Induction of lactation in the intended mother of a surrogate pregnancy: case report

Induced lactation in a transgender woman: case report

BACKGROUND

Breastfeeding offers significant health benefits, but its practice and success can vary. While research on induced lactation in cisgender women has been documented, there is limited research on lactation induction in transgender women.

CASE PRESENTATION

A 50-year-old transgender woman undergoing hormone therapy and living with a pregnant partner sought to co-feed using induced lactation. After approval by the hospital ethics committee, a regimen of estradiol, progesterone, and domperidone was initiated, accompanied by nipple stimulation. Lactation was successfully induced and maintained, with milk composition analysis indicating high levels of protein and other key nutrients. This case, the seventh reported, highlights the complexity of lactation induction in transgender women, considering factors such as age, obesity, and insulin resistance. The nutrient profile of the milk suggests its suitability for infant feeding, despite some differences from typical human milk.

CONCLUSIONS

Induced lactation is feasible in transgender women, expanding the understanding of non-puerperal lactation and its potential in diverse family structures. Further research is warranted to optimize lactation induction protocols in transgender women.

Lactation induction in a transgender woman: case report and recommendations for clinical practice

BACKGROUND

We present a case of non-puerperal induced lactation in transgender woman. Medical literature on lactation induction for transgender women is scarce, and the majority of literature and protocols on lactation induction is based on research in cisgender women. Healthcare professionals may lack the precise knowledge about lactation induction and may therefore feel insecure when advice is requested. Subsequently, there is a rising demand for guidelines and support.

METHODS

Patient medical record was consulted and a semi-structured interview was conducted to explore the motive for lactation induction, the experience of lactation induction, and to gather additional information about the timeline and course of events.

CASE PRESENTATION

In this case a 37-year-old transgender woman, who was under the care of the centre of expertise on gender dysphoria in Amsterdam, and in 2020 started lactation induction because she had the wish to breastfeed her future infant. She was in a relationship with a cisgender woman and had been using gender affirming hormone therapy for 13 years. Prior to initiating gender affirming hormone therapy she had cryopreserved her semen. Her partner conceived through Intracytoplasmic Sperm Injection, using our patient's cryopreserved sperm. To induce lactation, we implemented a hormone-regimen to mimic pregnancy, using estradiol and progesterone, and a galactogogue; domperidone. Our patient started pumping during treatment. Dosage of progesterone and estradiol were significantly decreased approximately one month before childbirth to mimic delivery and pumping was increased. Our patient started lactating and although the production of milk was low, it was sufficient for supplementary feeding and a positive experience for our patient. Two weeks after birth, lactation induction was discontinued due to suckling problems of the infant and low milk production.

CONCLUSIONS

This case report underlined that lactation induction protocols commonly used for cisgender women are also effective in transgender women. However, the amount of milk produced may not be sufficient for exclusive nursing. Nevertheless, success of induced lactation may be attributed to its importance for parent-infant bonding, rather than the possibility of exclusive chestfeeding.

Lactation Induction in a Transgender Woman Wanting to Breastfeed: Case Report

CONTEXT

Breastfeeding is known to have many health and wellness benefits to the mother and infant; however, breastfeeding in trans women has been greatly under-researched.

OBJECTIVE

To review potential methods of lactation induction in trans women wishing to breastfeed and to review the embryological basis for breastfeeding in trans women.

DESIGN

This article summarizes a case of successful lactation in a trans woman, in which milk production was achieved in just over 1 month.

SETTING

This patient was followed in an outpatient endocrinology clinic.

PARTICIPANT

A single trans woman was followed in our endocrinology clinic for a period of 9 months while she took hormone therapy to help with lactation.

INTERVENTIONS

Readily available lactation induction protocols for nonpuerpural mothers were reviewed and used to guide hormone therapy selection. Daily dose of progesterone was increased from 100 mg to 200 mg daily. The galactogogue domperidone was started at 10 mg 3 times daily and titrated up to effect. She was encouraged to use an electric pump and to increase her frequency of pumping.

MAIN OUTCOME MEASURE

Lactation induction.

