Dena Goffman, MD and Peter Bernstein, MD, MD

Disclosures

November 17, 2005

Question

I have a patient who is going to adopt a newborn in early October. She would like to breastfeed the baby. Are there any reliable medications to induce lactation, or should she simply begin trying to pump in the near future?

Response from Dena Goffman, MD and Peter Bernstein, MD, MD

Human milk is recognized as the optimal feeding for all infants, although preterm infants often require nutritional supplementation. The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life and partial breastfeeding (breastmilk plus complementary foods) for at least 12 months and as long as mutually desired thereafter.[1] Well-recognized short-term benefits to the infant include improved nutrition, gastrointestinal function, host defense, and psychological well-being. Breastfeeding is also associated with long-term benefits to the infant, both short and long-term benefits to the mother, and economic benefits for the family and society.[2]

Given that it is well recognized that breastfeeding provides ideal nutrition and has many additional benefits, the question about breastfeeding in the setting of adoption is an important one. Adopted infants in developing countries are usually breastfed, and successful lactation without the need for supplementation is crucial for the survival of adopted infants.[3] Fortunately, success has been documented.[3,4,5] In industrialized countries, where supplemental feeds are readily available and are of good nutritional quality, lactation may not be required for survival but may provide substantial benefit to the mother and infant.

It is possible for women who have never been pregnant or have never lactated to successfully breastfeed. With the use of preparation, medications, artificial aids, tried techniques, and significant support, induced lactation can be achieved. Preparing the breast can entail both administering medications and performing techniques. In women who are nulliparous or have never lactated, priming the breast with ethinyl estradiol 50 micrograms 3 times daily, or with 1-time administration of depot medroxyprogesterone acetate 100 mg intramuscularly, is recommended. Preparation of the breast should also be started in advance by using a breast pump for regular stimulation of the nipples.[3]

Galactagogues are medications that can induce or enhance breast milk production and have been used for inadequate milk supply, induced lactation and relactation. The most extensively studied galactagogue, documented to be safe and effective, is metoclopramide (Reglan). Metoclopramide is a central dopamine antagonist that acts to stimulate prolactin release. Recommended dosage options include 10 mg 2 to 4 times daily, followed by a taper rather than abrupt cessation. Potential side effects include fatigue, anxiety, dizziness, diarrhea, and gastric cramping; more rarely, extrapyramidal symptoms or depression may develop. There have been no documented reactions in infants exposed to metoclopramide in breast milk.[6] Chlorpromazine 25 mg 4 times daily can be used as an alternative to or in conjunction with metoclopramide. On rare occasions, when unsuccessful, methyldopa 125 mg 4 times daily may be added.[3]

Domperidone (Motilium) acts as a peripheral dopamine antagonist and also increases serum prolactin and milk yield. This is the only galactagogue proven effective through a small double-blind, placebo-controlled trial. It has fewer maternal side effects, and no side effects have been reported in infants exposed via breast milk. However, in the United States, domperidone can only be dispensed by a compounding pharmacy, and cost varies.[6]

Fenugreek, a European herb from the pea family, has anecdotally been reported to increase milk production, although data are lacking. It is theorized to stimulate sweat production, which may enhance milk secretion since the breast is a modified sweat gland. The usual dose is 2 to 3 capsules 3 times a day until adequate milk production is attained.[6]

Oxytocin, either oral or nasal spray, has been used in women with inadequate milk supply and is reported to cause a milk "letdown" effect. The medication causes contraction of the cells surrounding the alveoli and thus stimulates milk ejection, which may improve production by decreasing stasis.[6] Given the mechanism of action, it seems that the use of oxytocin alone would be less useful in attempts to induce lactation.

To optimize breastfeeding potential, infants should be put to the breast as soon as possible after birth and frequently thereafter, about every 2 hours. Artificial nipples should be avoided as babies learn different suckling techniques. To promote suckling when there is a lack of breast milk, formula can be poured over the areola from a cup or dropper to promote suckling. When supplementation of breast milk is necessary initially, other options include formula feeds given immediately after suckling with a cup and spoon or the use of Lact-aid. Lact-aid is a line attached to a pack which supplies formula through a feeding tube placed beside the maternal nipple. The infant learns to suckle at the breast while obtaining nutrition and does not become accustomed to a bottle. Supplementation is gradually reduced as maternal milk supply increases.[4]

Successful induction of lactation has been reported in adoptive mother-baby pairs. A group of 240 adopted infants is described in which 80% were previously bottle-fed, 35% of the mothers were nulliparous and 23% had never previously breastfed. Of these infants, 75% were willing to nurse by the end of the first week of trying, and more than 75% of mothers felt positive about their lactation experience; 54% required supplementation for the duration of nursing, but 25% of women who had never been pregnant before were able to eliminate supplements completely before weaning off the breast. The benefit of bonding was generally felt to be more important than milk production.[5]

With appropriate medical treatment, use of techniques, motivation, perseverance, and support, breastfeeding is a realistic option, with significant benefits to both mother and infant, in the setting of adoption.

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