19
Induced Lactation and Relactation
(Including Nursing an Adopted Baby)
and Cross-Nursing
Ruth A. Lawrence
KEY POINTS
• Induced lactation is the process through which a non-
puerperal woman is stimulated to breastfeed an infant
without a preceding pregnancy. Relactation is when a woman
who has given birth but stopped breastfeeding or never
initially breastfed is stimulated to lactate.
• Induced lactation and relactation are important processes
for assisting women to nourish infants (their own or
others) when circumstances have changed and there is an
urgent need for ongoing nutrition and nurturing. These
situations can arise in the early or late postpartum period,
Breastfeeding has returned to be the preferred form of nour-
ishment for the infant, and there has been an increased inter-
est in induced lactation. Induced lactation is the process by
which a nonpuerperal woman is stimulated to lactate—in
other words, breastfeeding without pregnancy. Relactation is
the process by which a woman who has given birth but
did not initially breastfeed is stimulated to lactate. This may
also apply to a mother who may have initially breastfed her
infant, weaned the infant, and then chooses to reinstitute lac-
tation. Relactation can also involve a woman who previously
breastfed a biologic child, even years before, and now is
adopting a newborn. There are no blinded controlled research
studies about either induced lactation or relactation. There
are occasional observation reports about successes in a small
series of dyads. The process has not been confirmed by clini-
cal trials.1 Otherwise the literature is meager and predomi-
nantly in the animal research field.
HISTORICAL PERSPECTIVE
Induced lactation and relactation are not new concepts but
rather are well known to history and to other cultures. The
motivation historically has been to provide nourishment for
an infant whose mother has died in childbirth or is unable to
nurse for some reason. A friend or relative would take on the
care of the child and with it the responsibility to nourish the
infant at the breast because no other alternatives were
available.
Relactation has been used in times of disaster or epidemics
to provide safe nutrition to weaned or motherless infants.
628
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as a result of health or social situations for the mother,
adoption, and emergencies or disasters that separate
infants from their mothers.
• The recommendations for facilitating the processes of
induced lactation or relactation have not been studied
through rigorous clinical trials but constitute suggestions
based on experience or empiric observation. There are a
variety of resources, published and online, for assisting
and supporting women in their efforts.
Numerous historical accounts of induced lactation are
recorded in the medical literature and reviewed in the writ-
ings of Brown.2 Mead recorded the occurrence of relactation
in her writings about New Guinea in 1935.3 Other anthropol-
ogists have made similar observations in other preindustria-
lized societies of women who have not recently borne
children and, after a few weeks of placing the suckling infant
to the breast, produce milk adequate to nourish the infant.4
Until recently, Western world literature reported the phe-
nomenon as an anecdotal report as part of the discussion of
aberrant lactation. In 1971, Cohen reported a patient who
had been nursing an adopted child successfully for weeks
when first seen in his pediatric office.5
Today, the interest in induced lactation in the industrial-
ized world stems from a desire on the part of adopting
mothers to nurture an adopted child at the breast even though
they were unable to carry the infant in utero. The interest in
relactation comes from mothers of sick or premature infants
who want to breastfeed their infants after the days and weeks
of neonatal intensive care are over. These mothers, although
postpartum, have not been lactating.
INDUCED VERSUS INAPPROPRIATE
LACTATION
The process of induced lactation is separate from galactor-
rhea, or inappropriate lactation, which has been described in
the medical literature for more than 100 years.6 Abnormal
lactation has been observed in various circumstances in
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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing
nulliparous and parous women and even in men. There are
many eponyms for these conditions, usually based on the
name of the physician who first described the syndrome, such
as Chiari-Frommel and Ahumada-del Castillo.
Normally in the absence of suckling, lactation ceases 14 to
21 days after delivery. Milk flow that continues 3 to 6 months
after abortion or any termination of pregnancy is termed
abnormal or inappropriate lactation, or galactorrhea.
Galactorrhea also refers to lactation in a woman 3 months
after weaning or the secretion of milk in a nulliparous woman
in association with hyperprolactinemia and amenorrhea.
Although these cases are pathologic in nature and, therefore,
different from the groups under discussion, it is noteworthy
that some knowledge of the initiation and maintenance of lac-
tation has been gained from the study of these syndromes.
A nonpregnant woman who develops spontaneous lactation
should be evaluated for hormonal disease. The most common
cause is a prolactinoma of the pituitary. Spontaneous lacta-
tion should not be ignored. See Chapter 16 Breast Conditions
in the Breastfeeding Mother for discussion of nipple dis-
charge and hyperlactation.
ANIMAL STUDIES
Information on the incidence of non-offspring nursing in 100
mammalian species has been assembled by Packer et al.7 The
incidence of non-offspring nursing is increased by captivity.
It is more common in species with large litters (polytocous
taxa) and differs from that which occurs with single young
species (monotocous taxa). In the latter, it is more common
for females to continue nursing after they have lost their own
young. Among nondomesticated animals, spontaneous lacta-
tion has been observed repeatedly only in the dwarf mon-
goose (Helogale parvula).
Lactation has been induced for scientific and commercial
purposes in nonpregnant and nonparturient animals by the
continual systematic application of a mechanical milking
apparatus to the mammary gland of the animal.8 The
response is produced through the release of a mammotropic
hormone from the anterior pituitary gland. This effect is abol-
ished if the pituitary stalk is transected. Ruminants respond
to the addition of estrogen or estrogen-progesterone combi-
nations, which facilitate mammary growth. Experiments in
goats involved applying ointment containing estradiol benzo-
ate to the udders of virgins, which resulted in development of
the udder and milk yield almost comparable to that of normal
postpartum animals.9 It was subsequently shown, however,
that a combination of estrogen-progesterone not only resulted
in better milk yield, but histologically the lobuloalveolar
growth was normal, whereas with estrogen alone growth was
cystic and irregular. It was also demonstrated that ovariecto-
mized goats could be stimulated to lactate with these two hor-
mones, with resultant normal histology of the udder and good
milk production. Initiation of regular milking had a significant
impact on production of milk.
Because lactation can be stimulated when the ovaries have
been removed but not when the pituitary stalk has been
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629
severed, this has significance for understanding some of the
postpartum lactation failures in women. Again, in ruminants,
growth hormone and thyroid hormone have been shown to
increase milk yield, although prolactin does not. This suggests
that prolactin is not deficient in ruminants. Because the moti-
vation, goals, and physiologic problems may be slightly differ-
ent, induced lactation and relactation in women are discussed
separately.
INDUCED LACTATION
When a mother chooses to nurse her adopted infant, the goal
is usually to achieve a mother!infant relationship that also
may have the benefit of some nutrition. In that perspective,
success can be evaluated on the basis of whether an infant will
suckle the breast and achieve some comfort and security from
this opportunity and close relationship with the new mother.
As has been well described by Avery,10 this is nurturing with
the emphasis on nurturing, not on “breastfeeding” or nutri-
tion. A mother who is interested in inducing lactation to
nurse an adopted infant may need to understand that she
may never be able to sustain the infant completely by her milk
alone without supplementation. Neither the physician nor
the mother should be disappointed. The nurturing goal is still
achieved. An adoptive mother induced lactation for prema-
ture twins who were exclusively breastfed by 2 months of age.
The mother succeeded because of careful planning and sup-
port of the health care team.11
Preparation of the Breast
Normally the breast is prepared by the proliferation of the
ductal and alveolar system throughout pregnancy in anticipa-
tion of the time when lactation will begin, when the infant
delivers and the placenta is removed.12 Thus it is appropriate
to assume that a period of similar preparation should take
place in induced lactation. It has been suggested that a woman
should begin systematically to express the breasts manually
and stimulate the nipples for up to 2 months before the arrival
of the infant, if time permits. A hand pump or other pumping
devices can be used, but manual expression may work as well
or better. Sometimes some secretion can be produced in this
manner if it is carried out systematically on a uniform sched-
ule throughout the day. The schedule should be practical, that
is, include times when a mother could take a moment for this
activity, such as morning and night plus any times she uses
the bathroom or can conveniently handle her breasts.
Hormones and Medications
A more aggressive approach involves hormones and medica-
tions. During pregnancy, the breasts are prepared by the hor-
mones generated by the pregnancy, estrogen, progesterone,
and human placental lactogen (see Chapter 3, Fig. 3.3).
To mimic this environment, it has been suggested that
starting a course of estrogen and progesterone would be
appropriate, namely, prescribing oral contraceptive dosing
that suppresses ovulation (such as Ortho-Novum). This dos-
ing should be maintained without a pause as it would be
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during pregnancy.13 Unfortunately, women who are adopting

