A woman who is willing to relactate needs the same supportive care that all breastfeeding women need, including adequate food and fluids (see Part 2).
She needs protection from violence, and access to a sheltered space with other breastfeeding women for help and support.
The general conditions to support relactation are outlined in Module 1 (p 36).
With Supportive Care, a woman with mild or moderate malnutrition can relactate immediately. She does not need to wait until she is better to start breastfeeding. If a woman is ill or severely malnourished, she should get appropriate treatment and start relactation when her condition improves.
Her infant may need a temporary artificial supplement. The supplement should be given in a way that encourages the infant to start breastfeeding. Do not give feeding bottles or pacifiers. When the baby wants to suckle, s/he should do so from the breast.
Before relactation starts
The health or nutrition worker (or other skilled helper) should explain to the mother that:
• It is possible to re-start breastmilk production while the infant is temporarily fed on other milk.
• Breastfeeding gives her infant the best chance of health and growth in the emergency situation.
The helper should:
• Talk with the woman several times, listen to her and try to understand how she feels.
• Try to decide the reason for her difficulties.
• Ensure that the woman is adequately motivated and believes that relactation is possible (but put no pressure on her, if she is unwilling).
• If possible, introduce her to other women who have relactated and can encourage her.
The helper should also explain to the woman:
• what she and the mother will do to start breastfeeding
• how long it may take, and her need to be patient and persistent
• how her infant will be fed while her milk production starts or increases.
The helper should also ask about practices that can interfere with breastfeeding.
• Factors that can reduce frequent and effective suckling:
- periods of separation from the infant. (Help the mother to stay with her baby.)
- feeding at fixed times or using a pacifier or bottle.
(Explain the need for feeding on demand.).
• Medicines that can reduce milk production:
- oestrogen-containing contraceptives (Provide a non-oestrogen method.)
- thiazide diuretics. (Try to find an alternative treatment.).
The helper should discuss with the mother how she can avoid these practices and explain why it is important that she do so.
Provide encouragement and support for the mother or wet nurse throughout relactation. At first this should be daily until she is confident and milk production starts and her milk starts to flow.
• Encourage the mother (or wet nurse) to breastfeed whenever the child shows interest and is willing.
• Tell her that resting can help her to breastfeed frequently.
• Explain to the woman's family and friends that she needs practical help and, if possible some relief from other duties for a few weeks so she can breastfeed often. She must be able to do this without risk to her own or her family's survival. (See Module 1 pp 35-6 on conditions that make breastfeeding more feasible.)
• Advise the mother that only she should care for the child. She should hold the infant close to her, sleep with him or her, and give skin-to-skin contact as often as possible. Kangaroo Care may be helpful (see Part 5.2).
If the infant is willing to suckle
Infants who have breastfed previously may be willing to suckle the breast even before much milk is produced.
If an infant is willing to suckle even a little, relactation is relatively easy. Many infants who have breastfed before are willing to suckle, even if there is not much milk being produced currently.
Encourage the woman to:
• Put the infant to the breast frequently, as often as s/he is willing, every one to two hours if possible and at least 8-12 times every 24 hours.
• Sleep with the infant so she can breastfeed at night.
• Let the infant suckle on both breasts, and for as long as possible at each feed - at least 10-15 minutes on each breast.
• Offer each breast more than once if the infant is willing to continue suckling.
• Make sure that the infant is well attached to the breast.
• Cup feed measured milk supplements, six times in 24 hours to begin with.
• Always put the infant to the breast to suckle before giving a cup feed.
A child who is more than six months old also needs complementary foods. These should be nutritious foods, not watery drinks (see Annex 1).
Offer the breast whenever the baby shows interest in sucking anything.
If the infant is unwilling or unable to suckle
Infants who have never breastfed, or who have become used to feeding from a bottle with a teat may not want to suckle the breast.
• They need more help to take the breast and suckle effectively.
• Check the infant for illness, and arrange treatment if necessary. Suckling can start as soon as the infant's condition improves enough.
• Suggest extra skin-to-skin contact or Kangaroo Care (see Part 5.2 and IFE 2/29), offering the breast at any time that the infant shows any interest.
• Encourage the mother to start the relactation process by stimulating her breasts with 20-30 minutes of hand expression 8-12 times a day.
The woman and infant are likely to need help at each feed. It may be most convenient to admit them to a health facility for a few days, or to let them stay near the clinic for much of the day. In this way health workers have a better chance of providing feed-by-feed help and reassurance, and of making sure that the mother (or anyone else) does not give a bottle, pacifier or unnecessary artificial feed.
When relactation is well started, the mother and child can be discharged. They should be followed-up by community-level helpers each day and checked as often as possible by a health or nutrition worker.
Giving milk supplements
The drop and drip technique
This is one way to give milk supplements during relactation. It encourages an infant to take an interest in the breast and to start suckling.
