding" cannot be found in most dictionaries, if at all, the term "breast feeding" likewise cannot be found. However, "nursing" is defined as:

"…synonymous with nourish and nurture, and means ... to nourish at the breast, suckle, or feed and tend an infant; to take care of; to care or provide for tenderly; to cherish; to foster; to bring up or rear care; to promote the growth or development, or progress; to hold in one's hand, to caress, to fondle…" Webster's New International Dictionary

From a purely nutritional approach, successful adoptive-"breastfeeding" occurs when an adoptive baby is totally breast fed, with no supplements of any kind provided after the initial period of building up the milk supply, with introduction of solids and cup delayed to age four to six months. Adoptive-nursing mothers rarely attain this. In the Auerbach/Avery study, less than 1% achieved this, and weight gains of their infants was questionable or poor, during the interval between stopping liquid supplements, and introducing solid foods. Most introduced solid foods to their adopted infants at 4 ½ months of age.

However, according to the definition of "nursing", a successful adoptive-nursing relationship consists of a happy bond of love and communication between the adoptive mother and baby. Thus, adoptive mothers especially should be counseled that any amount of milk produced is to be regarded as a delightful fringe benefit of that communication and love, rather than the primary goal.

The woman who has always longed to nurse a baby, and the woman who has shared an enjoyable and fulfilling nursing relationship with home made infants can certainly be expected to derive a great deal of fulfillment from an adoptive-nursing experience. Also, she can provide a unique kind of close mothering not available to most adoptive babies. Among those mothers who failed to lactate or continue an adoptive nursing relationship for more than a few weeks, almost all expressed the opinion that their efforts to nurse stimulated a close maternal bond with the baby.

While nursing can be a mutually fulfilling experience for a mother and child, related biologically or by adoption, not all mothers want to nurse and not all mothers who try enjoy the unique kind of closeness inherent in the act of nursing a baby. Therefore, emphasis should focus on obtaining adequate information about breastfeeding and adoptive-nursing prior to adoption. The woman contemplating nursing an adopted baby must be fully aware that any nursing relationship, biological or adoptive, entails a great deal of intimate skin contact between mother and baby. Furthermore; nursing requires between 20-30 minutes per feeding for the young baby under three months, often at 21/2 to 3 hour intervals; and, that bottle supplements must be avoided as much as possible in order to maintain the nursing relationship.

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 Data Sources 

The material included here is based upon information gathered from a variety of sources, 1971 to 1998.

Surveys.

• 1971: Avery Relactation Survey. Early in the development of Lact-Aid® System I conducted a survey of 32 adoptive nursing mothers. Most ,29, used the Research Model Nursing Supplementer (RMNS) The RMNS was the testing model for the Lact-Aid® Nursing Trainer™ System, a unique nursing supplemental device to aid breastfeeding. Three used bottles to supplement.
• 1971: Avery Adoptive Nursing Motivational Survey. A motivational survey of 32 women who were planning to nurse adopted babies.
• 1978: Auerbach and Avery Relactation Survey. Kathleen Auerbach, Ph.D. and I conducted a massive study of relactation and induced lactation for J.J. Avery, Inc., who was then the manufacturer of Lact-Aid® System. The results of the study of 606 women included 240 adoptive mothers, and the remaining 366 participants were other types of relactation/induced lactation situations (premature, hospital separated, untimely weaning). Reports based on the study are available from Lact-Aid Bookstore, and summaries have appeared in various medical journal articles. (See Bibliography at the end of this FAQ Report).
• 1985 to date: Avery Comparative Survey of Supplementer Users. This is an ongoing comparative survey of women who have used other types of supplementers then switched to Lact-Aid® System. (Available online as RPT021. in our Online Library)

Other data sources.

