When my husband and I decided to adopt, I immediately began researching how I could breastfeed this special baby. I had breastfed my two children by birth, and I knew that breastfeeding was an important part of how I mother a baby. I was very lucky because I had experience with breastfeeding and because, as an accredited La Leche League leader, I had access to plenty of support, information, and resources. Thinking about all the prospective adoptive mothers who do not have the breastfeeding background I have led me to write Breastfeeding Without Birthing: A Breastfeeding Guide for Mothers Through Adoption, Surrogacy, and Other Special Circumstances.

I believe that every mother and baby deserve the chance to breastfeed. Even if that baby did not grow in that mother’s uterus. Even if that baby is not a newborn. Even if that mother is not fertile. We are incredible, adaptive beings. Adoptive breastfeeding is one amazing example.

Breastfeeding is so much more than lactation, and the amount of milk produced may not be the most important aspect or biggest benefit. It is a relationship that fosters trust and connection between mother and baby through frequent close physical contact, as well as on a hormonal level. Thus, I use a deliberately broad definition of breastfeeding. It includes the mother who:

• Provides 100% of her baby’s food by suckling from her breast
• Provides some of her baby’s food by suckling from her breast, and offers the remainder as expressed milk or formula in a bottle or other feeding device
• Produces little-to-no milk and feeds her baby expressed milk or formula through an at-breast supplementer
• Comforts her little one at the breast without providing milk
• Produces milk that she pumps from her breasts and gives to her baby in a bottle.

One mother described adoptive breastfeeding as “one of the best experiences of my life. Worth every minute of frustration"(Cheales-Siebenaler, 1999). Yes, breastfeeding without birthing is challenging. It takes time and effort, but most women who attempt it find it immensely rewarding on many levels. The foundation of successful breastfeeding for all mothers, and this is especially true for mothers with special circumstances, is a strong support system. With that support system behind her, an adoptive mother can put together a plan for adoptive breastfeeding, which includes latching her baby at the breast and making milk, also known as inducing lactation. I will give an overview of each. If you have the desire to breastfeed your child, here’s what you need to know to get started.

First Questions: Adoptive Breastfeeding

After learning that, yes, breastfeeding is an option for them, adoptive mothers-to-be have many questions about the process. Here are the most common ones I hear, and the answers I give:

How much milk will I produce? This is usually the first question mothers-to-be ask me. I would love to tell them a certain number of ounces per day, or a percentage of their baby’s intake, but I can provide only a broad range. Milk production is influenced by many factors, some of which you have control over (quality and quantity of physical stimulation of the breasts, and the use of herbs and medications), and some that you may not (certain health issues, the prevalence of breastfeeding in your culture, and your prior breastfeeding experience). Most mothers from Western countries who induce lactation produce 25 to 75 percent of their baby’s nutritional needs (Auerbach & Avery, 1981). Some mothers can provide 100 percent of their baby’s nutritional needs. Some are not able to produce any milk.

How long will it take? In most cases, it takes at least a month to prepare the breasts to start making milk. Occasionally, it takes longer. The amount of time it takes to start producing the first droplets of milk does not indicate how much milk you will be able to eventually produce (Starr, 2008).

Can I breastfeed an older baby? Yes, although the process of learning to latch will likely take longer for an older baby, because the instincts for breastfeeding diminish over time. Just as it’s impossible to predict how much milk you will produce, it is impossible to predict how long it will take, or how difficult it may be, to get baby to latch at the breast. Despite the challenges, children as old as four years at placement have learned to breastfeed (Gribble, 2004).

When you induce lactation, is the milk different? Human milk contains over 200 components designed to meet the needs of infants. Only one study, including only two mothers, has investigated the composition of milk produced after inducing lactation. The two mothers in the study produced milk similar in composition to that of mothers who had birthed their babies. Although most mothers who induce lactation do not reach full milk production, their milk contains the same number of antibodies and other immune factors as mothers who birth and exclusively breastfeed their babies (Kulski et al., 1981).

Enlisting Support

Establishing a support network is the first and, arguably, the most important step for any mother planning to breastfeed. Mothers breastfeeding under special circumstances will need some specialized support. Some of those who can provide support are people you already know, some are people you can seek out.

Partner: Your partner, if you have one, may be the most important source of breastfeeding and mothering support (HHS, 2011; Wolfberg et al., 2004; Pisacane et al., 2005; Tohotoa et al., 2009). It is important that your partner understands why breastfeeding is important, why you have chosen to do it, and knows to hang in there when your hormone levels begin changing. Partners can also offer practical help—perhaps yours can be the official washer of breast-pump parts or the preparer of the at-breast supplementer. When couples approach breastfeeding as a team, the breastfeeding mother’s job becomes much easier and more rewarding.

