re lactation and induced lactation

RELACTATIONand

INDUCED LACTATION

by Marie Rose S. Yabut, MDFellow, Philippine Obstetrical &

Gynecological SocietyConsultant, Department of Obstetrics & Gynecology

Amang Rodriguez Medical CenterCardinal Santos Medical Center

INDUCED LACTATIONINDUCED LACTATION

process by which a nonpuerperal process by which a nonpuerperal woman is stimulated to lactatewoman is stimulated to lactate

RELACTATION RELACTATION

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

INDUCEDINDUCED LACTATIONLACTATION

Milk supply is established for Milk supply is established for an adopted baby (an adopted baby (adoptive adoptive

breastfeedingbreastfeeding) ) Mother never pregnantMother never pregnantMother has not been pregnant Mother has not been pregnant for yearsfor years

Goal: NURTURING with the emphasis on Goal: NURTURING with the emphasis on nursing, not on “breastfeeding” or nursing, not on “breastfeeding” or nutritionnutrition

Historically:Historically:

To provide nourishment for an To provide nourishment for an infant whose mother has died in infant whose mother has died in childbirth or unable to nurse the childbirth or unable to nurse the baby for some reasonbaby for some reason

Used in times of disaster or Used in times of disaster or epidemics to provide safe epidemics to provide safe nutrition to weaned or motherless nutrition to weaned or motherless infantsinfants

Baby imprinted to artificial nipplesBaby imprinted to artificial nipples

Baby tires at the breastBaby tires at the breast

Mother’s guilt feelingsMother’s guilt feelings

Baby is older, mother’s hormone level Baby is older, mother’s hormone level is lowis low

Lack of nipple stimulationLack of nipple stimulation

Adoptive mother has no prolactin Adoptive mother has no prolactin level elevationlevel elevation

COMMON PROBLEMSCOMMON PROBLEMS

SUCCESSFUL RELACTATION or SUCCESSFUL RELACTATION or INDUCED LACTATIONINDUCED LACTATION

MotivationMotivation

How much does she How much does she want?want?

Why does she want?Why does she want? Emotional preparationEmotional preparation

Baby’s initial resistanceBaby’s initial resistance

Frequency of sucklingFrequency of suckling Patience, Support, Special Patience, Support, Special

TechniquesTechniques

RELACTATIONRELACTATIONBASIC TECHNIQUEBASIC TECHNIQUE

Better prenatal preparationBetter prenatal preparationNipple stimulationNipple stimulation

Diet supplementation (fluids & Diet supplementation (fluids & calories, esp. proteincalories, esp. protein

Reading, learning, & communication Reading, learning, & communication with others with similar experience with others with similar experience

Support systemSupport systemFrom physician, counselor, other From physician, counselor, other mothers, husband mothers, husband

Preparatory hormones & lactagogues may be considered

Induction of let-downOxytocin nasal spray Frequent nursing

On demand, unrestricted

Use of lactation supplementing devices

Cont. RELACTATION BASIC TECHNIQUE

Nursing supplementer

LACT-AID NURSING TRAINER SYSTEM

SYRINGE SUPPLEMENTER

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

Thyrotrophin-releasing hormoneThyrotrophin-releasing hormone↓↓

PituitaryPituitary ↓ ↓ ↓ ↓ TSH ProlactinTSH Prolactin

Drugs that block hypothalamic PIFDrugs that block hypothalamic PIF PhenothiazinesPhenothiazines ReserpineReserpine MeprobamateMeprobamate AmphetaminesAmphetamines ΆΆ-methyldopa-methyldopa MetoclopramideMetoclopramide

10mg orally q 8hrs x 7 – 10 days10mg orally q 8hrs x 7 – 10 days SulpirideSulpiride

INDUCED LACTATIONBASIC TECHNIQUE

Induce lactation around one to Induce lactation around one to two months before baby arrivestwo months before baby arrives

Basic learning in lactation Basic learning in lactation managementmanagementBreast pumping/manual breast Breast pumping/manual breast expression/nipple stimulationexpression/nipple stimulation

Manual manipulation (gentle traction, Manual manipulation (gentle traction, or horizontal & vertical stretching, or horizontal & vertical stretching, fondling & suckling of the breasts by fondling & suckling of the breasts by the husband)the husband)Onset of lactation 1 – 6 wksOnset of lactation 1 – 6 wks

Herbal teas & galactagoguesHerbal teas & galactagogues

Good nourishment for the motherGood nourishment for the mother

Positive attitude, commitment & Positive attitude, commitment & determinationdetermination