typically do not have 9 months to prepare, so priming the
breasts with hormones may not be possible because the hor-
mones need to be discontinued a month before anticipated
lactation.
Concomitant with hormone therapy should be breast
stimulation with systematic pumping with a good electric
double pump. Timing should begin gradually, 5 minutes
three times per day, then 10 minutes three times a day,
increasing to a frequency every 4 hours. Pumping about the
same time every day is helpful. It usually takes about a month
before drops of milk appear. This is a good time to start dom-
peridone (not available in the United States).14!16 There have
been concerns in women taking domperidone about cardiac
mortality and prolonged QTc but no such infant mortality
resulting from exposure through breast milk. The schedule
adopted by Newman17 in Canada is 10 mg three times per
day, increasing during a month’s time to 20 mg four times
per day. Newman17 suggests using domperidone from the
beginning. Without a placenta, the adoptive mother does not
have “prolactin-inhibiting” hormone to block the breast from
responding to the prolactin secreted because of the breast
stimulation. Health care providers should be able to discuss
the use of domperidone and participate in a discussion with
the mother about the risks and benefits of its use in induced
lactation or relactation.18,19 When domperidone is initiated,
milk should appear in increasing quantities. Many women
have achieved success by pumping alone initially and then
adding galactagogues.
In other cultures, in which lactation is induced as a sur-
vival tactic for the infant, no period of preparation is available.
An infant is put to the adoptive mother’s breast and allowed
to suckle. Emphasis has been placed on herbal teas as galacta-
gogues and good nourishment for the mother, and the infant
is also given prechewed food, gruel, or animal milk. Mead
attributed much of the success of induced lactation to the
ingestion of ample supplies of coconut milk by the new
mother.3 Coconuts are well known in herbal medicine; the oil
Fig. 19.1 (A) Lact-Aid Nursing Trainer System (Lact-Aid International
pressed from ripe fruit is used for wound healing and inflam- Inc., Athens, Tennessee). (B) Supplemental Nursing System by Medela
mation reduction.20 Adoption is not an easy process, and, in (McHenry, Illinois), which provides additional nourishment to infant
fact, it can be quite stressful to become an instant parent. In while suckling at underproducing breast.
assisting such a mother, consideration should be given to the
infant’s age, previous feeding experience, and any medical
problems that may exist. Provision for additional nourish-
ment during the process of establishing some milk secretion suckles at the breast, thus stimulating production. It is further
is most important. Onset of lactation varies from 1 to 6 weeks, described later in this chapter and is called the Lact-Aid
averaging about 4 weeks after initiation of stimulation with Nursing Trainer System (Lact-Aid International Inc., Athens,
the appearance of the first drops of milk. When the infant is Tennessee) or Supplemental Nursing System (Medela Inc.,
actually nursing at the breast and being nourished by supple- McHenry, Illinois) (Fig. 19.1).
ments, milk may appear as early as 1 to 2 weeks.
Some infants are easily confused by switching back and Other Drug Schedules to Induce Lactation
forth between breast and bottle because the sucking technique As described in Chapter 3, estrogen and progesterone stimu-
is slightly different. Other nourishment can be offered by late the proliferation of the alveolar and ductal systems. These
dropper, by small medicine cup, or as solid foods. A unique hormones work in association with an increase in prolactin
system is available, however, for providing nourishment for production. Although the prolactin level is high during
the infant while suckling at the breast. It involves the use of a pregnancy, milk secretion is inhibited by the presence of
device to provide a source of nourishment while the infant the estrogen, progesterone, and placental lactogen, the

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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing
prolactin-inhibiting hormone. After delivery has occurred
and the placenta is removed, these hormone levels fall, and
prolactin initiates milk production. Efforts to stimulate this
hormonal response have had variable success and are not
usually recommended because of the possible effect on an
infant through the milk. Women taking oral contraceptives
have been noted in some cases to have breast enlargement. In
addition, although estrogen and progesterone may enhance
proliferation, they may inhibit lactation per se, so they must
be discontinued well before lactation is planned to begin.
The dosage of conjugated estrogens recommended by
Waletzky and Herman is 2.5 mg twice per day for 14 days
beginning on the fourth day of a regular menstrual cycle.21
Giving 0.35 mg norethindrone once daily for the morning
dose of estrogen prevents breakthrough bleeding. Medication
is given for 2 weeks and is comparable in dosage to 2 weeks of
oral contraceptives. This therapy may be accompanied by
some side effects. The regimen should include direct efforts to
stimulate lactation by pumping the breasts.
A report from Papua New Guinea, where inducing lacta-
tion is critical to adequate infant nutrition, recommends
priming the breast tissue of nulliparous women or those who
have not lactated with 50 mcg ethinyl estradiol three times
per day for a week.22 Medroxyprogesterone (Depo-Provera)
has been used to initiate lactation in nonpuerperal women.
A dose of 100 mg is given intramuscularly once, one week
before stimulating the breast with massage and pumping.
Galactagogues, such as metoclopramide, domperidone, or
herbals, can be introduced.23 (See Chapter 11 for discussion
of some galactagogues.) This approach was reported in Papua
New Guinea, and success was claimed in 24 of 27 women.24
When relactation is the goal in women who have previously
lactated, pumping and massaging alone are initiated.
Growth hormone and prolactin have considerable genetic
similarity, as reflected in some overlap of function.25 High con-
centrations of growth hormone can cause lobuloalveolar devel-
opment and casein expression. Growth hormone may play a
role in optimization of milk production during lactation and
even an accessory role in the induction of lactogenesis. Both
natural and recombinant human growth hormones are potent
inductors of milk synthesis in pregnant and lactating rats. This
effect is attributed to their effect on the prolactin receptor.25
Oxytocin is a critical component in the milk-ejection reflex
and may be helpful in the early initiation of ejection.
Physiologically, stimulation of the nipple in the lactating
woman results in the release of oxytocin by the hypothala-
mus, which then triggers the release of milk by stimulating
the contraction of myoepithelial cells and the ejection of milk
(see Chapter 3). The effect of intranasal administration of
oxytocin on the let-down reflex in lactating women was well
described by Newton and Egli.26 (Oral administration by tab-
let is not as effective because oxytocin is destroyed in the
stomach; therefore oral administration must be sublingual.)
Oxytocin nasal spray has been used in cases of nonpuerperal
lactation with some success in enhancing let-down but not
necessarily altering the volume produced. The original oxyto-
cin product, Syntonin, is no longer available, but a pharmacist
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631
by prescription can place the intravenous preparation in a
dropper bottle or a nasal spray container. The intravenous
preparation (10 units/mL) is one-quarter the strength of the
old nasal spray (40 units/mL). Therefore the dose needs to be
increased four-fold: 4 to 6 drops per dose in one naris and
feed the infant or pump immediately. The dose can be
repeated. Continued use of oxytocin for weeks has been asso-
ciated with diminished effect or even suppression of lactation.
In a randomized, double-blind trial of oxytocin nasal spray
in mothers expressing breast milk for preterm infants, there
were only marginal differences in the pattern of early milk
production. The use of oxytocin nasal spray did not signifi-
cantly improve outcome. Most of the subjects thought they
were receiving the real medicine, which demonstrates the
power of the placebo effect. All of the mothers had been preg-
nant, and their breasts had responded to the pregnancy.27
These data should not be extrapolated without further study
to women who had never been pregnant.
The chief benefit of oxytocin is often to break the cycle of
failure and instill a feeling of confidence once it has been
demonstrated that some secretion can be produced.
Galactagogues
Galactagogues, a substance, product, or medication used to
increase milk production, such as metoclopramide, domperi-
done, or herbals, can be introduced.23 (See Chapter 11 for addi-
tional discussion of some galactagogues.) Chlorpromazine has
been observed to act as a galactagogue as well as a tranquilizer
when given to patients in large doses (200 mg to 1000 mg). The
effect has been observed in both male and female patients in
mental institutions. The drug has been reported to increase
pituitary prolactin secretion several fold. It acts by the hypothal-
amus, probably by reducing levels of prolactin inhibitory factor
(PIF). Using this information, women well motivated to lactate
who have attempted induced lactation by suckling a normal
infant have had the process enhanced by small doses of
chlorpromazine.
In a program to induce lactation in refugee camps in India
and in Vietnam, nonlactating women were given 25 to
100 mg of chlorpromazine three times per day for a week to
10 days while infants were initially put to breast. Brown28
reports apparent enhancement of lactation with this treat-
ment. Chlorpromazine has the added pharmacologic effect of
acting as a tranquilizer. The program of management in these
women was supportive in other ways and also included the
usual herbal medicines associated with lactation in these
Eastern cultures. There was no control group.28 It is possible
that the drug contributed to both the physiologic and the psy-
chologic well-being of the women wanting to lactate. It has
been suggested that the desire to lactate is a strong component
of success because women whose breasts are frequently stim-
ulated sexually do not begin to lactate.
Theophylline also can increase pituitary prolactin secre-
tions.29 Therefore both tea and coffee should enhance prolac-
tin secretion and thus lactation. Excessive amounts may
inhibit milk let-down, however. (See Tables 19.1 and 19.2 and
for other agents that may affect induced lactation.)
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TABLE 19.1 Pharmacologic Agents to Induce Lactation: Possibly Effective for Selected
Indications
Domperidone Fenugreek Metoclopramide Silymarina
Chemical class Dopamine antagonist A commonly used spice; Dopamine antagonist Flavolignans (presumed
or properties active constituents are active ingredient)
trigonelline, 4-
hydroxyisoleucine, and
sotolon
Level of I (one study); other studies II-3 (one study in lactating III (mixed results in low- II-I (one study in lactating
evidence have inadequate women—abstract only) quality studies; effect on women)
methodology or overall rate of milk
excessive dropout rates secretion is unclear)
Suggested 10 mg orally three times “3 capsules” orally 10 mg, orally, three to Micronized silymarin,
dosage per day in the Level I (typically 580!610 mg), four times per day; 420 mg orally per day;
study; higher doses (20 three to four times per doses of 30!45 mg/day anecdotal; strained tea
mg orally TID) have been day; strained tea, 1 cup, were most effective (simmer 1 tsp of crushed
studied in this context three times per day ({1/4} seeds in 8 oz of water
tsp of seeds steeped in for 10 minutes), 2!3
8 oz of water for cups/day
10 minutes)
Length/duration Started between 3 and 4 1 week 7!14 days in various Micronized silymarin was
of therapy weeks postpartum and studies studied for 63 days
given for 14 days in the
Level I study. In various
other studies the range
was considerable:
Domperidone was started
between 16 and 17 days
postpartum and given for
2!14 days
Herbal — Need reliable source of — Need reliable source of
considerations standard preparation standard preparation
without contaminants without contaminants
Effects on Increased rate of milk Insufficient evidence; likely Possibly increased rate of Inconclusive
lactation secretion for pump- a significant placebo milk secretion; possible
dependent mothers of effect responders vs.
premature infants of nonresponders
younger than 31 weeks’
gestation in neonatal
intensive care unit
Untoward Maternal: Dry mouth, Generally well tolerated. Reversible CNS effects Generally well tolerated;
effects headache (resolved with Diarrhea (most common), with short-term use, occasional mild
decreased dosage), and unusual body odor similar including sedation, gastrointestinal side
abdominal cramps. to maple syrup, cross- anxiety, depression/ effects; cross-allergy
Although not reported in allergy with Asteraceae/ anxiety/agitation, motor with Asteraceae/
studies of lactation, Compositae family restlessness, dystonic Compositae family
cardiac arrhythmias (ragweed and related reactions, extrapyramidal (ragweed and related
resulting from prolonged plants), peanuts, and symptoms. Rare reports plants—possible
QTc interval are a Fabaceae family (e.g., of tardive dyskinesia anaphylaxis)
concern and are chickpeas, soybeans, and (usually irreversible),
occasionally fatal. This green peas—possible causing the FDA to place
may occur with either oral anaphylaxis). a boxed warning on this
or intravenous Theoretically: Asthma, drug
administration and bleeding, dizziness,
particularly with high flatulence, hypoglycemia,
doses, or concurrent use loss of consciousness,

