by Jody Segrave-Daly, RN, IBCLC and Lynnette Hafken, MA, IBCLC
Our goal is to ensure you have the accurate information you need for the best chance of success, with adequate attention to your mental and physical health and well being.
Before you start, it is important to manage your expectations. The limited research we have shows that while most mothers can produce some milk, developing a full milk supply is often not the case, especially under these very stressful pandemic circumstances. Please be very gentle to yourself throughout the process, because all sorts of feelings can come up. This study talks about those feelings.
In considering relactation, mothers need to consider the big picture. There are cons…:
- time spent pumping that takes time away from other important things, such as interaction with baby, sleep, and caring for other children
- less free time for mom, which is important for mood and stress levels
- potentially disappointing results
- mental health considerations
…as well as pros:
- another source of milk for the baby
- passive immunity from breast milk*
- for mothers who enjoyed breastfeeding, an additional way to spend more one-on-one time with baby
- feeling a sense of agency in a time when we have little control over our lives
*Since COVID-19 is caused by a novel coronavirus (SARS-CoV-2), no one has antibodies to prevent infection unless they have either been exposed to it or recovered from it. Once a mother is exposed and starts developing antibodies, it takes around two weeks to build up antibodies to have a clinical impact as passive immunity protection.
Here are our answers to commonly asked questions about relactation:
How do I relactate?
Part 1: Breast Milk Production Basics
Breast milk production depends on these things: prolactin and oxytocin hormone levels, nipple stimulation, milk removal, and individual breast physiology. Prolactin is the hormone that stimulates your mammary glands and causes milk to be produced. Prolactin has been called the “nurturing hormone,” because it is associated with caretaking behavior. Oxytocin is the other main hormone involved in lactation; it causes milk release during breastfeeding. Oxytocin can also be stimulated by environmental cues, such as hearing a baby cry, smelling or looking at your baby, and even the sound of your breast pump running.
Note: You should also review any medications you’re on with your doctor, as some can affect milk production. If you are taking hormonal birth control, you may want to switch to a non-hormonal method. LactMed is a good resource for any questions or concerns you have about medications and breastfeeding.
Part 2: Creating a Relactation Plan
Generally speaking, you can expect to commit to at least two weeks of stimulation before seeing milk production results. It takes at least 30 days of relactation effort to get a good idea of what your milk supply will be. There are several ways to create a relactation plan, and they each have pluses and minuses. Before you start, it is important to develop a support system, as this will be very time-consuming. Your family should take on all daily chores for the duration of this process, including making sure you have sufficient food and water.
Your pump should be a good quality double electric pump and if finances allow, consider renting a hospital grade pump. Having several pump kits to use will reduce the amount of washing and sanitizing parts in between pumping sessions. It is very important to change the valve membranes every 30 days, to have proper pump flange sizes(link), and to protect your nipples from getting sore by using a food grade lubricant before pumping to reduce friction (olive oil works well). Do not use lanolin as it is too sticky. A hands-free pumping bra is essential.
Plan 1 is the most time consuming, but most likely to result in more milk more quickly:
- Pump eight times a day on both breasts for 15–20 minutes using hands-on pumping techniques. Your first-morning session should be a power pump (see sample schedule below).
- Hand express before pumping for three to five minutes.
- Spend some time every day cuddling your baby skin to skin (the amount of time should be what you find enjoyable rather than a certain number of minutes).
- Offer to latch your baby occasionally, as a playful or relaxing activity with no pressure.
A typical schedule might look like this:
8:00 a.m.: pump 15–20 minutes
11:00 a.m.: pump 15–20 minutes
2:00 p.m: pump 15–20 minutes
5:00 p.m.: pump 15–20 minutes
8:00 p.m: pump 15–20 minutes
11 p.m.: pump 15–20 minutes, then go to bed. Another family member gives the baby a bottle while the mother sleeps for the next five hours.
4:00 a.m. to 5:00 a.m.: Power pump while someone else gives the baby a bottle.
Latch your baby as much as she’s willing, and use your pump when you can. If your baby will latch reliably, “parallel pumping” is more efficient than nursing followed by pumping.
Some relactation protocols suggest taking away the bottle and pacifier and only feeding the baby with a tube at the breast or with a cup. Mothers have frequently told us they found these alternative feeding methods stressful and time-consuming, so we will leave that decision up to individual parents.
Plan 2 is easier to work into your regular schedule, but you are likely to produce less milk and it may take longer. Many mothers find this to be a reasonable trade-off, as it allows more time for other important activities such as sleep. Doing some or all of the following should result in milk production of various amounts:
- Power pump for an hour, or two thirty-minute sessions, whenever you have time during the day, using hands-on pumping techniques.
- Do not wake up at night specifically to pump, but if you’re up anyway, do some pumping before going back to bed (unless you are too tired).
- Hand express whenever you can, such as in the shower; even if you’re not able to collect the milk, you’re sending the signal to the “factory” to ramp up production.
- Keep a hand pump within reach to use for when you have 5–10 minutes but not enough time for a full pumping session.
- Do a full pumping session (15–20 minutes) when you can, as opposed to doing it on a schedule.
- Continue to offer the breast to your baby (remember, no pressure).
Plan 3 is to take what you want from Plans 1 and 2 and create a plan that works best for you.
Other tips you can use in addition to the above:
- Audio cues during pumping, such as the sound of your baby crying or cooing
- Scent cues such as smelling your baby’s head or an item of clothing he’s worn
- Looking at your baby and focusing on the cute things he does
- Guided meditation for lactating mothers
- Imagining other sounds or images that remind you of letdown or milk release (such as picturing a waterfall and then changing that image in your mind to your breasts releasing a “waterfall” of milk); guided imagery is also freely available on the internet.