Be present at the delivery of babyBe present at the delivery of babyfor bondingfor bonding

for first feedingfor first feeding

Cont…..INDUCED LACTATION BASIC TECHNIQUE

Stimulate as much as possible Stimulate as much as possible the natural biological techniques the natural biological techniques of breastfeedingof breastfeeding

Be present in as many feedings as Be present in as many feedings as possible while baby is in hospitalpossible while baby is in hospital

Breastfeed before any other Breastfeed before any other nourishment is givennourishment is given

Avoid stressing baby with hungerAvoid stressing baby with hunger


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


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


Monitor:Monitor:amount of supplementamount of supplement

number of wet diapersnumber of wet diapers

bowel movementsbowel movements

weight of babyweight of baby

Follow all instructions for Follow all instructions for relactationrelactation


Drugs to Induce Lactation:Drugs to Induce Lactation:

Oxytocin nasal spray Oxytocin nasal spray (Let-down reflex)(Let-down reflex)

Short duration of use onlyShort duration of use only

Chlorpromazine Chlorpromazine (increase Prolactin)(increase Prolactin)

25 – 100 mg TID x 7 – 10 days25 – 100 mg TID x 7 – 10 days

Theophylline Theophylline (increase Prolactin)(increase Prolactin)

Metoclopramide Metoclopramide (increase Prolactin)(increase Prolactin)

IV, IM, oralIV, IM, oral

LactagoguesLactagogues

LACTAGOGUESLACTAGOGUES

Special food, drinks, or herbs Special food, drinks, or herbs believed to increase milk supplybelieved to increase milk supply

Don’t work like drugsDon’t work like drugs

Psychological effect (?)Psychological effect (?)

Nutritional effectNutritional effect

Cont. LACTAGOGUESCont. LACTAGOGUES

MalunggayMalunggay

tulya/halaan/other shellfish brothtulya/halaan/other shellfish broth

other soups & herbal teasother soups & herbal teas

milk (?)milk (?)

alcoholic drinks (???)alcoholic drinks (???)

fenugreek seedfenugreek seed

blessed thistle herbblessed thistle herb

brewer’s yeast, oatsbrewer’s yeast, oats

warm cereal drinkswarm cereal drinks

garlic capsule garlic capsule

DRUGS TO INCREASE MILK DRUGS TO INCREASE MILK SUPPLYSUPPLY

ChlorpromazineChlorpromazine

phenothiazine derivativephenothiazine derivative

dopamine antagonistdopamine antagonist

tranquilizer, antiemetictranquilizer, antiemetic

sedative effectsedative effect

in large doses in women, causes in large doses in women, causes moderate breast engorgement & moderate breast engorgement & lactationlactation

Dose: 25mg TID x 7 – 10 daysDose: 25mg TID x 7 – 10 days

may repeat course oncemay repeat course once

MetoclopramideMetoclopramide

dopamine antagonistdopamine antagonist

induces release of prolactin without CNS induces release of prolactin without CNS effects of phenothiazineseffects of phenothiazines

Dose: 10 to 15mg TID for up to 3 monthsDose: 10 to 15mg TID for up to 3 months

TheophyllineTheophylline

Domperidone (Motilium)Domperidone (Motilium)

Dopamine antagonistDopamine antagonist

Anti-emetic/anti-nauseaAnti-emetic/anti-nausea

Increases prolactin levelsIncreases prolactin levels

Not readily cross blood-brain barrierNot readily cross blood-brain barrier

Dose: 20 -20 mg QID till milk secretion is fully Dose: 20 -20 mg QID till milk secretion is fully establishedestablished

Cont….DRUGS TO INCREASE MILK SUPPLY

OCP (Yasmin or Microgestin)OCP (Yasmin or Microgestin)

3 mg Drospirenone3 mg DrospirenoneFor breast developmentFor breast development

OCP + Domperidone = OCP + Domperidone = milk productionmilk production

OCP + Domperidone + Baby = OCP + Domperidone + Baby = copious milk productioncopious milk production

OCP + D + B + Herbs, Oatmeal + Water =OCP + D + B + Herbs, Oatmeal + Water =RECIPE FOR INCREASED MILK SUPPLYRECIPE FOR INCREASED MILK SUPPLY

Cont….DRUGS TO INCREASE MILK SUPPLY

SUMMARYSUMMARY

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

Look at the effort in terms of the Look at the effort in terms of the enhancement of the mother-baby enhancement of the mother-baby relationship. relationship.

