Induced Lactation

Abstract

Although a small minority in the United States, a num-

ber of adoptive mothers continue to seek information

regarding the induction of lactation. Because of the

level of support needed by these women to successful-

ly induce lactation, it is necessary for nurses and other

healthcare workers to gain a thorough understanding

of the various processes and medications frequently

used. Often, women who induce lactation cannot pro-

duce enough milk to exclusively breastfeed their infant

but find satisfaction in this rigorous process because of

the maternal-infant bonding it promotes. The adoptive

mother seeking to induce lactation is a unique client in

need of highly tailored and personalized care.

Key Words: Breastfeeding; Lactation; Induced; Milk;

Human; Adoption.

Induced LactationGaining a BetterUnderstanding

Sarah L. Wittig, Student Nurse, and Diane L. Spatz, PhD, RNC, FAAN

This article explores the process of inducing lactation forwomen who adopt infants. Nurses are well aware ofthe superiority of breast milk for infant feeding, but be-cause induced lactation is rare, little has been writtenabout it in the nursing literature.

It is difficult to measure the number of adoptions takingplace in the United States because there are so many differ-ent methods of adoption (private, public, domestic, interna-tional). Citizenship and Immigration Services keeps exactnumbers on international adoptions only; there are no oth-er comprehensive data available (Beauvais-Godwin & God-win, 2005). The latest statistics seem to indicate that thereare about 100,000 nonrelative adoptions in the UnitedStates each year (Beauvais-Godwin & Godwin, 2005). Asadvocates work to increase the proportion of mothers whobreastfeed, it is crucial that they not ignore an especially in-terested group of potential breastfeeding women. Althoughan extremely small population, adoptive mothers wishingto induce lactation exist, and they require significant sup-port from knowledgeable healthcare workers. These moth-ers may face numerous questions and challenges from themedical community.

Inducing lactation is the process by which a woman whohas not been pregnant with the infant she intends to breast-feed and who is not currently breastfeeding another childproduces breast milk (Cheales-Siebenaler, 1999). Historical-ly, induced lactation has been used as a method to providenutrition to infants of mothers who either could not breast-feed or who died in childbirth; however, current interest ismostly by adoptive mothers desiring to breastfeed theiradopted infants (Biervliet, Maguiness, Hay, Killick, &Atkin, 2001). Many nurses remain unfamiliar with the

76 VOLUME 33 | NUMBER 2 March/April 2008

techniques, preparation, effort, motivation, andsupport required by a woman and her family tosuccessfully induce lactation.

Literature regarding induced lactation remainsrelatively sparse. It is difficult to determine thetrue number of women who induced lactation,but older research, case reports, various Websites, and a small number of publications indicatethat the practice continues today (Auerbach,1981; Auerbach & Avery, 1981; Biervliet et al.,2001; Bryant, 2006; Cheales-Siebenaler, 1999;Kirkman & Kirkman, 2001; Nemba, 1994; Ryba& Ryba, 1984; Thearle & Weissenberger, 1984).Procedures commonly used to induce lactationinclude both pharmacologic and nonpharmaco-logic methods, often in combination. Because it isalmost impossible for an adoptive mother to know the ex-act time frame when she will receive the infant, it is fre-quently a great challenge for a mother to initiate prepara-tion for lactation induction in an adequate amount of time.Furthermore, research indicates that even if adoptive moth-ers cannot produce a milk supply adequate to exclusivelybreastfeed their child, most women undertaking lactationinduction consider their endeavor successful on the basis ofthe maternal-infant bonding experienced (Auerbach & Av-ery, 1981; Thearle & Weissenberger, 1984; Cheales-Siebe-naler, 1999). Healthcare workers need an in-depth under-standing of lactation induction in order to provide theirclients with the most accurate time frame as to how longthe process should take. This way, they can provide clientswith the closest estimate of the appropriate time to beginpreparations for lactation induction.