- Try to make sure you are doing enough self-care and getting sufficient sleep
What are my chances of success?
The answer to this question depends on how you define success. We define success as satisfaction with the amount of milk produced without adverse effects on the mother. Most mothers who attempt relactation do produce milk, sometimes a little, and more rarely, a lot. It is unfortunately not possible to predict how much an individual mother will produce. There have been case reports and very small studies of mothers who have been able to produce a full milk supply, however larger and higher quality research, like meta-analysis, needs to be done in order for us to understand best practices and to predict outcomes. Publication bias is also likely (relactation cases with negative outcomes are less likely to be submitted or published). The concept of “relactation” is often poorly defined in the literature; in some studies babies were still partially breastfed when “relactation” was attempted, and in others, “successfully relactated” could mean full or partial lactation. Few studies followed infant weight gain or health, or maternal satisfaction, for a significant time after relactation was achieved.
Factors that are typically associated with relactation success are:
- shorter time since cessation of lactation
- full milk supply prior to weaning
- support from family and health care providers
- younger infant
- age and health of the mother
- maternal motivation*
*motivation is a slippery concept, because it can be a cause of success or it can be an effect of success; mothers who are having more success may find they are increasingly motivated, whereas mothers who are putting in a lot of effort and seeing little results naturally lose motivation. It is also a term that is emotionally loaded. After years of running the FIBF support groups, we are painfully aware of how the concept of “maternal motivation” can be used to victim-blame. It is included here to reflect what the published literature states, but we would like readers to be aware of the connotations and limited definition of that term.
When trying to relactate, it is important to cultivate an attitude of acceptance of whatever amount of milk you end up producing. It would of course always be nice to have more, but remember—your worth as a mother is not based on milk production; it is based on your caring and love for your baby.
How long before I see results?
If you have recently stopped lactating, you may still be able to express drops. You should plan to spend a few weeks building your supply to the maximal level your body is able to produce at this time. If you have not lactated for several months, it may take 30 days or longer before you reach a ceiling (the point at which your supply stabilizes and further increases are not possible).
Will herbs or foods help increase milk production?
There are many herbs and foods that some cultures have traditionally used to increase milk production such as oats, fennel, and brewer’s yeast; however, there is no scientific evidence that these provide anything more than a placebo effect. That said, the placebo effect is real, and may help with milk production even if you are aware it is a placebo. Fenugreek should not be used, as it can have dangerous side effects such as low blood sugar, painful intestinal cramping for both mom and baby, and can reduce milk supply. With regard to food for lactating parents, our only advice is to eat sufficient calories and drink enough fluids to stay well hydrated.
I want to take Reglan or Domperidone to help increase my supply; is this a good idea?
You will need to talk to your physician to determine if prescribing medication is a good choice for you. Reglan is contraindicated for those who have a history of depression and in rare cases can cause side effects such as involuntary muscle movements. Domperidone can have serious cardiac side effects, and for this reason, it is banned in the US. In countries where it is prescribed, mothers should talk to their doctors about their cardiac history and request an EKG prior to considering this drug. Safety in infant feeding is our number one priority, for baby and mother.
What kinds of adverse physiological or emotional concerns should I watch out for and when will I know if I should stop trying to relactate?
- insufficient sleep
- obsessive feelings about number of milliliters produced
- a sense of panic about not being able to increase milk production
- increased stress or change in quality of life
- insufficient time for self-care and relationship with spouse and other children
If you experience these side effects, we recommend reevaluating whether relactation is the best way to provide for your baby. As stated above, although anxiety is understandable, there is no shortage of formula. Your mental health is important both because you are important, and because it can impact your relationship with your baby, partner, and family.
What are some ways I can encourage my baby to latch? :
Before answering this question, we want to emphasize that your baby has a say in whether he wants to breastfeed directly or not. Latching should be approached as an experiment, not as something you need to “get” your baby to do, and experiments take time and patience. You and your baby will also have the best chance of success if you adopt a no-pressure attitude. Here are some strategies that tend to work well:
- Supplementing at breast using a dropper, syringe, or supplemental nursing system (the presence of milk can be used to coax baby to breast and encourage him to maintain latch and continue swallowing)
- Offering your breast while carrying your baby in a wrap
- Giving most of the feeding using a bottle, then offering the breast at the end of the feeding as “dessert”
- Offering your breast when your baby is half asleep (“dream feeding”)
- Trying a nipple shield (some babies will latch more readily since nipple shields are similar to the bottle nipples they have been used to. Baby can be weaned off of the shield once he is reliably latching)
- Nursing in a place that is free of distractions for mother and baby, or in a darkened room while listening to soothing music.
- Offering to breastfeed while rocking in a rocking chair or glider.
As you can see, relactation usually takes a lot of effort and time; it can also have emotional, physical, and relationship effects. We have heard many different reactions from mothers who were asked afterward “was it worth it?”
We do want to know about your relactation experiences so we can give advice and tips to other mothers. We want to know the good, the bad, and everything in between. Above all, #wesupportyou!
Jody Segrave-Daly is a champion for debunking pseudoscience in the breastfeeding community because parents need to be truly informed when making parenting decisions. She is also a staunch advocate for protecting underfed exclusively breastfed babies and is the reason why she co-founded the Fed Is Best Foundation. She provides parents with the most up to date scientific resources and includes her extensive neonatal nursing knowledge and infant feeding clinical experiences, to help parents make the best infant feeding decision that works for them. Are you a lactation consultant who wants to join our infant feeding team? Contact Jody directly at email@example.com
https://sci-hub.se/https://www.liebertpub.com/doi/abs/10.1089/bfm.2011.0026 (10% succeeded in relactating but it’s implied that it was partial relactation, not exclusive bf)