(Continued)

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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing 633

TABLE 19.1 Pharmacologic Agents to Induce Lactation: Possibly Effective for Selected
Indications—cont’d
Domperidone Fenugreek Metoclopramide Silymarina
of drugs that inhibit skin rash, wheezing, but
domperidone’s no reports in lactating
metabolism (see women
Interactions, later).
Neonatal: Very low levels
in milk and no QTc
prolongation in premature
infants who had ingested
breast milk of mothers
taking domperidone
Interactions Increased blood levels of Hawthorne, hypoglycemics Monoamine oxidase Caution with CYP2C9
domperidone when including insulin, inhibitors, tacrolimus, substrates—may
combined with some antiplatelet drugs, aspirin, antihistamines, any increase levels of the
substrates metabolized heparin, warfarin, drugs with CNS effects drugs. Possible increased
by CYP3A4 enzyme feverfew, primrose oil, (including clearance of estrogens
inhibitors (e.g., many other herbal agents antidepressants) (decreased blood levels).
fluconazole, grapefruit Possible increased levels
juice, ketoconazole, of statins
macrolide antibiotics)
Comments In the United States, the If patient develops Some studies suggest No prescription required
FDA has issued an diarrhea, reducing the tapering the dose at the
advisory against the use dose is often helpful end of treatment
of domperidone for
lactating women.
Do not advise exceeding
maximum dosage; no
increased efficacy but
increased untoward
effects.
Licensed for use as a drug
for gastrointestinal
dismotility in some
countries (but not in the
United States), where for
this indication in some
regions it is accepted that
if no response at the initial
dose occurs, dose may be
increased. Some areas
use as drug of choice
when prolactin stimulation
is thought to be needed.
However, there are no
studies of the safety or
efficacy of this practice in
lactating women

CNS, Central nervous system; CYP, cytochrome P; FDA, US Food and Drug Administration.
a
Silymarin (micronized silymarin) or S. marianum (milk thistle).
Modified from Brodribb W. ABM clinical protocol no. 9: use of galactogogues in initiating or augmenting maternal milk production, second
revision 2018. Breastfeed Med. 2018;13(5):307!314. doi:10.1089/bfm.2018.29092.wjb.

Because the role of prolactin is the initiation and mainte-
nance of lactation, whereas oxytocin regulates the glandular
emptying through the milk-ejection reflex, it is reasonable to
speculate that enhancing prolactin release would be produc-
tive in inducing lactation. The exact activating mechanism of
the neuronal reflex arc from breast to brain has not been deci-
phered. Secretion of prolactin appears to be influenced, if not
controlled, by changes in hypothalamic dopamine turnover.
Correspondingly, suckling has been observed to deplete
dopamine stores.

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TABLE 19.2 Pharmacologic Agents to Induce Lactation: Controversial or Not Recommended,

Although Possibly Effective
Human Growth Hormone
Chemical Protein-based polypeptide hormone:
class or stimulates multiple growth, and
properties anabolic and anticatabolic effects
Level of I, II
evidence
Suggested 0.2 international units/kg/day, given
dosage intramuscularly or subcutaneously
Length/ 7 days, starting 8!18 weeks
duration postpartum
of therapy
Effects on Increased milk secretion in a selected
lactation population of normally lactating
women with no feeding problems and total yield of milk not exceeding
with healthy, thriving infants between
8 and 18 weeks postpartum
Untoward None observed in mothers or infants
effects studied to date. Potentially: Joint
swelling, joint pain, carpal tunnel
syndrome, and an increased risk for
diabetes or heart disease
Interactions Other hormones, including
contraceptives, insulin, cortisol, and
others
Comments Insufficient study; not practical—
requires injection and is very
expensive
Sulpiride Thyrotropin-Releasing Hormone
Substituted benzamide (antipsychotic, A tripeptide hormone that
antidepressant); antagonism of stimulates the release of TSH and
presynaptic inhibitory dopamine prolactin by the anterior pituitary
receptors
II-I (only two studies) I
50 mg orally two times per day; do 1 mg four times daily by nasal spray
not use higher doses because of
sedation of mother and baby
4-day course starting at 3 days 10 days
postpartum; no evidence to use for a
longer course of treatment
Increased milk secretion in a selected Increased milk secretion in selected
population: Primiparous women with population of primiparous women
with insufficient milk supply at 5
50 mL for the first 3 postpartum days postpartum
days
Severe drowsiness; extrapyramidal Elevated TSH and hyperthyroidism
effects same as for metoclopramide
(above); weight gain
Levodopa, other drugs with CNS Other hormones, including
effects contraceptives, insulin, cortisol,
and others
Concern about untoward effects Insufficient study, very expensive,
no commercial product available

CNS, Central nervous system; TSH, thyroid-stimulating hormone.

Modified from Brodribb W. ABM clinical protocol no. 9: use of galactogogues in initiating or augmenting maternal milk production, second
revision 2018. Breastfeed Med. 2018;13(5):307!314. doi:10.1089/bfm.2018.29092.wjb.

Investigation of other drugs that are known to stimulate
prolactin release has identified some possible therapeutic
materials. Kramer reported that metoclopramide induces pro-
lactin release regardless of the route of administration.22
Prolactin levels are increased three to eight times normal
levels within 5 minutes when a 10-mg dose of metoclopra-
mide is given either intravenously or intramuscularly. The
effect is achieved within an hour when metoclopramide is
given orally. The effect persists for 8 hours. The suggested reg-
imen is 10 mg of metoclopramide, three to four times per day
for a week.30 This is then gradually tapered (see Chapter 11).
Metoclopramide is also used in neonates with esophageal
reflux. The side effects are irritability and diarrhea. Rarely,
susceptible infants experience dystonic reactions, which have
been described in adults. Metoclopramide has also been used
in combination with chlorpromazine, 25 mg four times per
day, in Papua New Guinea.22 Metoclopramide has been used
to enhance lactation, as well, especially among mothers of
premature infants.28
The regulation of prolactin secretion in humans has been stud-
ied to further the understanding of abnormal lactation and to pro-
vide information on the regulation of pituitary function of the
brain.31 It has been shown experimentally that the hypothalamus
secretes PIF, which acts on the mammotropin-releasing cells of
the pituitary to inhibit release of the hormone prolactin. The
hypothalamus can also regulate prolactin secretion by a stimula-
tory mechanism, the secretion of thyrotropin-releasing hormone
(TRH). When human volunteers (nonpregnant, nonlactating) are
given infusions of TRH, increases in thyrotropin and prolactin are
observed within minutes of injection, with values peaking in
20 minutes. The level of thyroid hormone in the volunteers ini-
tially influences the results. Patients with hypothyroidism have
been observed to secrete excessive amounts of prolactin, whereas
patients with hyperthyroidism are relatively insensitive to TRH.
This may explain some of the variable results obtained with
prolactin-stimulating drugs used to enhance lactation. Studies
using TRH have been done on relactation but not on newly
induced lactation. Thyroid activity has not been measured.

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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing 635

TABLE 19.3 Influence of Drugs on Prolactin Secretion

Plasma Prolactin
Pharmacologic Agents Concentration Mechanism of Drug Action
L-Dopa Decrease Increase in hypothalamic dopamine-catecholamine levels, leading to
enhanced activity of PIF
Ergot alkaloids (ergocornine, Decrease Direct inhibition of adenohypophyseal prolactin secretion; possible
ergocryptine) increase of hypothalamic PIF activity (continued PIF function)
TRH (pyroglutamyl histidyl- Increase Direct stimulation of adenohypophyseal lactotroph for increased
prolinamide) prolactin secretion
Theophylline phenothiazines Increase Decreases in hypothalamic dopamine-catecholamine levels, leading to
(chlorpromazine) diminution of PIF activity
Metoclopramide Increase Inhibition of hypothalamic PIF secretion through dopamine
antagonism
Sulpiride Increase Increase in hypothalamic prolactin-releasing hormone
Growth hormone Increase Causes lobuloalveolar development and casein expression
Recombinant human growth Increase Affects prolactin receptors
hormones

PIF, Prolactin inhibitory factor; TRH, thyrotropin-releasing hormone.