Methods of Inducing LactationThe process of inducing lactation relies on mimicking thephysiology of lactation that occurs during pregnancy. Nor-mal lactation requires the maintenance of a delicate balanceof various hormones with frequent and regular stimulationof the breasts. Prolactin, considered the most importanthormone involved in lactation, stimulates milk productionand secretion from the alveolar cells of the breasts (Bryant,2006). Pregnancy produces high levels of estrogen andprogesterone that inhibit the effects of prolactin on breastmilk production (Gabay, 2002). After childbirth and the re-moval of the placenta, estrogen and progesterone levelsdrastically drop, allowing prolactin to increase dramaticallyand initiate milk production (Biervliet et al., 2001). Imme-diately after delivery of the infant and placenta, breast milksecretion begins. Adoptive mothers who have not recently

March/April 2008 MCN 77

RM / Custom Medical Stock Photo / Newscom

given birth to another child do not naturally undergo thehormonal changes needed to stimulate lactation, so theymust use artificial means to achieve what is a normal physi-ologic process for biological mothers. Nurses must under-stand both pharmacologic and nonpharmacologic methodsof inducing lactation in order to better assist and supporttheir clients with this process.

Nonpharmacologic Methods of Lactation InductionSuccessful induction of lactation has been reported to occur as aresult of several measures not involving any type of hormonal ordrug supplementation. Nipple stimulation seems to be the mostfrequently used technique and the most important factor in pro-moting lactation of nonpuerperal breasts. It has been known for

many years that mammary stimulation is associated with in-creased levels of prolactin secretion and subsequent breast milkproduction in nonlactating women (Thearle & Weissenberger,1984). Nipple stimulation by hand or pump mimics the sucklingof a newborn infant. One technique for nipple stimulation byhand is to gently squeeze the breast, place the thumb and forefin-gers 2 to 3 cm behind the nipple, and press inward toward thechest while squeezing and gently rolling toward the nipple, re-peatedly changing finger position around the areola (Riordan,2005). This method allows for as much stimulation of the breastas possible to most effectively promote lactation.

The suggested time period to commence nipple stimula-tion techniques is several weeks before the date of arrival ofthe adopted infant (Thearle & Weissenberger, 1984). Handstimulation of the nipple should occur several times a dayfor about 5 minutes on each breast over ideally a period ofat least 6 weeks before the infant’s arrival in order to bringabout lactation (Ryba & Ryba, 1984). The preferredmethod for nipple stimulation is use of a hospital-grade elec-tric breast pump. The mother should be instructed to pumpboth breasts simultaneously every 3 hours approximately 2months before the infant is expected (Riordan, 2005).

A 1997 case report involving attempted induction of lacta-tion by six Nigerian women who had all previously been preg-nant but had not breastfed for 9 months to 12 years before thestudy showed successful results through the sole means ofsuckling and the provision of counseling (Abejide et al., 1997).Although hand expression techniques were not practiced inthis study, the women were encouraged to suckle their adoptedinfants for at least 10 minutes on each breast 10 times per day(Abejide et al., 1997). In approximately 13 to 18 days, all ofthe women were able to progress to partial breastfeeding,

which became exclusive breastfeeding after 21 to 28 days(Abejide et al., 1997). With the exception of one child whodied, 16 weeks into the study all of the infants fell into the ex-pected weight range for their age (Abejide et al., 1997). Thisstudy gives a good indication that when provided with appro-priate resources and counseling, induced lactation can be at-tained through the use of nipple stimulation exclusively if awoman had a prior pregnancy and lactation. In another studyin which only 6% of women used pharmacologic methods toinduce lactation, women who had previously lactated werethree times as likely to have milky secretions before infantsuckling than women who had been pregnant but never lactat-ed and women who had never been pregnant and never lactat-ed previously (Auerbach & Avery, 1981). This finding suggeststhat women who have previously been pregnant and lactatedmay have an advantage in their ability to induce lactation.