Other family members and friends: When any mother brings a new baby home, the support of family and friends is invaluable. They can help with meals, housework, and the care of older children. If you need to travel to meet your child, support back home can be even more essential.

Breastfeeding friends and family members: Start with mothers you know who have successfully breastfed or, even better, who are currently breastfeeding their babies — your sister, mother, sister-in-law, friends. According to the U.S. Surgeon General, "women with friends who have breastfed successfully are more likely to choose to breastfeed"(HHS, 2011, p. 12). These women are likely to want to share their stories with you and offer encouragement and support. On the contrary, notes the Surgeon General, "Negative attitudes of family and friends can pose a barrier to breastfeeding"(HHS, 2011, p. 12). You know who will be able to support you well.

Birth family: Adoption plans are emotionally difficult for the birth family. Throwing your breastfeeding plans into the mix can be an added concern for them. Most birth families will not expect you to intend to breastfeed, and will need some time to adjust to the idea. Until the birth parents have signed the consent for adoption, the baby is still their child, and it is imperative that you honor their wishes regarding the feeding of their baby, even if they are contrary to your breastfeeding success. Even if the birth family expresses support for your decision to breastfeed, consider how difficult it may be for the baby’s birth mother to witness you sharing the intimate relationship of breastfeeding with this baby she has just birthed.

Lactation consultant: Professional breastfeeding support should come from an International Board Certified Lactation Consultant (IBCLC). You should schedule your first meeting with your lactation consultant as soon as you begin to consider breastfeeding. A lactation consultant can answer questions you have, work with you to develop your breastfeeding-without-birthing plan, and provide guidance along the way. Not all lactation consultants have experience working with adoptive mothers: Don’t hesitate to ask whether there is an expert in this area in your community.

Your doctor: Breastfeeding-without-birthing may require your primary care physician or OB/GYN to write a prescription or to evaluate the safety of medications for you. Also, breastfeeding affects, and is affected by, your health. Your doctor can help you understand your health history. If you experienced infertility due to hormonal imbalances, such issues may have an impact on lactation.

Your baby’s doctor: Although pediatricians receive little-to-no education on breastfeeding in medical school, many have seen for themselves the importance of breastfeeding to a baby’s health. When interviewing a potential pediatrician, try to determine whether he or she is breastfeeding-friendly by asking:

• What percentage of the patients in your practice are breastfeeding at six weeks? Six months? Into toddlerhood? (Granju & Kennedy, 1999; Kuhn, 1999)
• Does the office have an IBCLC on staff, or a regular IBCLC it refers patients to?
• Does the office have promotional or "educational" materials provided by formula companies? These tend to undermine breastfeeding success (Granju & Kennedy, 1999).
• Did you/your wife/your partner breastfeed?

When I first brought my daughter, Rosa, to our family doctor, at two weeks old, she was well above her birth weight. Upon seeing her chart, the doctor asked in a few different ways what I was feeding her in addition to breastfeeding. I finally convinced him that Rosa was exclusively breastfed. He sat and stared for a minute or so, then abruptly stood up and dashed from the room. He returned a few minutes later with the nurse practitioner. "You’ve got to see this!" he exclaimed. For our quiet and reserved family doctor of many years, this response was totally out of character. That was all the encouragement to continue adoptive breastfeeding I could ask for!

Hospital staff and hospital policies: Breastfeeding during the hospital stay can be complicated in adoption. Hospitals may allow the baby to receive only her birth mother’s milk or infant formula until the birth parents have signed the consent for adoption. If the birth mother decides not to sign, the hospital may be held liable if another mother has breastfed the baby. The adoptive mother is not a patient, and, therefore, the hospital has no medical records for her. Even if allowed by the hospital, it may not be sensitive or advisable to breastfeed until the birth parents have consented and your baby is in your custody.

If you are adopting in a state where the birth mother can sign her consent any time after the birth, and you will be breastfeeding at the hospital, notify the delivering obstetrician and hospital pediatrician beforehand, if possible. With no warning, objections to this out-of-the-ordinary situation are more likely. Even if you won’t be breastfeeding in the hospital, it helps to inform staff of your plans, because they may be able to support you in other ways: by providing a place for you to pump, allowing you to use one of the hospital’s breast pumps, allowing you to store expressed milk in a refrigerator, feeding your baby-to-be in a way that supports breastfeeding, and not offering a pacifier.