Modified from Vorherr H. Human lactation and breast feeding. In: Larson BL, ed. Lactation. New York, NY: Academic Press; 1978.

Table 19.3 summarizes the influence of drugs on prolactin secre-

tion.29 ABM protocol no. 9 discusses the use of galactagogues and TABLE 19.4 Composition of Normal
their effects and side effects (see Tables 19.1 and 19.2).32 Breast Milk and “Galactorrhea Milk”
Any pharmacologic regimen to stimulate milk production Milk Normal “Galact-
is most effective if it is initiated after the breast tissue has Components Breast orrhea Induced
responded to mechanical stimulation because the hormones and Properties Milk Milk” Lactation
that act as the prolactin-stimulating compounds are thought Components
by many to be ineffective in unprimed breast tissue. Jelliffe
points out that the most important factor for continued pro- Fat (g/dL) 3.7 3!8
duction of milk is not drugs or hormones but “mulging.”33 Lactose (g/dL) 7.0 3!5 5.4
He explains that mulging (stimulation) is a word created by
Total protein 1.2 2!7 1.6
N. W. Pirie to mitigate the confusion between the words suck-
(g/dL)
ing and suckling. The word comes from the Latin mulgere, to
milk. Suck, according to the dictionary, means to draw into Sodium (mg/dL) 15 70 22.0
the mouth by means of a partial vacuum created by action of Potassium 50 5 19.8
the lips and the tongue.34 Suckle, however, refers specifically (mg/dL)
to the breast and means “to give suck to,” as at the breast, or
Calcium (mg/dL) 35 38
to take nourishment from the breast; thus, by definition, a
bottle is not suckled. Chlorine 45 50 18.4
(mg/dL)
Composition of Induced Milk Phosphorus 15 2
Concern has been expressed that the composition of the milk (mg/dL)
produced by stimulation of suckling rather than as a result of
Ash (mg/dL) 20 40!70
pregnancy might differ from “normal human milk.”35 Such
induced milk is not different in other species that have been
Properties
studied extensively, including bovine and rat milk. In devel-
Specific gravity 1030!1033 1031
oping countries, the fact that the infants showed normal
growth and weight gain was taken as evidence that induced Milk pH 6.8!7.3 7.3
milk is adequate. From Kulski JK, Hartmann PE, Saint WJ, et al. Changes in the milk
Kulski et al.36 reported the analysis of the galactorrheal composition of non-puerperal women. Am J Obstet Gynecol.
secretion produced by the breast after hyperstimulation; 1981;139:597 (reprinted with permission from the American College
Table 19.4 lists the comparative analysis of normal breast of Obstetricians and Gynecologists).

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636 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing

60 Biologic mother’s milk Albumin

25
Colostrum
50 Transitional
20
Total protein (mg/mL)

Mature
40 Milk from 5 nonbiologic
15
Non- mothers: 10 samples
biologic = SD
30 10
mother’s
milk
5
20
0
10 IgA
25
0
20
Days 0–5 6–15 16+ 0–5
n= 38 57 27 10 15

mg/mL
Fig. 19.2 Total protein changes over time: biologic versus non-
10
biologic mother’s milk, protein value 6 standard deviation. (From
Kleinman R, Jacobson L, Hormann E, et al. Protein values of milk
5
samples from mothers without biologic pregnancies. J Pediatr.
1980;97:613.)
0
55 α-Lactalbumin
milk with “galactorrhea milk” and milk from induced lacta-
tion. The induced lactational milk did not differ from puer- 40
peral milk. Brown reported higher values of fat, protein, and
lactose in galactorrheal milk.2 Kleinman et al. reported pro- 35
tein content changes over time and in the milk of biologic and 30
nonbiologic mothers. The volume of secretion was small in
these subjects (Figs. 19.2 and 19.3).37 25
The composition of the breast secretion produced by two
20
women who induced lactation artificially by breast hyperstim-
ulation was close to the composition obtained for women with 15
normal lactation, according to Kulski et al. (see Table 19.4).36
These investigators also examined the milk of a woman in 10
whom lactation had occurred when medicated with a psycho- 5
tropic drug (haloperidol). She had been pregnant 4 years pre-
viously. Her galactorrhea lasted 38 months. Her milk had a 0
composition like that of colostrum for a week but resembled Fig. 19.3 Concentrations of albumin, immunoglobulin A (IgA), and
mature milk at 1 month. A woman with hypothyroidism and α-lactalbumins: biologic versus nonbiologic mother’s milk. SD, Standard
elevated prolactin and thyroid-stimulating hormone (TSH) deviation. (From Kleinman R, Jacobson L, Hormann E, et al. Protein
had colostrum-like milk for 53 days of sampling. Two women values of milk samples from mothers without biologic pregnancies.
J Pediatr. 1980;97:614.)
with galactorrhea and amenorrhea associated with pituitary
tumor and hyperprolactinemia had transient colostrum-like
secretion, which changed to mature-appearing milk. In tandem nursing, when a mother continues to nurse an
Protein values of milk samples from five mothers without older child and puts an adopted newborn on the breast simul-
biologic pregnancies were measured by Kleinman et al.37 Two taneously, the composition of milk will not return to colos-
of the mothers had nursed previous babies, and three had trum as it does after a biologic pregnancy.
never been pregnant and had never breastfed. These authors Lactation has been induced in men, usually when a father
did not distinguish among them. The mean total protein con- tries to replace the mother who has died suddenly. A young
centration of milk samples from the “nonbiologic” mothers married man collected and froze several liters of normal
differs from that for “biologic” mothers (see Figs. 19.2 and appearing milk over a year’s time of taking estrogen and pro-
19.3). If the goal of induced lactation is nurturing, these dif- gesterone and using mechanical breast stimulation.
ferences are clinically less important. However, a clinician
needs to keep these values in mind when counseling a
mother!infant dyad about induced-lactation nutrition, espe-
cially if the infant was premature or small for gestational age.
MANAGEMENT OF MOTHER AND INFANT
A creamatocrit test for fat and energy content is an appropri- The collected experiences of counseling women in the
ate first step (see Chapter 22). Western world who want to induce lactation have resulted in