• Data presented here is also based on frequent reviews of medical and paramedical literature concerning abnormal lactation, induced lactation, breastfeeding, infant development, and adoption.
• My personal experience includes nursing my two adopted babies.
• For more than 28 years I have been a lactation consultant, medical author, editor, publisher, lecturer, trainer, and health educator.
• Additional data has been acquired via communication with physicians, scientists, medical researchers and educators, and other lactation consultants, 1971 to the present.
• Extensive correspondence and consultations with Lact-Aid clients, 1971 to the present has yielded massive data as well..

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BIBLIOGRAPHY: 

• AHSF: AHFS Drug Information 1998. American Hospital Formulary Service, p. 2442, 1998. (lists cautions & drug side effedts for metoclopramide)
• Applebaum, Richard M. Abreast of the Times. Miami: Applebaum, 1969.
• Applebaum, R. "The Modern Management of Successful Breastfeeding," Pediatric Clinics N. Amer., 17: (l) 203-225, Feb. 1970.
• Auerbach, Kathleen G., Ph.D.; Avery, Jimmie Lynne: Nursing the Adopted Infant: Report from a Survey. RHNI Monograph M005. Resources in Human Nurturing, International, Denver, Colorado. 1979. Reprinted: Athens, Tennessee, Lact-Aid International, Inc, 1983. This report is based on their 1978 study of 240 adoptive mothers.
• Avery, J.L.: A Discussion of an Adoptive Nursing Survey. A pilot market research study of 32 women. 1971.
• Avery, J.L.:A Brief Discussion of Adoptive-Nursing., Athens, Tennessee. 1984 (Out of press, 1998)
• Avery, J. L.: Ovarectomy, HRT and Breastfeeding Adopted Infants. Report R011. Athens, Tennessee. Lact-Aid International, 1998 https://www.lact-aid.com/
• Avery, J. L: Lact-Aid Excellence: a survey of women who switched to Lact-Aid Nursing Trainer™ System after first using another system. Publication P121. Athens, Tennessee. 1997.
• Avery, J. L: Unpublished Data, Research and Development of a Nursing Supplementer. Denver, Colorado, J. J. Avery, Inc.1969-1983.
• Avery, J. L: Unpublished Data, Market Research and Confidential Data of Lact-Aid Clients. Athens, Tennessee. 1983-1998
• Avery, J. L: Unpublished Data, A Survey of Women Planning to Nurse Their Adopted Babies. Denver, Colorado 1973
• Avery, J. L. Induced Lactation: A Guide for Counseling and Management. Denver: J. J. Avery, Inc., 1973.
• Avoron, et al.: "Increased incidence of levodopa therapy following metoclopramide use", in JAMA, 274:(22)1780, Dec 13, 1995.
• Baguely, W.A., et al: "Cardiac dysrhythmias associated with the intravenous administration of ondansetron and metoclopramide." Anesth Analg. 84(6):138-1 June 1997.
• Berde, Botond. Recent Progress in Oxytocin Research. Illinois- Thomas, 1959.
• Blacker, K. "Mothers Milk and Chloropromazine," Am. J. Psych., 119:(2) 178-79, Aug. 1962.
• Davis, H., R. R. Sears, H. C. Miller and A. J. Brodback. "Effects of Cup, Bottle, and Breastfeeding on Oral Activities of Newborn Infants," Pediatrics, 2:549, 1948.
• Cope, E.: "Galactorrhea," Practitioner, 200:692, May, 1968.
• Cope, E.: "Ovarian morphology in amenorrhea-galactorrhea" Amer. J. Obstt.Gyn., 1968.
• Emde, R., Koenig, K.: Study Film of a Nulliparous Lactating Mother Breastfeeding Her Adopted Infant.. Denver: Infant Development Research lab., Univ Colorado. Med. School. May, 1970.
• Foss, G. L. and D. Short, "Abnormal Lactation," 1. Obstet. Gynaec. Brit. Emp., 58:35,1951.
