Re Lactation And Induced Lactation

RELACTATION and INDUCED LACTATION by Marie Rose S. Yabut, MD Fellow, Philippine Obstetrical & Gynecological Society Consultant, Department of Obstetrics & Gynecology Amang Rodriguez Medical Center Cardinal Santos Medical Center

INDUCED LACTATION process by which a nonpuerperal woman is stimulated to lactate RELACTATION process by which a woman who has given birth but did not initially breastfeed is stimulated to lactate, or may have initially breastfed her infant, weaned him, then wishes to reinstitute lactation

RELACTATION Milk supply re-established after lactation has stopped *infant weaned prematurely because of illness

Breastfeeding began after prior postpartum lactation suppression *sick or premature infant cannot be fed initially *to nurse an adopted infant *delayed desire for breastfeeding

Breastfeeding resumed after weaning to formula feeding *infant allergic to formula

INDUCED LACTATION Milk supply is established for an adopted baby (adoptive breastfeeding)

Mother never pregnant Mother has not been pregnant for years Goal: NURTURING with the emphasis on nursing, not on “breastfeeding” or nutrition

Historically: To provide nourishment for an infant whose mother has died in childbirth or unable to nurse the baby for some reason Used in times of disaster or epidemics to provide safe nutrition to weaned or motherless infants

COMMON PROBLEMS Baby imprinted to artificial nipples Baby tires at the breast Mother’s guilt feelings Baby is older, mother’s hormone level is low Lack of nipple stimulation Adoptive mother has no prolactin level elevation

SUCCESSFUL RELACTATION or INDUCED LACTATION • Mot iva tion How m uch doe s s he wan t? Why doe s s he wan t? • Emo ti ona l prepa ra ti on Bab y’ s i ni ti al re sistan ce Fre quency o f suckli ng • Patie nce , Su pport, Spec ial Techniqu es

RELACTATION BASIC TECHNIQUE Better prenatal preparation Nipple stimulation Diet supplementation (fluids & calories, esp. protein Reading, learning, & communication with others with similar experience

Support system From physician, counselor, other mothers, husband

Cont. RELACTATION BASIC TECHNIQUE

Preparatory hormones & lactagogues may be considered Induction of let-down Oxytocin nasal spray Frequent nursing On demand, unrestricted

Use of lactation supplementing devices

Nursing supplementer

SYRINGE SUPPLEMENTER

LACT-AID NURSING TRAINER SYSTEM

Drugs to Induce Relactation (works in breasts primed by mammogenesis)

Thyrotrophin-releasing hormone ↓ Pituitary ↓ ↓ TSH Prolactin

Drugs that block hypothalamic PIF  Phenothiazines  Reserpine  Meprobamate  Amphetamines  Ά-methyldopa  Metoclopramide

10mg orally q 8hrs x 7 – 10 days  Sulpiride

INDUCED LACTATION BASIC TECHNIQUE

Induce lactation around one to two months before baby arrives Basic learning in lactation management Breast pumping/manual breast expression/nipple stimulation Manual manipulation (gentle traction, or horizontal & vertical stretching, fondling & suckling of the breasts by the husband) Onset of lactation 1 – 6 wks

Cont…..INDUCED LACTATION BASIC TECHNIQUE

Herbal teas & galactagogues Good nourishment for the mother Positive attitude, commitment & determination

Be present at the delivery of baby for bonding for first feeding

Cont…..INDUCED LACTATION BASIC TECHNIQUE

Stimulate as much as possible the natural biological techniques of breastfeeding Be present in as many feedings as possible while baby is in hospital Breastfeed before any other nourishment is given Avoid stressing baby with hunger

Cont…..INDUCED LACTATION BASIC TECHNIQUE

When supplementing, use donor human milk or appropriate infant formula (not cow’s milk with its long stomachemptying time)

Cont…..INDUCED LACTATION BASIC TECHNIQUE

Avoid rubber nipples or pacifiers Provide other supplements by dropper, spoon, cup, or nursing supplementer) Medela’s Supplemental Nursing System or Lact-Aid Nursing System

Create positive atmosphere

Cont…..INDUCED LACTATION BASIC TECHNIQUE

Monitor: amount of supplement number of wet diapers bowel movements weight of baby

Follow all instructions for relactation

Drugs to Induce Lactation: Oxytocin nasal spray (Let-down reflex) Short duration of use only