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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing
reports on several thousand women. The request for informa-
tion and advice is increasing and becoming widespread
throughout the United States and other Western countries.35
Because simple means of supplementing the nutritional
needs of an infant are available, counseling should center on
the relationship and the nurturing aspects. When the process
is undertaken in preindustrialized nations, the antiinfective
properties of human milk become important even though
total nourishment with human milk may not be possible. One
measure of success is having the infant content to nurse at the
breast.
A woman should be encouraged to go to a physician’s
office for a counseling visit before the arrival of the adopted
infant to discuss the process of induced lactation. The physi-
cian ideally has a lactation-friendly office. There are physi-
cians who specialize in breastfeeding and lactation. They can
be located by contacting the Academy of Breastfeeding
Medicine (ABM) at 8735 W. Higgins Road, Suite 300,
Chicago, IL 60631; (800) 990-4ABM (United States toll free);
phone: 847-375-4726; fax: 847-375-4713; email: abm@bfmed.
org; website: www.bfmed.org.
A couple who is planning to adopt an infant should have
at least one visit with a pediatrician so that parenting can be
discussed, just as any couple should do before the birth of a
first child. At this visit, while discussing lactation with the
couple, it is helpful to explore the motives and general con-
cepts of what is involved. All authors on the subject have
pointed out that a husband’s interest in, and support of, lacta-
tion is critical to success. His participation in the preparation
of the breasts may be a means by which the father can share
intimately and constructively in the process.
Equally important is to engage the services of a licensed,
board-certified lactation consultant (International Board!
certified lactation consultant [IBLCL]) who is preferably asso-
ciated with the physician’s office. The lactation consultant
will need to spend time in the day-by-day, week-by-week
counseling and support of the mother.
Instruction of a mother in preparation of the breasts for
suckling is critical in induced lactation, whereas with puer-
peral lactation it may not be necessary at all. Exercises to
stimulate the nipples should be undertaken several times per
day and will be most successful if they are scheduled for times
when, and situations in which, it is easy, feasible, and readily
remembered. A few minutes multiple times per day is more
successful and less likely to overemphasize milk versus moth-
ering than rigid excessive exercises once or twice per day.
Manual manipulation with gentle traction or horizontal and
vertical stretching can be suggested. Avery10 suggests that a
father be encouraged to assist in breast massage and other
techniques. She notes that “many adoptive parents felt that
this technique (fondling and sucking of the breasts by the
husband) added to the mutual sharing in preparation for
adoptive nursing similar to the closeness many couples expe-
rience in preparing for natural childbirth.” Raphael38 reports
that among 40 nursing adoptive mothers, dozens of varia-
tions on the theme of preparation were used. A positive atti-
tude seemed to be the only consistent factor.
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637
The need for dietary counseling is obvious. Lip service on
behalf of well-balanced nutritious meals is not enough.
Discussion should center on the absolute needs in kilocal-
ories, fluids, and nutrients to produce milk (see Chapter 8).
A physician should point out that stimulation of the nip-
ples may cause amenorrhea. Although the variation in men-
ses is not uniform, decreased flow, irregular cycles, and total
cessation of menstrual flow are possible. Conversely, the
menstrual cycle may be maintained and the flow of milk may
seem to vary during menses. Changes in breast size, heavi-
ness, and feeling of fullness should accompany the induced
lactation. A woman may have an associated weight gain of 10
to 12 lb (4.5 to 5.4 kg), on average, attributed to the response
of the body to developing stores for lactation, just as in preg-
nancy (i.e., increased fluid retention and appetite increase).10
The weight gain may be a simple phenomenon of excessive
intake. There is no need to gain excessive weight, however,
during this experience. Mothers (who may be nutritionally
depleted) in non-Western countries who induce lactation are
given added diet, nourishment, and herbal teas but do not
usually gain weight. Failure to experience change in breast
size, menstrual regularity, or weight should not be construed
as a failed response as it might be in pregnancy.
Auerbach and Avery39 reported a retrospective question-
naire study of 240 women: 83 had never been pregnant or lac-
tated, 55 had been pregnant but never lactated, and 102 had
breastfed one or more biologic children before the adoptive
nursing (lactation). Most respondents used more than one
technique to stimulate their nipples. These mothers stated
that the most effective method of nipple stimulation was nip-
ple exercises combined with infant suckling. Hand-operated
pumps caused soreness and irritation. The nipple exercises
included nipple stroking, massaging the breast, and rolling
the nipple between thumb and finger.
In this study, infants’ willingness to suckle improved over
time and was related to the age at which the infant was first
put to breast. Infants who were younger than 8 weeks of age
had more than a 75% success rate; those older than 8 weeks of
age had only 50% success. No infants failed to thrive, but
nearly all needed some type of supplementation. Mothers
who had nursed a biologic baby before were able to wean
from supplementation partially or completely. This group
was also more disappointed if they had to supplement.39
PROTOCOLS FOR INDUCED LACTATION
The Newman-Goldfarb protocols were developed by Dr. Jack
Newman and Ms. Lenore Goldfarb and are on the website Ask
Lenore at https://www.asklenore.info/breastfeeding/induced_
lactation/gn_protocols.shtml. Also available are protocols for
induced lactation with accelerated menopause. The protocols
use hormonal stimulus using birth control pills and domperi-
done initially until the breasts have responded and enlarged;
pumping is initiated within 1 month of the beginning of
feeding. Various herbs recognized as galactagogues are also
added.33 Domperidone is not available in the United States by
Food and Drug Administration mandate.16 The authors of
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638 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing
various protocols for induced lactation point out that starting
9 months before the baby arrives is ideal preparation time.
They also provide information for more rapid induction.
They do not recommend pumping until the hormone treat-
ment has been effective. They recommend stopping the hor-
mones as pumping is begun. Domperidone is maintained
throughout. A woman should always consult her own physi-
cian before starting any protocol or trying any medication,
hormones, or herbs.
Experience and Expert Opinion
Following personal experience, Bryant prepared a review,
“Nursing the Adopted Infant.”40 As a physician she was able
to view the issue as a physiologic, pharmacologic, and psycho-
logic challenge.
GUIDELINES FOR INDUCED LACTATION
The following simple guidelines, developed as a result of
experiences reported by several authors and many mothers,
may be helpful to physicians in counseling mothers to induce
lactation:
1. Before arrival of the baby, initiate frequent, brief manual
stimulation of nipples and breasts, increasing time gradually
to approximately 10 minutes per session. Initiate mechanical
pumping stimulus after 2 weeks or so of manual stimulus if
time permits. Hand pumps usually cause more soreness.
Modern electric pumps with milking action and pressure
cycling are most effective. Pumps that can be controlled in
cycle frequency and strength are best. Double-sided pumps
maximize stimulus and save time.
2. On arrival of the baby, depending on the infant’s age,
limit sucking to breastfeeding, using a lactation supple-
menter if necessary.
3. Breastfeed before any other nourishment is provided for
a given feeding.
4. Avoid stressing baby with hunger, responding in a
timely fashion to early hunger cues.
5. When supplementing, use donor human milk or
prepared formula, not cow’s milk, with its long stomach-
emptying time and potential for allergic response.
6. Avoid rubber nipples and pacifiers to encourage appro-
priate suckling at breast.
7. Provide other supplements by dropper, spoon, cup, or
supplementer.
8. Create a positive atmosphere; “mother the mother.”
A trial of oxytocin nasal spray once the infant is estab-
lished at the breast may facilitate let-down and even encour-
age prolactin release.
Rigid conformity to a system of feeding may be a symp-
tom of a more serious problem. Women who are rigid and
compulsive may have trouble lactating because of the inabil-
ity to have a good ejection reflex, which can be inhibited by
stress and emotional conflict. Mothers who demonstrate an
inordinate attention to volume of production of milk more
than the value of the relationship may feel as if they have
failed.
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WHEN ADOPTING MOTHERS ARE A SAME-
SEX COUPLE
• As inducing lactation for an adopted infant by same-sex
couples has become more common, so has the desire to
breastfeed the infant by both women in a lesbian
relationship.
• Physiologically inducing lactation is usually possible for
both women, although often one is the primary nursing
mother. A case is reported by Wilson et al. in which both
adopting women and the biologic mother breastfed the
infant.41 Milk induction was stimulated with hormones,
domperidone, and scheduled breast pumping. Defining
parental roles was complex and maintenance of milk
production was difficult.
• Inclusion, open discussion, respect, and consistent
lactation support are important when the infant of a
same-sex couple has been born to one member of the
couple by artificial insemination, and both women plan
to breastfeed the baby, one by lactation induction.
• A case is reported as an ethical issue when the physician
refuses to assist the patient inducing lactation.42 The
conclusion of the ethics consults was that the physician’s
objections were unfounded. The value to the infant
outweighed any objections. It was thought that the objection
showed a troubling unfamiliarity with the clinical facts of
lactation and a double standard for treating lesbian, gay,
bisexual, transgender, queer, plus (LGBTQ 1 ) patients and
heterosexual patients.42
RELACTATION OR REINITIATION OF
LACTATION
The initiation of lactation and establishing relactation in an out-
patient setting with mothers whose infants are younger than
6 weeks old in India is described by Banapurmath et al.; over
a thousand mothers were followed with 91.6% succeeding
in establishing lactation within 10 days.43 Proper latch was
reported to be essential for success. Focus was on understanding
the process, positioning, and building confidence. Medications
were not used. Establishing lactation in India for mothers who
are adopting babies usually in social crises is challenging.
Another report from India was done of 23 mothers, all of whom
were given metoclopramide 10 mg twice a day for 15 to 20
days. They put the baby to breast immediately on receipt of the
infant.12 Motivation was critical to success. Lactation has been
induced in a primiparous woman with Sheehan syndrome (see
Chapter 15), which is usually described as a delivery in which
there is excessive loss of blood and maternal shock that also
shocks the pituitary. Most of these women develop permanent
hypopituitarism. A patient of our Lactation Study center in
Rochester, NY suffered such an event. The mother had an emer-
gency hysterectomy. She wished desperately to breastfeed. She
was given daily oxytocin by nasal spray and pumped the breasts
with increasing frequency. She began producing milk in 2 weeks
and fully lactating in 4 weeks. The infant was 36 weeks’
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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing
gestational age when admitted to the neonatal intensive care
unit (NICU). She nursed the infant for a year, although she had
hypopituitary function.
Early successful relactation in a case of prolonged lactation
failure was reported by Agarwal and Jain.44 The case was
a mother with hemorrhage and shock at delivery. At 31/2
months the infant was very ill with diarrhea, dehydration,
and shock as a result of formula intolerance. The mother
induced lactation with the drip and drop method. A tube was
used along the breast just beyond the nipple and an assistant
presses on the syringe causing milk to drip as the infant
suckles, similar to the Lact-Aid device. Supplement was given
by cup and spoon until the mother’s milk supply was enough
to sustain the infant.
Relactation was reported in a series of 15 mothers being
managed in a clinic in Davangere, Karnataka, India, who had
stopped breastfeeding for 2 weeks or more.43 The mothers had
stopped because they thought they did not have enough milk
and began supplementing. The management began immedi-
ately with putting the infant to the breast 10 to 12 times per
day for at least 10 to 15 minutes on each breast. Key to success
was the pouring of milk (formula or donor milk) by spoon or
small cup by a helper (a nurse or relative). The amount of milk
dripped over the breast was reduced as a mother’s supply
increased until the process could be stopped. The group of
mothers included two with premature infants and two surro-
gate mothers who had not breastfed for 16 and for 6 years,
respectively. Milk appeared at 7 and 8 days of pumping, and
exclusive breastfeeding was accomplished in 45 and 40 days,
respectively. Follow-up and support were intense. Babies were
seen and weighed weekly. Of the 15 mothers, 10 were exclu-
sively breastfed and 5 continued with some supplementation.
The authors encourage clinicians to initiate relactation when-
ever a mother thinks her supply has dwindled.
These protocols have not been tested with placebo-
controlled blinded studies but reflect the experience of a num-
ber of practitioners.
Nutritional Supplementation
The need to supplement an infant’s intake while the milk sup-
ply is being developed should be discussed. An older infant
who has already been receiving solid foods can be continued
on solids by spoon with careful attention to nutritional con-
tent so that the diet includes a balance of protein and other
nutrients. Supplements with milk or formula should be
appropriate to the age of the infant. The infant younger than
12 months should receive infant formula rather than whole
milk if donor breast milk is not available. The milk supple-
ments should be full strength, 20 kcal/oz, and provided dur-
ing the feeding by dropper or supplementer or after the
nursing by dropper, spoon, or cup in preference to artificial
nipple, which may confuse the infant during adaptation to
nursing at the breast.
Postmenopausal Lactation
Women have had infants after menopause thanks to modern
fertility techniques and hormone therapy. The question arises
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639
as to whether these woman can breastfeed. They will require
maintenance hormone therapy paralleling levels in postpar-
tum lactating women. The oxytocin and prolactin should
respond with removal of the placenta and suckling of the
infant at the breast. Three cases have been reported to the lac-
tation center in which producing milk was successful. No
long-term follow-up was available.
A postmenopausal woman may wish to induce lactation.
Some of these women are young and had surgical menopause;
however, most of them had emergency hysterectomies and
still retain their ovaries. The situations are different, and the
treatment is different.
In natural menopause, the woman may be on hormone
replacement therapy, which should be modified to match
pregnancy levels of estrogen and progesterone. A program of
regular systematic dual pumping should be initiated with
the addition of galactagogues, such as domperidone, after the
breast has responded with enlargement, turgescence, and the
first drops of milk. The woman who has retained her ovaries
can be managed in the same manner as a premenopausal
woman.
Support Systems
The process of induced lactation requires considerable com-
mitment and determination.45 It is far more arduous a task
than initiating postpartum lactation, but it is possible and
worth the effort, according to the many mothers who have
attempted it. The situation is better managed if a doula is
available. It is appropriate for a physician to suggest that, in
addition to medical support, the mother seek counseling from
a licensed, certified lactation consultant experienced in
induced lactation. Day-by-day contact for verbal support may
be helpful, and these needs may be beyond the scope of a busy
office practice unless there is a lactation consultant on staff.
A nurse practitioner may be invaluable in this situation, par-
ticularly if home visits are made.
Ensuring that the child grows appropriately is the respon-
sibility of a pediatrician; however, this task is best carried out
in a nonthreatening way so a mother can concentrate on nur-
turing and nourishing the infant.46 Monitoring the usual
growth parameters of weight and height and the patterns of
voiding and stooling is essential.
Psychological Factors
Although the general process of nipple stimulation, having
the infant suckle the breast, and setting the stage for lactation
is similar, a woman who has experienced successful lactation
previously may have not only the physiologic but also the psy-
chologic edge. As Jelliffe wrote decades ago, “Breastfeeding is
a confidence game.”33
Prospective Study
A prospective study of mothers whose infants were in
the NICU in Durham, North Carolina, was reported by
Bose et al.47 The profile of the mothers is listed in Table 19.5.
Mothers and babies were admitted to the clinical research unit,
where they were assisted with relactating, including help using
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TABLE 19.5 Historical and Clinical Data of Mothers in Relactation Study