• Garza, C., et al: "Changes in the nutrient composition of human milk during gradual weaning." Am. J. Clin. Nutr. 37:61, 1983.
• Gunther, Mavis. "Instinct and the Nursing Couple," Lancet, 268:1024, 1955.
• Hartman, P. E., and Kulski, J. K.: "Changes in the composition of the mammary secretion of women after the abrupt termination of breastfeeding." J. Physiol. 275:1, 1978.
• Huntingford, P.J., "The Inter-relationship of Pituitary Hormones and Maintenance of Lactation," J. Obstet. Gynaec. Brit. Comm., 70:929, 1963.
• Kapell, A.: To all intrested in breastfeding an adopted baby. A commentary on the hazards of starvation as a method to induce lactation. Michigan. Kapell, 1971.
• Ibrahim, M. and N. Z. El-Tawil. "The Effect of a New Long-Dosage Oral Contraceptive Pill on Lactation," lnt. Surgery, 49:561-565, 1968.
• Israel L.: Menstrual disorders & sterility. 5^th Ed. New York: Hoeber, 1967.
• Jeliffe, Derrick. Infant Nutrition in the Tropics and Subtropics. Geneva: World Health Organization, 1968.
• Jeliffe, D. B. and E. F. P. Jelliffe. "Non-Puerperal Induced Lactation," Pediatrics, 50:171, July, 1972.
• Kaern, T. "Effect of an Oral Contraceptive Immediately Post Partum on Initiation of Lactation," Brit. Med. J., 3:644, 1967.
• Khazan, N. "The Mammotropic Effect of Tranquilizing Drugs," Arch. lnt'l Pharmacodyn.136:(34) 290-305,1962.
• Le Leche League International. The Womanly Art of Breastfeeding. Franklin Park, Ill., LLLI, 1958.
• L.L.L.I. Nursing an Adopted Baby. Information Sheet No. 55 A. Suerth, Ed., LLLI, 1972.
• L.L.L.I. Relactation Aids. Information Sheet No. 69-B. J. Kahrl, Ed., LLLI, 1972.
• Marmet, C., and Shell, E.: "Training Neonates to Suck Correctly," MCN. 10:401-47, Nov/Dec 1984.
• Mobbs, G.A., and Babbage, N.F.: "Breastfeeding adopted children." Med. J. Aust. 2:436-437, 1971.
• Neifert, M.D.: "Lactation Failure Due to Insufficient Glandular Development of the Breast,". Pediatrics. 76:823-28, 1985.
• Neville, M. C., and Neifert, M. R., Eds.: Lactation: Physiology, Nutrition, and Breast-Feeding. New York, Plenum Press, 1983.
• Newton, Michael. "Human Lactation." Milk, The Mammary Gland and Its Secretion. Kon & Cowie, Eds. New York: Academic Press, 1961.
• Newton, M., and G. Egli. "Intra-nasal Oxytocin," Amer. 1. Obstet. Cynec., 76:103, 1958.
• Newton, M., and Niles Newton. "The Normal Course and Management of Lactation," Clinical Obstet. Gynec. 5:(l), March, 1962.
• Ojofetimi, E.O.: "Effect of duration and freqency of breastfeeding on ostpartum amenorrhea." Pediatrics. 69:164, 1982.
• Pasteels, J.L., Robyn C. (Eds). Human Prolactin. New York/Amsterdam: Excerpta Medica/American Elsevien, 1973.
• Phillips, Virginia. "Establishment of Lactation for the Breastfeeding of an Adopted Baby and Re-establishment of Lactation After the Weaning of a Breast-Fed Baby," Research Bull. of Nursing Mothers Assn. of Australia, June, 1971.
• Selye, H. and T. McKeown. "The Effect of Mechanical Stimulation of the Nipples on the Ovary and Sexual Cycle," Surg. Cynec. Obstet., 59:886, 1934,
• Vorher, H.: The breast, morphology, physiology and lactation. (Section "C. Breast involution postlactation." Pp 212 -216) New York: Academic Press, 1974.

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Disclaimer: The information presented here is for educational purposes only, and is not intended to provide or substitute for medical advice in any way. Anyone with a health question about breastfeeding, induced lactation, relactation, medications, adoption or for any other reason should discuss it with their physician.