The literature suggests several other nonpharmacologicmethods for inducing lactation that have been used prima-rily in conjunction with nipple stimulation. Nipple stimula-tion may be aided with the application of warm compressesto the breasts, breast massage, the application of a comfort-able heat source (e.g., warm sunlight or a heat lamp), orbathing in hot tubs or spas to facilitate circulation duringbreast stimulation (Ryba & Ryba, 1984; Kirkman & Kirk-man, 2001). In breast massage, the hands are used to cupand support the breasts, the breasts are gently pushed to-gether, and the hands gently rotate around the breasts for 1to 2 minutes (Riordan, 2005).

The use of dietary aids in promoting induction of lacta-tion remains controversial. Early published literature sug-gested that drinking extra fluids, taking brewer’s yeast or Bcomplex vitamins, and increasing protein intake in the formof meats, dairy products, whole grains, and legumes maybe helpful in promoting lactation (Auerbach, 1981; Thearle& Weissenberger, 1984). However, this assumption lacksscientific merit. Notably, in Abejide et al.’s (1997) case re-port of six Nigerian women inducing lactation, none of themothers received nutritional supplementation, althoughthey all came from low social class backgrounds, in whicha balanced diet may have been difficult to achieve (Abejideet al., 1997). This finding indicates that maternal diet mayhave little or no influence on milk production and that ef-fective, frequent suckling plays a more important role in in-ducing lactation (Abejide et al., 1997). Despite this evi-dence, clients undergoing lactation induction should receiveencouragement to maintain a well-balanced diet simply topromote general health and well-being. Nurses can also as-sist clients by educating them about nipple stimulation andbreast massage techniques and the use of a breast pump.

Pharmacologic Methods of Lactation InductionIn addition to the various nipple stimulation techniques,several pharmacologic approaches have been used to inducelactation (Table 1). These methods include supplementationwith galactagogues—drugs used to mimic a pregnancy in awoman’s body and the period of lactation after delivery.Some pharmacologic treatments have proved more effectivethan others, and several carry significant side effects that


Because timing of adoption is rarely

specific, it is frequently a great

challenge for a mother to initiate

preparation for lactation induction

in an adequate amount of time.

must be thoroughly understood and considered beforechoosing a pharmacologic regimen. These pharmacologicapproaches can be used alone, but they are most effectivelyused in conjunction with nipple stimulation techniques.

Hormonal SupplementationNumerous case reports exist in which women have used vari-ous exogenous hormones to mimic pregnancy and inducelactation. Case reports published by Thearle and Weis-senberger (1984) and Nemba (1994) described the use ofsupplemental estrogen and progesterone to stimulate the pro-liferation of the alveolar and ductal systems, as would occurnaturally during pregnancy. Participants in the Thearle andWeissenberger study were treated with the nonandrogenicprogestogen, medroxyprogesterone (Depo-Provera), in dosesof 2.5 to 40 mg, in addition to treatment with estrogen in

doses of 0.05 to 0.4 mg daily to produce a “pseudo-pregnan-cy” over a 6- to 9-month period. The study recommendedthat any hormonal treatment used should cease within 24 to48 hours of starting the adopted infant suckling on thebreast, a task that may prove difficult given the sometimesunpredictable timing of adoption (Thearle & Weissenberger,1984). In Nemba’s (1994) study, women who had never lac-tated were treated with a single priming dose of medrox-yprogesterone (Depo-Provera), 100 mg, 1 week before re-ceiving chlorpromazine, 25 mg, four times daily or metoclo-pramide, 10 mg, four times daily. Of the 11 women who at-tempted this method of inducing lactation, all achieved suc-cess (Nemba, 1994). Hormonal treatment may prepare themilk alveoli and ducts, as would occur during a normal preg-nancy. After ceasing hormonal treatment, milk secretion,controlled primarily by prolactin, and milk ejection, stimulat-