Time
Time From Last to Time to
Lactation to First Half Time to
Time From Delivery Entry Into Postpartum Breast Breast Milk Complete
Case Gestational to Entry Into Study Study Breast Milk Supplyb Relactation
No. Age (Days) (Days) Involutiona (days) (days) (days)
1 Term 10 10 None 1 4 8
2 Term 120 120 Incomplete 4 20 28
c
3 Twins, 31 wk 49 49 Complete 7 28 Never
4 32 wk 70 42 Complete 7 39 Never
5 28 wk 150 135 Complete 9 Never Never
6 32 wk 30 16 None 4 17 58
7 Term 5 yr 5 yr Complete 21 Never Never
(adopted)
a
Mothers were asked if their brassiere size was different from that before this pregnancy.
b
Estimated on the basis of a decrease in formula intake.
c
Ceased to suckle her infants after 28 days in the study to return to full-time employment.
From Bose CL, D’Ercole J, Lester AG, et al. Relactation by mothers of sick and premature infants. Pediatrics. 1981;67:565.

the Lact-Aid. The infants’ nutritional intake was recorded.
Mother and infant were discharged when the mother was
comfortable with the Lact-Aid and feeding was established
(approximately 3 days). Follow-up occurred every week or
two. All but one infant were initially reluctant to suckle, but all
received their entire nutritional intake at the breast, with or
without Lact-Aid, within the first week of the study. Most of
the mothers had trouble initiating suckling, with the most sig-
nificant factor being the length of separation from their infants
and not the degree of prematurity, postnatal age, weight, or
feeding regimen. Nipple tenderness occurred in all mothers,
but it was transient. All the mothers (except number seven,
who was an adoptive mother) produced milk in 1 week, with
maximum milk production occurring from 8 to 58 days, pro-
portional to the time since delivery.
Although it was done with a small population, this study
established some important information. Given appropriate
techniques and support, many women appear to be able to
relactate and premature infants can learn to breastfeed after
initial bottle-feeding.
A retrospective study of relactation was reported by
Auerbach and Avery48 in which 366 women responded with a
completed questionnaire of more than 500 contacted from a
list of names obtained from manufacturers’ lists, magazine
ads, and requests to breastfeeding support groups. The bias
was in favor of well-educated, affluent women who had prob-
ably obtained their lactation goals. The population included
those who had untimely weaning (n 5 174), after delivery of
low-birth-weight infants (n 5 117), and after hospitalization
of mother or baby or both (n 5 75). Three quarters of the
study participants rated their experience positively, often
stressing the importance of nursing to the mother!infant
relationship. Milk production was less often a goal, but when
it was, it was more likely to influence the mother to evaluate
her experience negatively and result in difficulty in achieving
a total milk supply.48
Previous Suckling Experience
An infant’s willingness to nurse was related to previous suck-
ling experience, but responses in the first week of effort were
not directly correlated with ultimate successful suckling.
After 1 month, 50% of mothers were able to discontinue sup-
plementing; however, 24% were never able to eliminate sup-
plements completely. Once established, the nursing patterns
were similar to those of ordinary breastfeeding. The authors
point out that keeping the baby hungry in the mistaken
notion that the infant will nurse more often and for longer
periods does not help and may negatively influence outcome.
It is of interest that fewer than 10% of respondents thought
that they had received helpful advice from health care
professionals.48
Relactation in mothers of children older than 12 months
of age have been reported.49 Six Australian children 12 to 18
months of age had been weaned by their mothers, with no
further stimulus to the breast, and then were reinitiated to
breastfeeding. The length of time without breastfeeding ran-
ged from 1 week to 6 months (Table 19.6). All of the children
had been actively weaned and initiated the suckling, although
the mothers did not forcibly resist. All of the mothers reestab-
lished milk supplies and nursed for 48 months to 5 years.49
Tandem Nursing
Tandem nursing an adopted child is a phenomenon in which
the adoptive mother is still nursing a biologic child and puts
an adopted infant to the breast and intends to nourish the
newcomer totally. Usually the older child is a toddler and

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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing 641

TABLE 19.6 Relactation in Mothers of Children Older Than 12 Months of Age

Length of How Long from Age at
Case Time Off Evidence of Presence Relactation to Final
No. Age of Child Breast Methods of Milk Weaning Weaning
1 48 mo 4 mo Child suckled from Child verbally reported After milk appeared 48 mo
breast presence of milk
Mother relaxed, not Mother saw whitish milk
anxious over outcome
2 12 mo 1 wk Child took four feeds Milk had not quite dried up 1 yr 2 yr
daily
3 201/2 mo 21/2 mo Mother gave in to Mother noticed child’s .10 mo Sometime
demands of child and swallowing while after
suckled her breastfeeding 21/2 yr
4 2 yr 1 mo Child suckled from both Mother saw the milk flow was Approximately 1 yr . 3 yr
breasts avidly enough to soak the bed next
morning
Mother heard swallowing
5 . 3 yr 6 wk Child suckled from both Mother saw the milk Approximately 2 yr 5 yr
breasts Mother noticed swallowing
6 Approximately Approximately Mother attached child Mother began to feel let-down 12 mo Almost
2 yr 6 mo to breast to of milk 3 yr
demonstrate

From Phillips N. Relactation in mothers of children over 12 months. J Trop Pediatr. 1993;39:45.