Drip milk from a dropper or a container directly onto the breast while the mother is attaching the infant to the breast.
However, after the infant is well attached and suckling, milk dripped in this way does not go into his/her mouth so easily.
The drop and drip technique
The breastfeeding supplementer technique
This method of giving milk supplements is useful for an infant who is unwilling to suckle at a breast which is not yet producing milk.
A breastfeeding supplementer consists of a tube that leads from a cup of supplement to the breast. It then goes along the nipple and into the infant's mouth.
The infant suckles and stimulates the breast, and at the same time draws the supplement through the tube, and so is fed and satisfied.
This feeding method is usually done under supervision at a health facility.
Using a breastfeeding supplementer
Use a fine nasogastric tube or other fine plastic tubing. A gauge 8 tube is satisfactory. If there is no fine tube, use the best available.
Cut a small hole in the side of the tube, near the end of the part that goes into the infant's mouth (this is in addition to the hole at the end). This helps the flow of milk.
Fine plastic tubing is difficult to clean. So:
• Immediately after use rinse the tubing thoroughly with hot water and soap. Do this by drawing water through with a syringe or by sucking the tubing like a straw.
• Then sterilise with household bleach drawn through the tubing, or alternatively boil the tubes.
• Immediately before using the tube again, rinse again with clean water.
• Replace the tubing every few days.
Show the mother how to:
• Prepare a cup of supplement (expressed breastmilk or artificial milk) containing the amount that her infant needs for one feed.
• Put one end of the tube along her nipple, so that her infant suckles the breast and the tube at the same time. Tape the tube in place on her breast.
• Put the other end of the tube into the cup of supplement.
• Tie a knot in the tube if it is wide or put a paper-clip on it, or pinch it. This controls the flow, so that the infant does not finish the feed too fast.
• Control the flow of milk so that the infant suckles for about 30 minutes at each feed. Raising the cup makes the feed flow faster, lowering the cup makes it flow more slowly. As the infant gains strength, the woman can slow down the flow through the supplementer so that the infant suckles the breast longer.
Clean and sterilise the cup and the tube of the supplementer each time they are used, or teach the mother how to do this.
Encourage the woman to let the infant suckle at any time that s/he is willing - not just when she is giving a feed through the supplementer.
When the infant is willing to suckle at the breast without the supplementer, the mother can start giving the supplements by cup instead.
There are medicines called lactogogues that can increase a low breastmilk production by increasing prolactin levels.
It is uncertain how much they help when breastfeeding has stopped completely.
They are rarely necessary for relactation because full stimulation of the breasts is usually enough by itself.
Full stimulation of the breasts is usually all that is needed for relactation.
Only consider using a drug as an added stimulus if the methods described above have been tried for at least two weeks, and breastmilk has not been produced. This is because:
• Relying on lactogogues can create dependency upon them among mothers and health and nutrition workers.
• Use of lactogogues early in the relactation process may reduce the amount of Basic Aid and Further Help that are offered.
• Lactogogues given as a "short cut" to relactation are unlikely to work.
• Lactogogues may also have some side effects on the mother and her infant.
1 Dosage recommendations, personal communication, Professor Thomas Hale. See also "Medications and Mothers' Milk, " 2004 edition, Pharmasoft (ISBN 0-9636219-8-X), pp 259, 548; author Thomas W. Hale (Professor of Pediatrics, Texas Tech University School of Medicine), and WHO website: http://www.who.int/child-adolescent health/New_Publications/NUTRITION/BF_Maternal_Medication.pdf
The drugs that are sometimes used are:
Domperidone 10-20 mg x 3-4 per day
Metoclopramide 10 mg x 3 per day
To discontinue both drugs:
Reduce by 10mg/day, and monitor the mother's milk supply
These are effective only if the woman receives adequate help and her breasts are fully stimulated as well.
Words of caution
Domperidone is the safer option for a mother and her infant. It has few side-effects and the levels detected in breastmilk are minimal.
Metoclopramide has a number of significant side-effects, in particular it can cause depression in mothers. Its use needs to be balanced against the risks for the mother and infant, especially given the stresses of an emergency setting.
Once drugs are discontinued, good management of breastfeeding will ensure that breastmilk production continues.
If a woman or her family believe that a traditional drink or food will help a mother produce more milk, then taking it may help her psychologically. Most traditional 'remedies' are harmless. Usually they are high-nutrient foods such as oatmeal or millet porridge, or teas prepared from aromatic spices such as fenugreek, anise or fennel. It is important not to undermine a woman's faith in these drinks or foods, even if you do not believe in their efficacy. You may be able to provide warm teas, gruels, or other foods that breastfeeding women believe to be helpful, in a mother-baby tent. These can be part of ongoing support for relactation.