RESULTS

At one month, she had noticed a significant increase in her breast size and fullness. Her milk supply had increased rapidly, and she was producing up to 3 to 5 ounces of milk per day with manual expression alone.

CONCLUSIONS

We report the second case in the medical literature to demonstrate successful breastfeeding in a trans woman through use of hormonal augmentation.

Metoclopramide induces preparturient, low-level hyperprolactinemia to increase milk production in primiparous sows

Inadequate milk production by sows often limits the growth of piglets. A successful lactation requires prolactin (PRL)-induced differentiation of the alveolar epithelium within the mammary glands of sows between days 90-110 of gestation. We hypothesized that induction of late gestational hyperprolactinemia in primiparous sows by oral administration of the dopamine antagonist metoclopramide (MET) would enhance mammary epithelial differentiation, milk yield, and piglet growth rate and that these effects would carry over into a subsequent lactation. Twenty-six gilts were assigned to receive either MET (n = 13, 0.8 mg/kg) or vehicle (CON, n = 13) twice daily from days 90-110 of gestation. The same sows were followed into their second lactation without additional treatment. On day 90 of gestation, circulating PRL concentrations peaked 45 min after feeding MET (P < 0.001) and then returned to baseline 3 h later. This response occurred daily out to day 104 of gestation (P < 0.05). Compared with CON, MET-treated gilts had enlarged alveoli on gestation day 110 (P < 0.05). Treatment with MET did not affect feed intake, body weight, or body fatness during pregnancy or lactation. Piglets born to MET-treated sows had both increased body weights and average daily gain on lactation days 14 and 21 (P < 0.05). Milk intake by piglets was estimated from deuterium oxide dilution. Although milk intake by piglets nursing MET sows was not statistically different from those nursing CON sows on day 21 of lactation (P = 0.18), there was a greater increase in milk consumption by piglets born to MET-treated sows between days 9 and 21 of lactation than for those in CON litters (P < 0.001). In one group of second parity sows (n = 11) that were treated with MET during their first gestation, milk yield increased by 21% during their second lactation (P < 0.05) in association with a 14% decline in body fatness across lactation compared with a 7% decline in CON sows (P < 0.05). These findings demonstrate that MET-induced hyperprolactinemia in primiparous sows during late pregnancy can increase milk yield and piglet growth rate, setting the stage for further large-scale studies.

Induced Lactation in a Mother Through Surrogacy With Complete Androgen Insensitivity Syndrome (CAIS)

INTRODUCTION

Breastfeeding offers the optimal feeding option for newborns in terms of nutritional content and reinforces mother-infant bonding. As a physiological process intrinsically linked to parturition, breastfeeding is no longer reserved for puerperal mothers. Progress in understanding the intricacies of lactogenesis and breastfeeding has further paved the way for artificially induced lactation in recent years.

MAIN ISSUES

We describe the case of a mother through surrogacy with XY karyotype and complete androgen insensitivity syndrome who wished to breastfeed her child.

MANAGEMENT

Through a combination of estrogen therapy, galactagogues, and mechanical breast stimulation she was able to partially breastfeed her child for one month.

CONCLUSION

This case further shifts the concept that breastfeeding is a physiological process confined to only puerperal mothers and offers an opportunity to a wider group of nontraditional mothers to take part in the unique experience of breastfeeding.

Methods and Success Factors of Induced Lactation: A Scoping Review

BACKGROUND

Induced lactation enables a woman who has not given birth to breastfeed a child. Lactation may be induced through both pharmacological and non-pharmacological methods, although the desired outcome cannot always be achieved.

RESEARCH AIMS

The aims of this scoping review was to assess the different methods used to induce lactation, as well as the factors related to sucking the breast effectively and the production of human milk.

METHODS

We searched five databases from June 2019-February 2020 for studies referring to methods and factors related to breast suckling and/or the volume of milk produced after inducing lactation, using the following search terms and Boolean operators: breastfeeding AND induced lactation AND adoptive mothers OR surrogate mothers OR female homosexuality OR non-gestating. The final review included a total of 24 articles.