TABLE 1 Pharmacologic Agents to Induce LactationAgent Mechanism of

ActionRecommendedDosage

Availabilityin theUnitedStates

Side Effects Hale’sLactationRiskCategory*

References

Metoclopramide Dopamine antagonist;crosses blood-brainbarrier

Oral: 10-15 mg, 3 times per day

Yes Diarrhea, sedation,depression, tremor, bradykinesia

L2 Biervliet et al.,2001; Bryant,2006; Gabay,2002; Hale, 2006

Domperidone** Peripheral dopamineantagonist; crossesblood-brain barrier minimally

Oral: 10-20 mg, 3-4 times per day

From a compoundingpharmacist

Dry mouth, skin rashor itching, headache, gastrointestinal distur-bance

L1 Bryant, 2006; da Silva &Knoppert, 2004;Gabay, 2002;Hale, 2006;Riordan, 2005

Sulpiride Selective dopamineantagonist

Oral: 50 mg, 2 times per day

No Tremor, bradykinesia,acute dystonic reac-tions, sedation

L2 Emery, 1996;Gabay, 2002;Hale, 2006

Chlorpromazine Central nervous system tranquilizer;blocks dopamine receptors

Oral: 25 mg, 4 timesper day reported; usenot recommendedbecause of associated adverse reactions

Yes Sedation, lethargy,tremor, bradykinesia,weight gain

L3 Gabay, 2002;Hale, 2006;Nemba, 1994

Fenugreek Herbal supplement;reputation as a galacta-gogue, but mechanismof action unknown

Oral: 2-3 capsules, 3 times per day; variable

Yes Maple syrup odor inurine and sweat, diarrhea, hypoglycemia,dyspnea

L3 Bryant, 2006;Hale, 2006

Blessed Thistle Herbal supplement;reputation as a galacta-gogue, but no data support this use

Unknown Yes None L3 Bryant, 2006;Hale, 2006

*Hale’s Lactation Risk Categories are as follows: L1 (Safest) = The drug is not orally bioavailable in the infant, or no increase in adverse effects to the infant hasbeen noted in controlled studies or observed with a large number of breastfeeding mothers; L2 (Safer) = A limited number of studies of this drug has shown noincrease in adverse effects to the infant and/or little evidence exists of risk to breastfeeding infant; L3 (Moderately Safe) = No controlled studies by breastfeedingwomen exist, but risk of untoward effects to infant is possible. Therefore a risk benefit assessment should be made.

**In 2004, the U.S. Food and Drug Administration issued a statement warning against the use of domperidone to induce lactation, citing published reports andcase studies of cardiac arrhythmias, cardiac arrest, and sudden death in patients receiving intravenous domperidone as an antiemetic during cancer chemothera-py. No data suggest that the use of oral domperidone in breastfeeding mothers produces similar effects.

ed by oxytocin release, are thought to occur as a response tothe suckling reflex of the infant (Nemba, 1994).

The use of oxytocin as a means of hormonal supplemen-tation has also been reported in the literature (Gabay,2002). In 1981, Auerbach and Avery documented the useof oxytocin by women desiring to induce lactation in theirstudy of adoptive nursing in 240 women. Although only6% of women in this study used any kind of hormonalsupplementation at all, their hormone of choice was anoxytocin nasal spray, which is used to enhance the milk-ejection reflex (Auerbach & Avery, 1981). The women’sopinions were divided on the efficacy of oxytocin, often re-porting that milk ejection was more likely to occur if oxy-tocin use was supplemented with nipple stimulation (Auer-bach & Avery, 1981). It is thought that oxytocin increasesintramammary pressure in the milk ducts (Emery, 1996).Few women today use oxytocin as a means of inducing lac-tation because of its unavailability on the U.S. market.