Chlorpromazine (increase Prolactin) 25 – 100 mg TID x 7 – 10 days

Theophylline (increase Prolactin) Metoclopramide (increase Prolactin) IV, IM, oral

Lactagogues

LACTAGOGUES Special food, drinks, or herbs believed to increase milk supply Don’t work like drugs Psychological effect (?) Nutritional effect

Cont. LACTAGOGUES Malunggay tulya/halaan/other shellfish broth other soups & herbal teas milk (?) alcoholic drinks (???) fenugreek seed blessed thistle herb brewer’s yeast, oats warm cereal drinks garlic capsule

DRUGS TO INCREASE MILK SUPPLY Chlorpromazine phenothiazine derivative dopamine antagonist tranquilizer, antiemetic sedative effect in large doses in women, causes moderate breast engorgement & lactation Dose: 25mg TID x 7 – 10 days may repeat course once

Cont….DRUGS TO INCREASE MILK SUPPLY

Metoclopramide dopamine antagonist induces release of prolactin without CNS effects of phenothiazines Dose: 10 to 15mg TID for up to 3 months Theophylline Domperidone (Motilium) Dopamine antagonist Anti-emetic/anti-nausea Increases prolactin levels Not readily cross blood-brain barrier Dose: 20 -20 mg QID till milk secretion is fully established

Cont….DRUGS TO INCREASE MILK SUPPLY

OCP (Yasmin or Microgestin) 3 mg Drospirenone For breast development OCP + Domperidone = milk production OCP + Domperidone + Baby = copious milk production OCP + D + B + Herbs, Oatmeal + Water = RECIPE FOR INCREASED MILK SUPPLY

SUMMARY Don’t be too focused on how soon and how much milk will be produced or the length of time they nurse their babies. Few mothers ever produce a quantity or quality of milk that will totally satisfy baby and provide all his needs. It is realistic to be prepared to need some supplemental formula.

Look at the effort in terms of the enhancement of the mother-baby relationship. While total nourishment by breast milk may not be possible in all cases of relactation and induced lactation, mother and baby can still enjoy the emotional and physical benefits of breastfeeding. What is important is the whole act of breastfeeding and the close bonding it entails.

Remember, it is the quality of your relationship, not the quantity of milk, that is desirable. It is possible the baby may not be totally breastfed.

The ultimate goal of breastfeeding is the nurturing of a happy, healthy baby.

PROTOCOLS for INDUCING LACTATION & MAXIMIZING MILK PRODUCTION: The REGULAR PROTOCOL: Suitable for intended mothers expecting a baby via surrogacy or adoptive mothers with a long lead time 1.Six months (or longer) before birth: Take the “active” pill OD + Domperidone 10mg QID x 1 wk, then increase to 20mg QID.

Cont REGULAR PROTOCOL

1. Five months before baby is due, “active” birth control pill + Domperidone 20mg QID 2. Four months before baby is due, same regimen 3. Six wks before birth, stop birth control pill, continue Domperidone 20mg QID. Over the next 2 weeks: Pump breasts every 3hrs: a) Pump 5-7 min on low or medium setting b) Massage, Stroke, Shake c) Pump 5-7 min

Cont REGULAR PROTOCOL

1. One month before baby is due, continue Domperidone 20mg QID & pumping (during the day + at least once at night). > Once pumping has started, can add HERBS: Blessed Thistle herb 390mg cap- 3 capsules TID Fenugreek seed 610mg cap3 capsules TID > Domperidone taken ½ hr before meals > Oatmeal for breakfast at least 3x a week

Cont REGULAR PROTOCOL

1. Once baby arrives, Domperidone 20mg QID until substantial milk supply is achieved or mother is ready to wean.

The ACCELERATED PROTOCOL: • Yasmin or Microgestin is taken for 30-60 days non-stop (active pills only) + Domperidone 20mg QID. • If significant breast changes occur in 30 days, pill stopped & pumping schedule begins + herbs. Pumping with a double electric breast pump. A hand pump is just not up to the job.

The MENOPAUSAL PROTOCOL: • • •

Yasmin or Microgestin once a day x 60 days + Domperidone 10mg QID x 1 wk then increase to 20mg QID Once with significant breast changes, stop Yasmin, maintain Domperidone & begin pumping with double electric breast pump. Can add the herbs.

THANK YOU!!!