Your adoption team: Your adoption agency or attorney and social workers may be able to foster communication with the expectant mother, advocate for you at the hospital, and connect you with sources of support. My adoption professional put me in touch with another adoptive mother who had successfully breastfed.

Breastfeeding mothers’ groups: In Western countries, many mothers find that they don’t have rich sources of breastfeeding support among their family and friends. This is where breastfeeding mothers’ groups can be helpful — even essential — to breastfeeding success. The original breastfeeding mothers’ group was La Leche League International (LLLI), which still runs groups all over the world and continues to be a leading resource for mother-to-mother support, information, and encouragement. Your community may have other resources as well, such as Nursing Mothers Council, Breastfeeding USA, hospital-based breastfeeding groups, retail-based breastfeeding groups, WIC, or individual groups led by lactation consultants.

Before stepping in to a breastfeeding mothers’ group meeting, consider how you may feel at seeing pregnant women, hearing birth stories, or simply seeing women who easily produce plenty of milk.

Latching

Being able to latch your baby to the breast is half of the breastfeeding equation. Making milk is the other half. Babies younger than eight weeks are most likely to latch to the breast without difficulty (Auerbach & Avery, 1981). Older babies who were bottle-fed while being held closely by a loving, consistent caregiver may take to breastfeeding without much difficulty. For most babies adopted beyond the newborn stage, however, the road to breastfeeding is likely to be longer. In some cases, breastfeeding is never achieved.

Make the transition: An older baby adopted from foster care or an institution may have been fed with a propped bottle and/or an enlarged nipple to speed the feeding, may have been fed thickened formula, and may be uncomfortable maintaining eye contact. Watch for your baby’s cues and gradually begin to bottle-feed in a way that supports breastfeeding: holding baby close while feeding, using the slowest-flow bottle nipple, and feeding expressed breastmilk, if available. In between feedings, you can work to "reset your baby’s start in life" through frequent skin-to-skin contact and wearing your baby in a sling or other type of soft carrier that allows for direct contact between parent and baby. Such parenting techniques keep your baby near your breast, allow him to feel your heartbeat and breathe in your smell, and increase levels of the "attachment hormone" oxytocin in mother and baby — the same hormone that is responsible for milk ejection (Moberg, 2003).

Setting the stage for a successful latch: Create a calm and loving environment in which to make your first attempts at latching. You might try breastfeeding in a darkened room. Candles provide soft light and a sense of warmth, but use unscented candles, so nothing gets in the way of your baby’s connecting with your smell.

Don’t try offering the breast when your baby is too hungry. Latching is a skill he has to learn, and he may quickly get frustrated on an empty stomach. If you approach these early sessions as nursing for comfort and "practice," you’ll feel less pressure, too.

 Making Milk

Lactation consultant Diana Cassar-Uhl has said, "Mothering success is not measured in ounces — or drops — of milk that flow from breast to mouth. It’s measured in the love that flows between mother and baby" (Cassar-Uhl, 2012). This is helpful to keep in mind as you work at inducing lactation. Mothers experience such a wide range of outcomes that it’s impossible to predict what any individual’s outcome will be. Begin this endeavor with an open mind, believing that any amount of milk you produce will be supremely beneficial to your baby.

Approaches to making milk without pregnancy and birth can be broken down into three steps. Steps 1 and 2 are optional, so inducing lactation can be simple or more involved, depending on your values and circumstances.

STEP 1 — Preparing Your Breasts for Making Milk: During pregnancy, the hormones estrogen, progesterone, and prolactin develop the milk ducts and glandular tissue in a woman’s breasts in preparation for breastfeeding. A woman who is pregnant will observe changes in her breasts: enlargement, tenderness, feeling of fullness or increased weight, a darkening of the areola, or an increased elasticity of the nipples. The same breast changes can be induced in a woman who is not pregnant, through the use of physical stimulation, such as hand expression and breast massage, and/or pharmaceutical or herbal medications.

STEP 2 — Starting to Make Milk Before Your Baby Arrives: This is the exciting point at which you may start producing milk by pumping or hand expressing on a regular basis throughout the day. Taking medications is likely to increase the amount of milk you produce, but this is always optional.

The recommended length of time in Step 2 is about six weeks before your baby arrives. Four to six weeks is generally enough time to bring in some milk, so planning for six weeks will accommodate a baby who arrives early (Avery, 2012). If your baby arrives on very short notice — or you’re matched after the baby has been born — no problem! Move directly to Step 3: putting that beautiful baby to the breast is better than any breast pump, any day! Because Step 2 involves pumping or hand expressing at least eight times per day, spending much longer than six weeks in this step can drain your energy and enthusiasm for breastfeeding.