Nutrition Supplementation for the InfantAlthough numerous successes have been demonstrated inthe induction of lactation by adoptive mothers who werenot recently pregnant, most women who succeed in induc-ing lactation require supplementation in order to providean adequate amount of nutrition to their infants; provisionfor additional nourishment during the period of establish-ing milk production is essential (Biervliet et al., 2001). Inexclusively breastfed healthy infants (age 1-6 months), aver-age 24-hour milk intake is 788 ± 169 g (range 478-1,356 g)(Kent et al., 2006). For the adoptive mother, any amount of

milk she can produce benefits the infant, but supplementa-tion may be required to meet infant intake needs. In orderto evaluate milk transfer during breastfeeding, pre- andpost-weights can be done with an electronic scale that is ac-curate to at least ± 2 g (Riordan, 2005). For pre- and post-weights, the infant is completely dressed and weighed be-fore and after feeding; none of these conditions can be al-tered. For example, if the infant stools/voids during breast-feeding, the diaper cannot be changed until after the post-weight is done. One gram of weight gain approximates 1mL of milk intake and serves as the technique of choice inclinical and research settings for determining milk transfer(Riordan, 2005). Electronic scales accurate within 2 g arealso now available to perform pre- and post-weights in thehome setting. Rental costs vary by region of the UnitedStates but generally run about $80 to $90 per month.

If the adoptive mother is unable to achieve a full milk sup-ply, nutrition supplementation can occur via a specially de-signed supplementer that allows the infant to suckle at thebreast while receiving supplementary nutrition (Figure 1). Sev-eral supplemental feeding devices are available on the market.These devices are worn by the mother and filled with formula(Bryant, 2006). The mother wears a bag with a connectingflexible tube that is positioned near her nipple, allowing the in-fant to suckle at the breast in order to stimulate milk produc-tion while ingesting supplementary nutrition through the tube(Biervliet et al., 2001). In one study of 240 adoptive motherswho induced lactation, 57% of the women used a similar sup-plementary device exclusively, and an additional 41% used onein combination with another method of supplementation(Auerbach & Avery, 1981). The women who used the supple-menter alone or in combination with other methods of supple-


Figure 1. Mother usingSupplemental NurserSystem. Photo courtesy of MedelaCorporation, used with permission.

mentation reported having more positive feelings about theirbreastfeeding experience (Auerbach & Avery, 1981). Varioushospitals, medical supply stores, and private lactation consult-ants rent or sell products to assist with inducing lactation,including pumps, supplemental nursing systems, and electronicscales accurate within 2 g. It is important for nurses whoprovide care to an adoptive mother interested in inducinglactation to make sure her expectations of milk production arerealistic and provide her with resources to locate the necessarysupplementary supplies she may require.

ConclusionBecause most adoptive mothers who attempt to induce lac-tation do so to achieve the enhanced mother-infant relation-ship that breastfeeding promotes rather than the nutritionalbenefits it brings, it is important for nurses to understandwhy an individual adoptive mother may have made the de-cision to breastfeed and what she expects to gain from herexperience (Auerbach & Avery, 1981). This understandingallows for the development of the most realistic plan for anindividual woman to achieve lactation. Enlistment of herfamily and other primary support network is critical in pro-viding the best care. For many adoptive mothers, the primarygoal of inducing lactation is not milk production but ratherthe establishment of an emotional bond with the infant(Bryant, 2006). Preparedness with adequate resources andtiming allows for the best bonding to occur.

It has been shown that a mother who is motivated, confi-dent, and knowledgeable on the topic experiences the bestchance of successfully inducing lactation (Nemba, 1994).Because of the rigorous nature of the methods by which lac-tation is induced, a woman must be extremely motivated topersist with this process. Support and counseling are essentialto successful induction of lactation. Nurses can best providecare to mothers who desire to achieve this highly personalbonding experience with their adopted child when fully edu-cated on this topic. A mother who feels confident in herability to lactate and is reassured by those around her willbe most likely to feel successful in this great endeavor. <

Sarah L. Wittig is a Student Nurse, BSN Candidate, Uni-versity of Pennsylvania, Philadelphia. She can be reachedvia e-mail at [email protected]

Diane L. Spatz is the Helen M. Shearer Term Chair inNutrition, Associate Professor, University of Pennsylvania,School of Nursing, and Clinical Nurse Specialist–Lactation,The Children’s Hospital of Philadelphia.