feeding only a few times per day or for comfort and receiving
the major nourishment from other food and drink. In bio-
logic tandem nursing, the milk returns to colostrum-like con-
stituency with the birth of the new baby; in the absence of a
pregnancy, however, the milk volume may increase with
increased nipple stimulus while the constituents do not
change. Data on milk constituents beyond a year postpartum
or in the case of relactation have been noted earlier. In most
cases reported anecdotally, the adopted infant is several weeks
or months old, so the absence of colostrum is less of a prob-
lem. On the other hand, the active state of lactation in terms
of immediate availability of milk is an advantage.
An additional concern, as in any situation of tandem nurs-
ing, is the development of the younger child. The physician
will need to be alert to these issues in counseling the family
and ensuring adequate total nutrition for the adopted child.
Eighteen respondents to the survey on adoptive nursing by
Auerbach and Avery39 reported tandem-nursing experiences;
11 of these mothers were able to discontinue supplements
totally (two within the first month). Most of the infants were
started on solids by 41/2 months, which may be the most
effective method of supplementing if nutritional value is
maintained. For physicians, it is important to be knowledge-
able about tandem adoptive nursing and to support the family
accordingly.
Drugs to Induce Relactation
Some medications that have been tried in relactation seem to
work only when the breast has been primed by mammogen-
esis, that is, by pregnancy.
Thyrotropin-releasing hormone (TRH) use has been
reported by Tyson50 and Brodribb32 to induce lactation (see
Table 19.2). Each woman in the study was primed with estro-
gens beforehand. Thyroliberin (also known as TRH) stimu-
lates the pituitary to release both TSH and prolactin. Drugs
that produce a decrease in hypothalamic catecholamines,
such as phenothiazines, reserpine, meprobamate, ampheta-
mines, and α-methyldopa, cause an increase in prolactin
secretion by blocking hypothalamic PIF.
The feasibility of pharmacologically manipulating puer-
peral lactation was demonstrated by Canales et al.51 using
bromocriptine and thyroliberin sequentially.51 They sup-
pressed lactation using bromocriptine orally for 8 days in four
mothers whose infants were premature or ill and could not be
nursed. These mothers did not lactate during this time. On
the 8th day, they were given thyroliberin intravenously and
then orally daily for 4 days (8th to 12th postpartum days). On
the 14th day, they initiated breastfeeding by putting the
infants to the breast. Prolactin levels were measured from the
day of birth. Levels were depressed by bromocriptine and rose
when the thyroliberin was given. The mothers subsequently
nursed successfully. Bose et al.47 also studied thyroliberin and
the basal and stimulated serum prolactin concentrations.
Prolactin Concentrations
Prolactin concentrations were measured followed by levels at
15 and 30 minutes after intravenous infusion of 200 mg (range
100 to 500 mg) of thyroliberin. Prolactin levels were also mea-
sured before and after suckling at weekly intervals. Serum pro-
lactin levels rose 15 minutes after infusion of thyroliberin or

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thyrotropin-releasing hormone (TRH) (Table 19.7). The abso-
lute rise in prolactin concentrations did not appear to be related
to establishment of milk production. The change over time in
the basal prolactin levels was not predictably related to lactation
progress.
Lactation can be reestablished with metoclopramide,
according to Sousa et al.52 Metoclopramide is a derivative of
procainamide, as is sulpiride (see Chapter 11).
Metoclopramide and sulpiride are potent stimulators of
prolactin release.53 A marked increase in prolactin is seen
when metoclopramide is given, as noted previously in this
chapter. Sousa et al.52 used metoclopramide to reestablish lac-
tation in women who had experienced diminished milk sup-
ply (Table 19.8). All five mothers experienced increased
production of milk when 10 mg was given orally every 8 to
12 hours for 7 to 10 days. No side effects were noted, although
this drug is known to cause cardiac arrhythmias and extrapy-
ramidal signs in some adults. No side effects were noted in
the infants, but the level of drug was not measured in the
milk. The results were encouraging, but further study is
needed to determine the minimum dosage necessary to pro-
duce the effect and the amount passed into the milk.
In a controlled double-blind study with a placebo, Lewis
et al.54 found no difference in the success rate of induced lac-
tation in 10 patients medicated with 10 mg metoclopramide
orally three times daily for 7 days compared with 10 matched
patients medicated with lactose capsules. Successful lactation
was attributed to the special advice and support provided
equally for these women by the nursery staff. Before conduct-
ing the study, these authors measured the amount of drug

TABLE 19.7 Basal and Stimulated Serum Prolactin Concentrations (ng/mL)

Case
TRH STIMULATION SUCKLING STIMULATION: PRESUCKLING/POSTSUCKLING
No.
15 min/ 4th!5th 6th!7th 8th!9th
Basal 30 min 1st wka 2nd wk 3rd wk wk wk wk
1 179.2 611.1/423.5 136.9/155.4 72.3/123.8 — — — —
2 38.7 80.9/70.3 17.2/119.3 38.6/214.3 16.6/180.6 186.2/244.5 — —
3 19.9 89.6/77.3 17.9/23.5 — — — — —
4 9.5 89.9/63.4 12.5/12.7 — 7.0/437.6 5.5/47.3 — —
5 13.9 40.6/36.3 21.1/58.2 37.8/82.0 38.3/57.7 77.2/98.5 24.6/54.2 —
6 31.7 335.6/274.7 9.5/11.4 — 16.5/18.4 11.8/16.3 7.8/13.3 —
b
7 43.6 78.8/69.9 8.8/59.6 17.0/77.7 — — 34.4/147.1 19.2/60.5
a
Suckling test performed on day 1 or 2 of study.
b
In this mother, the suckling test was done first, followed 1 h later by thyrotropin-releasing hormone (TRH) infusion; thus 8.8 is the true basal
concentration.
From Bose CL, D’Ercole J, Lester AG, et al. Relactation by mothers of sick and premature infants. Pediatrics. 1981;67:565.

TABLE 19.8 Data Regarding Mothers Taking Metoclopramide

Age
Age of of Daily Length of Education
Case Mother Infant Dose Treatment Side Level of
No. (y) (mo) (mg) (days) Effects Results Mother
1 27 2 30 6 None Increase in milk University
volume;
infant not weaned
2 25 10 30 10 None Same as above University
3 29 1 20 7 None Same as above High
school
4 35 3 30 7 None Same as above University
5 20 2 20 7 None Same as above High
school

From Sousa PLR, Barros FC, Pinheiro GNM, et al. Reestablishment of lactation with metoclopramide. J Trop Pediatr Environ Child Health.
1975;21:214.