While total nourishment by breast milk While total nourishment by breast milk may not be possible in all cases of may not be possible in all cases of relactation and induced lactation, mother relactation and induced lactation, mother and baby can still enjoy the emotional and baby can still enjoy the emotional and physical benefits of breastfeeding.and physical benefits of breastfeeding.

What is important is the whole act of What is important is the whole act of breastfeeding and the close bonding it breastfeeding and the close bonding it entails.entails.

Remember, it is the quality of your Remember, it is the quality of your relationship, not the quantity of milk, relationship, not the quantity of milk, that is desirable.that is desirable.

It is possible the baby may not be It is possible the baby may not be totally breastfed.totally breastfed.

The ultimate goal ofThe ultimate goal of

breastfeeding isbreastfeeding is

the nurturing of a the nurturing of a

happy, healthy happy, healthy baby.baby.

PROTOCOLS for INDUCING PROTOCOLS for INDUCING LACTATION & MAXIMIZING MILK LACTATION & MAXIMIZING MILK PRODUCTION:PRODUCTION:

The REGULAR PROTOCOL:The REGULAR PROTOCOL:

Suitable for intended mothers expecting a Suitable for intended mothers expecting a baby via surrogacy or adoptive mothers baby via surrogacy or adoptive mothers with a long lead timewith a long lead time

1.Six months (or longer) before birth: 1.Six months (or longer) before birth: Take the “active” pill OD + Take the “active” pill OD + Domperidone 10mg QID x 1 wk, then Domperidone 10mg QID x 1 wk, then increase to 20mg QID.increase to 20mg QID.

2.2. Five months before baby is due, “active” Five months before baby is due, “active” birth control pill + Domperidone 20mg birth control pill + Domperidone 20mg QIDQID

3.3. Four months before baby is due, same Four months before baby is due, same regimenregimen

4.4. Six wks before birth, stop birth control pill, Six wks before birth, stop birth control pill, continue Domperidone 20mg QID. Over continue Domperidone 20mg QID. Over the next 2 weeks: Pump breasts every the next 2 weeks: Pump breasts every 3hrs:3hrs:

a) a) Pump 5-7 min on low or Pump 5-7 min on low or medium settingmedium setting

b)b) Massage, Stroke, ShakeMassage, Stroke, Shakec)c) Pump 5-7 minPump 5-7 min

Cont REGULAR PROTOCOL

5.5. One month before baby is due, continue One month before baby is due, continue Domperidone 20mg QID & pumping Domperidone 20mg QID & pumping (during the day + at least once at night).(during the day + at least once at night).>> Once pumping has started, can Once pumping has started, can add HERBS:add HERBS:

Blessed Thistle herb 390mg Blessed Thistle herb 390mg cap- 3 capsules TIDcap- 3 capsules TID

Fenugreek seed 610mg cap- Fenugreek seed 610mg cap- 3 capsules TID3 capsules TID

>> Domperidone taken ½ hr before Domperidone taken ½ hr before mealsmeals>> Oatmeal for breakfast at least 3x a Oatmeal for breakfast at least 3x a

weekweek


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


The ACCELERATED PROTOCOL:The ACCELERATED PROTOCOL:

1.1. Yasmin or Microgestin is taken for Yasmin or Microgestin is taken for 30-60 days non-stop (active pills 30-60 days non-stop (active pills only) + Domperidone 20mg QID.only) + Domperidone 20mg QID.

2.2. If significant breast changes occur in If significant breast changes occur in 30 days, pill stopped & pumping 30 days, pill stopped & pumping schedule begins + herbs.schedule begins + herbs.

Pumping with a double Pumping with a double electric breast pump. A electric breast pump. A

hand hand pump is just not pump is just not up to the job.up to the job.

1.1. Yasmin or Microgestin once a day x 60 Yasmin or Microgestin once a day x 60 days +days +

2.2. Domperidone 10mg QID x 1 wk then Domperidone 10mg QID x 1 wk then increase to 20mg QIDincrease to 20mg QID

3.3. Once with significant breast changes, Once with significant breast changes, stop Yasmin, maintain Domperidone & stop Yasmin, maintain Domperidone & begin pumping with double electric breast begin pumping with double electric breast pump. Can add the herbs.pump. Can add the herbs.

The MENOPAUSAL PROTOCOL:The MENOPAUSAL PROTOCOL:

THANK YOU!!!

re lactation and induced lactation

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