Disclosure: Dr. Spatz is a consultant for Medela Corpo-ration, who supplied Figure 1 in this article.

ReferencesAbejide, O. R., Tadese, M. A., Babajide, D. E., Torimiro, S. E. A., Davies-Adetugbo,

A. A., & Makanjuola, R. O. A. (1997). Non-puerperal induced lactation in aNigerian community: Case reports. Annals of Tropical Paediatrics, 17, 109-114.

Auerbach, K. G. (1981). Extraordinary breast feeding: Relactation/inducedlactation. Journal of Tropical Pediatrics, 27, 52-55.

Auerbach, K. G., & Avery, J. L. (1981). Induced lactation: A study of adoptive nurs-ing by 240 women. American Journal of Diseases of Children, 135, 340-343.

Beauvais-Godwin, L., & Godwin, R. (2005). The complete adoption book:Everything you need to know to adopt a child (3rd ed.). Avon, MA:Adams Media.

Biervliet, F. P., Maguiness, S. D., Hay, D. M., Killick, S. R., & Atkin, S. L.(2001). Induction of lactation in the intended mother of a surrogatepregnancy. Human Reproduction, 16, 581-583.

Bryant, C. A. (2006). Nursing the adopted infant. Journal of the AmericanFamily Board of Medicine, 19, 374-379.

Cheales-Siebenaler, N. J. (1999). Induced lactation in an adoptive mother.Journal of Human Lactation, 15, 41-43.

da Silva, O. P., & Knoppert, D. C. (2004). Domperidone for lactatingwomen. Canadian Medical Association Journal, 171, 725-726.

Emery, M. M. (1996). Galactogogues: Drugs to induce lactation. Journal ofHuman Lactation, 12, 55-57.

Gabay, M. P. (2002). Galactogogues: Medications that induce lactation.Journal of Human Lactation, 18, 274-279.

Hale, T. W. (2006). Medications and mothers’ milk (12th ed.). Amarillo, TX: Hale.Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., &

Hartmann, P. E. (2006). Volume and frequency of breastfeedings andfat content of breast milk throughout the day. Pediatrics, 117, 387-395.

Kirkman, M., & Kirkman, L. (2001). Inducing lactation: a personal accountafter gestational “surrogate motherhood” between sisters. Breast-feeding Review, 9, 5-10.

Nemba, K. (1994). Induced lactation: A study of 37 non-puerperal moth-ers. Journal of Tropical Pediatrics, 40, 240-242.

Riordan, J. (2005). Breastfeeding and human lactation (3rd ed.). Sudbury,MA: Jones and Bartlett.

Ryba, K. A., & Ryba, A. E. (1984). Induced lactation in nulliparous adoptivemothers. New Zealand Medical Journal, 97(768), 822-823.

Thearle, M. J., & Weissenberger, R. (1984). Induced lactation in adoptivemothers. Australian and New Zealand Journal of Obstetrics and Gy-naecology, 24, 283-286.

U.S. Food and Drug Administration. FDA talk paper: FDA warns againstwomen using unapproved drug, domperidone, to increase milk pro-duction. Retrieved October 4, 2007, from www.fda.gov/bbs/topics/ANSWERS/2004/ANS01292.html


International Lactation Consultant Association www.ilca.orgLa Leche League International www.lalecheleague.orgThe National Women’s Health Information Center www.4woman.gov/breastfeeding

Medela, Inc.www.medela.comAmeda/Hollister Incorporatedwww.ameda.comInternational Academy of Compounding Pharmacistswww.iacprx.org

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Suggested Clinical Implications Nurses who work with women who are adopting achild and wish to breastfeed should• Provide support and encouragement to women

inducing lactation• Answer basic questions about inducing lactation

for a client and her family or support network• Demonstrate nipple stimulation and breast mas-

sage techniques to the client• Assist in showing client the proper use of a breast

pump or supplementary feeding device• Provide resources to client and referral to a lacta-

tion consultant

Documents

Induced Lactation