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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing
that appeared in the milk of 10 women after a single 10-mg
dose of metoclopramide given orally at 7 to 10 days postpartum.
The mean 2-hour postdose plasma level was 68.5 6 29.6 ng/mL.
The simultaneous mean concentration in the breast milk was
125.7 6 41.7 ng/mL. If an infant consumed a liter of milk per
day, the dose to the infant would be calculated at 130 mg or
45 mg/kg, a subtherapeutic dose. These data do not address pos-
sible accumulation in the infant, however, when multiple doses
are given to the mother.
Domperidone has a better track record anecdotally for
stimulating lactation but has not been studied in induced lac-
tation or relactation. Herbal agents such as fenugreek have
not been studied for this purpose either but could be used as
an adjunct to protocol.55
SPECIAL DEVICES
Although many mechanical devices have been developed
since Roman times to augment lactation and give other feed-
ing opportunities, lactation-supplementing devices provide a
unique ability to adequately nourish an infant while the infant
is suckling at the inadequately lactating breast (see Fig. 19.1).
The suckling stimulates the mother’s own supply. On the
other hand, the infant continues to suckle the breast because
milk is available. The devices have been carefully engineered
to provide a source of milk that is obtained by suckling, not
by gravity. The capillary tube through which the milk flows
can be placed along the human nipple without interfering
with suckling. The plastic containers that serve as reservoirs
for the supplemental milk are sterilizable or disposable. The
milk is naturally warmed by hanging the bag beside the
mother’s breast, as shown in Fig. 19.1.
Gradual weaning from the supplementer can be provided
by putting increasingly less in the container each day. Thus the
infant can obtain milk from the breast in increasing amounts
because the nipple stimulation affects milk production.
An increasing number of mothers want to nurse their sick
premature infants; however, it is often not possible for the
infant to breastfeed for weeks. Meanwhile, the mother may
pump but only obtain minimal volume. When the infant is
finally ready for discharge from the hospital, it is mandatory
that the baby continue to receive reliable nourishment every
day. Starving the infant into submission is inappropriate and
dangerous. A lactation supplementer is an excellent alternative
for providing adequate nourishment and continuing stimulat-
ing suckling at the breast to increase milk production.
For years, mothers of premature and sick infants have been
assisted in breastfeeding their infants in preparation for dis-
charge from the hospital and during the early weeks at home
by using dropper feeding, complementary feeds by bottle after
each breastfeeding, or solids. The success rate was low and the
aggravation for the mother often insurmountable.
Weaning From the Device
Weaning from the supplementation device is usually not a
problem for most of the infants. It was a problem, however,
for an occasional mother who could not nurse without the
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supplementer even though it contained less than an ounce of
formula per feeding and the breast was supplying the rest.
Because the mother may use this as a “crutch,” careful antici-
patory counseling should address this issue.
Use of a supplementation device should be started with a
full understanding of its role in nourishment of infants and
with a plan for weaning from it that begins the first day.
Weaning should be appropriate to an infant’s age and nutri-
tional needs. The nourishment provided should be donor
human milk or regular-strength formula, 20 kcal/oz, and not
just water, sugar water, or diluted formula. Starvation, even
for a day or so in a premature infant, can compromise growth,
especially of the brain. An infant who has been in the inten-
sive care nursery is in special jeopardy.
Several alternative devices have been suggested by profes-
sionals interested in the transient supplementation of lacta-
tion while a mother increased her milk supply for her full-
term baby. Usually in these situations, lactation failure has
been the result of inadequate initial advice. The devices are
rigged from readily available feeding tubes and syringes but
lack the special engineering and safety features of the supple-
menter. Special precautions are advised when employing
such handmade equipment to avoid milk aspiration by the
infant, which is the chief hazard. Because they will allow milk
to flow without sucking, they do not stimulate the infant to
suck. Other devices, such as hand pumps and a variety of elec-
tric pumps, which are useful in initiating relactation or
induced lactation and in puerperal nursing, are illustrated in
Chapter 22.
RELACTATION DURING DISASTERS
Relactation has assumed new significance as the plans for
disaster preparedness are reviewed. World attention has been
drawn to major disasters, hurricanes, earthquakes, tsunamis,
tornadoes, and fires that leave infants without their mothers to
nurse them (see Chapter 23). Such disasters have allowed peo-
ple to recognize the value and safety of human milk and breast-
feeding when simple things such as clean water, sanitation,
heat, and light are not available. Brown recounts the experience
of 100,000 orphans in the city of Saigon during a disaster,
many of whom were newborns who ended up breastfeeding.2
In times of disaster, surrogate mothers were housed in orpha-
nages, fed well, and received a daily dose of chlorpromazine for
a week. Many women were able to nourish two babies.
The need to relactate exists in a number of circumstances,
including the following:
1. A sick or premature infant cannot be fed initially, or at
all, until several weeks or months old (Fig. 19.4).
2. An infant is weaned prematurely because of illness in
the infant or in the mother.
3. An infant who was not previously breastfed develops an
allergy or food intolerance.
4. A mother who has lactated weeks, months, or years
earlier wants to nurse an adopted infant.
5. A mother who is nursing a biologic child wants to nurse
an adopted child (without benefit of pregnancy).
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644 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing
Fig. 19.4 Premature infant at breast: infant weighed 1300 g at time
of photograph.
6. A town or village is in a time of crisis in the area and
infants need clean, safe food.
Historical reviews provide many examples of infants suck-
led in times of crisis by women who have not lactated for
years. The process of reestablishing lactation under these cir-
cumstances is generally easier than that of nonpuerperal lac-
tation. Investigations have shown that a breast that has been
previously primed by pregnancy to respond to prolactin will
produce milk more readily but the majority of women can
succeed at relactating.2,24,28,48
WET NURSING, CROSS-NURSING,
CO-FEEDING, OR MILK SHARING
Although feeding an infant by one who is not the mother is an
established means of sustaining life, it has been uncommon in
Western cultures. There are no medical contraindications pro-
vided the nursing woman is in good health, was infection free,
and was taking no medications. The threat of human immu-
nodeficiency virus (HIV) infection has reinforced the need for
assessing the risk-to-benefit ratio in a given situation of one
woman providing breast milk for another woman’s child. In
special cases, surrogate nursing would be acceptable by indi-
vidual arrangement, with HIV testing in both mother and
infant. The chief obstacles have been psychologic or social.
Women who are trying to develop a supply of milk when their
own infants cannot nurse because of prematurity or illness
would be benefited by having a vigorous, normal suckling
infant nurse at their breasts.
In contemporary society, the term cross-nursing has
replaced wet nursing to disassociate the phenomenon from
negative historical connotations.56 In reviewing mothers’
experiences of sharing breastfeeding or breast milk, Thorley1
offered a new term to replace cross-nursing: co-feeding. She
points out that wet nursing initially was an occupation and
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was done for hire and did not include any reciprocity. When
sisters or friends nurse each other’s infants, reciprocity exists.
The term co-feeding is thought to suggest sharing. The term
milk siblingship has been proposed to suggest the bond
between children breastfed by the same woman. In cross-
nursing the mother continues to breastfeed her own child in
addition to the child she takes for a feeding or two per day.
The circumstances described in the report by Krantz and
Kupper56 usually involve babysitting arrangements, which
may be daily and formal or random and informal. They inter-
viewed three women involved in a mutual agreement for
babysitting purposes. The mothers were married and well-
educated. The babies were girls and 4 months old. The
mothers reported no physical effects on the babies. The
behavioral reactions of the babies were being disturbed and
“looking puzzled” if the surrogate mother spoke. Some diffi-
culty was noticed in let-down, and all three mothers noted a
difference in the way each baby suckled.
Another purpose of cross-nursing is for maternal benefit,
wherein an experienced, vigorous infant is nursed by a
woman whose own baby is unable to give proper stimulus to
milk production. This has been done by private arrangement
and has not caused any known problems. Usually the normal
newborn is younger than 2 months. Cross-nursing also has
been used to stimulate lactation in adoptive nursing. In this
situation, the infants are exchanged to stimulate the adoptive
mother’s breasts and also to show the adopted infant that
milk comes from breasts and how to suckle at the breast.
Cross-nursing had been used in NICUs by mothers to
encourage their own milk production. It is usually a private
arrangement between mothers who have babies to nourish.
A mother of an immature infant who could not be put to the
breast sought out a friend who was actively feeding a full-
term infant and borrowed the infant to stimulate her produc-
tion. An infant who needs to learn how to suckle correctly
after weeks of bottle-feeding or no feeding may benefit from
being nursed by a fully lactating woman. The best pump is
always a suckling infant.
The hazards to cross-nursing are undocumented but wor-
thy of consideration. The physical problems are the potential
for infection, either of mother or of baby; interruption of milk
supply for the mother’s own baby; and the difference in com-
position of milk if babies are of different chronologic or con-
ceptual ages. The psychologic hazards could include failure of
mother let-down, refusal of infant to nurse (which does occur
when infants are introduced to the practice after 4 months of
age), and negative impact on siblings and the household envi-
ronment. The long-range effects are not documented.
Reasonable caution is certainly appropriate, taking care to
ensure that the cross-nursing mother is healthy and well-
nourished without any general or local infection, not taking
any medications, and not smoking. The infants probably
should be close in age to the mother’s own baby and also free
of infection, including thrush. If this were a commercial ven-
ture in a public daycare setting, regulations of certification and
screening for tuberculosis, syphilis, hepatitis, cytomegalovirus,
herpesvirus, HIV, and other infectious agents would be in
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 CHAPTER 19 Induced Lactation and Relactation (Including Nursing an Adopted Baby) and Cross-Nursing
order. Documents of liability might be required with signed
consent forms. Mothers’ experiences of sharing breastfeeding
or breast milk were reviewed in Australia from 1978 to 2008
by Thorley.1 The objective of the study was to explore the
mothers’ experiences when they shared breastfeeding, why it
was done, and the process used. The most common reason to
participate was to provide human milk for their babies, exclu-
sively, including whenever they were separated from their
infants or temporarily unable to feed the infants themselves.
Most of the respondents to the survey were selective about
with whom they would share. They otherwise found positive
response from friends and health care professionals, although
they noted a change in attitude in the 30 years.
Various cultural “rules” exist for milk-sharing. In Chinese,
Japanese, and Thai families, milk can be shared only for
infants of the same sex. Moslem tradition is strict in its ban
on marriage between children who had the same wet nurse.
In some cultures, breast milk is a conduit of ancestral power.
Sharing is restricted to the same clan or lineage.
Informal milk sharing is a more recent terminology that
describes various situations (not directly nursing) of sharing
of breast milk by donor mothers with infants of other mothers
without using milk banks. The exchange of breast milk occurs
between relatives, friends, connections made specifically for
exchange, connections made through websites, and now
more directly person to person over the Internet. The respon-
sibility for safe milk exchange is born by the donor and the
parents of the infant to receive the milk. The ABM has issued
a position statement on informal breast milk sharing to pro-
vide guidance to health care providers about the safe sharing
of breast milk for the term healthy infant.57 The statement
emphasizes a “mother-to-mother” screening process regard-
ing the donor mother’s health, any medication use, most
recent prenatal and postnatal infectious screening tests (HIV,
hepatitis B or C virus, human T-cell leukemia virus type 1) or
risk for such infections, and social practices of the donor
mother related to marijuana, alcohol, smoking, or illegal drug
use. The statement also provides guidelines for “home pas-
teurization” of donated breast milk using the flash heating
method.
Perhaps as breastfeeding knowledge and understanding reach
a greater number of professionals and women, such opportu-
nities may be more common. At present, it is significant to recog-
nize cross-nursing as a viable option, as long as appropriate
infection precautions are taken, or safe informal milk sharing can
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be practiced by using the ABM’s recommendations for appropri-
ate use of shared breast milk. A hospital or a physician should
not be the agent of arrangement or exchange.
SUMMARY
Relactation or induced lactation may be practiced in a variety
of situations to provide breast milk to an infant in need.
Careful medical management of an adopted infant who is
breastfed is important. Many times the prenatal care of this
infant as a fetus in utero and the biologic mother has not been
optimal. Any failure in growth should be identified quickly so
that appropriate supplementation can be provided. In cases
of relactation to provide for sick or premature infants, close
follow-up is mandatory. A child who does not have a power-
ful suck may appear to be content yet be underfed.
Relactation and induced lactation are special events
requiring the positive support of medical personnel.46 A phy-
sician can serve as a well-informed stable resource in a pro-
cess that will require considerable effort and commitment by
the participants and will go better if there is an experienced
licensed IBLCL available as a supporter. A pediatrician is
responsible for monitoring adequate growth, nutrition,
adjustment, and development of the child.
Mother-Initiated Preparation
1. Nipple stimulation: Hand massage and nipple exercise,
hand pump, electric “milkers”
2. Diet supplementation: Fluids and calories, especially
protein
3. Reading, learning, and communicating with others with
similar experience
Physician-Initiated Preparation
1. Knowledgeable, sympathetic support
2. Preparatory hormones and lactagogues to promote mam-
mogenesis for prescription
3. Induction of let-down: Oxytocin nasal drops to initiate
or enhance let-down
4. Counseling about breast preparation and diet supple-
mentation in the context of total care of the mother and
the infant
5. Appropriate use of pumping milk extraction devices and
of lactation-supplementing devices
The Reference list is available at www.expertconsult.com.
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