STEP 3 — Breastfeeding and Making More Milk: The third step begins when your baby arrives and you begin breastfeeding. A baby who nurses well is the most effective means of increasing milk production. In order to nurse well enough to build milk production, most babies require an ample flow of milk, either directly from the mother’s breasts or from at-breast supplementer.

Some mothers continue to pump following breastfeeding to further stimulate milk production, while others find breastfeeding, pumping, and caring for a new baby to be too much. As with any of the steps, medications may be helpful, but they are never necessary.

At this point, if you find you are able to make enough milk for your baby, congratulations! It will still be important to monitor your baby, since her nutritional needs will increase as she grows. However, most mothers who induce lactation will need to supplement their milk production from the start.

Protocols for inducing lactation: Breastfeeding experts have suggested several approaches, or protocols, for inducing lactation. They vary in intricacy, and in the steps they involve (find full details on each of the protocols in my book). For example, the Traditional Protocol starts at Step 3 and simply involves frequently breastfeeding your baby when she arrives. It tends to be most common and successful in cultures where breastfeeding is the norm, and when mother has breastfed babies by birth. The Newman-Goldfarb Protocol is the most intricate, and one of the most popular, due to its effectiveness. Most mothers using the Newman-Goldfarb Protocol for at least 3.5 months before their babies arrive will produce 60 to 100 percent of their babies’ nutritional needs (Mohrbacher, 2010). It entails following all three steps, including physical techniques, such as pumping and breast compression, herbs and medications, including domperidone, and, often, the use of an at-breast supplementer. Review all of the established protocols carefully and determine which seems right for you. You may also work with an IBCLC to create a protocol that suits your individual situation and values, using other protocols as a guide.

Value the Process, Not Just the Product

What if, despite your devoted efforts, your baby does not latch? Your efforts were not in vain. Any movement toward latching is valuable to your baby, and to your relationship with your baby. A baby who has never attached to a caregiver but learns to be cuddled has come a long way. A baby who has a history of abuse, who now knows that her cries will be responded to, has learned trust.

What if, despite all the best information and help, you aren’t able to make much, if any, milk? You can still breastfeed successfully. There are many mothers who nurse satisfactorily, supplementing their partial milk supply. They keep their focus on the milk they can make, and look at the breast as "half full" rather than "half empty." Other adoptive mothers breastfeed without producing any milk at all. They use an at-breast supplementer to feed their baby, or they may choose to feed with a bottle and comfort their baby at the breast, much as we use a pacifier in our culture.

If you embark on a breastfeeding-without-birthing journey, I hope you’ll share your experiences with other mother-baby pairs. Many adoptive mothers don’t breastfeed simply because they didn’t know it was possible — and all who do need encouragement. Good luck!

Excerpted from Breastfeeding Without Birthing, published by Praeclarus Press. Used with permission. 

Bibliography

Auerbach, K., & Avery, J. L. (1981). Induced Lactation: A study of adoptive nursing by 240 women. American Journal of Diseases of Children, 135, 340-343.

Avery, J. (2012). Frequently asked questions about nursing adopted babies. Retrieved from lact-aid.com/faq-about-nursing-adoptive-babies.

Cassar-Uhl, D. (2012). "Yes, you can breastfeed!" Supporting mothers with mammary hypoplasia/insufficient glandular tissue as a lactation consultant in private practice. Lactation Consultant in Private Practice Workshop. Philadelphia.

Cheales-Siebenaler, N. (1999). Induced Lactation in An Adoptive Mother. Journal of Human Lactation, 15(1), 41-43.

Granju, K. A., & Kennedy, B. (1999). Attachment parenting: Instinctive care for your baby and young child. New York: Pocket Books.

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Pisacane, A., Continisio, G., Aldinucci, M., D’Amora, S., & Continisio, P. (2005). A controlled trial of the father’s role in breastfeeding promotion. Pediatrics, e494-e498.

Starr, D. (2008). Preparation for adoptive nursing. Retrieved from fourfriends.com/abrw/Darillyn%27s/preparation.htm.

Tohotoa, J., Maycock, B., Hauck, Y., Howat, P., Burns, S., & Binns, C. (2009). Dads make a difference: An exploratory study of paternal support for breastfeeding in Perth, Western Australia. International Breastfeeding Journal, 4:15. doi:10.1186/1746-4358-4-15.

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