RESULTS

Pharmacological methods were not always used to produce milk, although breast stimulation was essential. The age of the child, interference due to bottle feeding, breast stimulation, and the support received were important factors in the induction of lactation. There were several factors that may account for the differences between developing and higher income countries in methods of induced lactation and the amount of milk that study participants produced. There was no consensus over whether previous pregnancy and/or breastfeeding experience influenced induced lactation.

CONCLUSION

Health professionals need to have adequate knowledge about induction methods, the preferences of each woman, and the reasons for inducing lactation, to provide proper assistance. However, the lack of standardization about induction of lactation makes it difficult.

Knowledge and practice of induction of lactation in trans women among professionals working in trans health

BACKGROUND

Breastfeeding is emerging as an important reproductive rights issue in the care of trans and gender nonconforming people. This study sought to understand the tools available to professionals working in the field of trans health to help trans women induce lactation and explore the concept of unmet need.

METHODS

In November 2018, we conducted a cross-sectional study which surveyed attendees at the World Professional Association for Transgender Health (WPATH) symposium in Buenos Aires, Argentina. Eligible participants were 18 + years old, had professional experience with transgender populations, were able to complete a survey in English, and were conference attendees. Descriptive data were collected using a 14-item written survey encompassing demographic characteristics, experience in transgender health, and lactation induction in trans women.

RESULTS

We surveyed 82 respondents (response rate 10.5%), the majority of whom were healthcare professionals (84%). Average age of respondents was 42.3 years old. They represented 11 countries and averaged 8.8 years of work at 21.3 h/week with trans populations. Healthcare professionals in this sample primarily specialized in general/internal medicine, psychology, endocrinology, and obstetrics/gynecology. One-third of respondents (34%) stated that they have met trans women who expressed interest in inducing lactation. Seventeen respondents (21%) knew of providers, clinics, or programs that facilitated the induction of lactation through medication or other means. Seven respondents (9%) have helped trans women induce lactation with an average of 1.9 trans women in the previous year. Two protocols for lactation induction were mentioned in free text responses and 91% believe there is a need for specialized protocols for trans women.

CONCLUSION

This exploratory study demonstrates healthcare professionals' interest in breastfeeding protocols for lactation induction in trans women. Additional studies are needed to capture insights from breastfeeding specialists, e.g. lactation consultants and peripartum nurses, and to understand patients' perspectives on this service.

Breastfeeding experiences of same-sex mothers

BACKGROUND

Family structures are diversifying in the United States, and more same-sex female couples are building families. For two-mother families, complexity exists for breastfeeding as more than one mother can provide human milk. The purpose of this study was to explore the lactation experience and level of lactation support of birth mothers in a same-sex (two female) relationship.

METHODS

This study consists of a mixed methods design using an online survey to identify the demographic of same-sex mothers and qualitative interviews to provide an in-depth understanding of the mothers' experiences. Qualitative content analysis is applied to develop themes from the interviews.

RESULTS

Sixty-eight participants completed the online survey. Thirty-seven mothers (59%) reported breastfeeding for more than one year. Fourteen (21%) respondents reported accessing induced lactation information for the nongestational parent from their health care practitioner. Forty-three (63%) respondents reported receiving breastfeeding and induced lactation information from other sources. Only nine (13%) nongestational parents underwent induced lactation. Eighteen gestational mothers participated in qualitative interviews. Five themes emerged from the qualitative data: (a) committed to a year, (b) deciding "how to do it," (c) sources of information, (d) involvement of partner, and (e) need for inclusive and educated health care practitioners.

CONCLUSIONS

Same-sex mothers have strong intentions to breastfeed and are resourceful in educating themselves for induced lactation and conursing. Nongestational parents are essential support partners and equivalent in motherhood. Providers need to better equip themselves and incorporate inclusive language in breastfeeding policy statements to support lactation outcomes.

Stem cells in human breast milk

Recent studies have demonstrated that breast milk contains a population of cells displaying many of the properties typical of stem cells. This review outlines progress made in this newly emerging field of stem cell biology and provides an analysis of the available data on purification, propagation and differentiation of certain types of progenitor cells from breast milk. The possible fates of breast milk cells, including microchimerism caused by their transmission to the distant organs of the infant, are also discussed. Unique properties of breast milk-derived stem cells, such as their unusually low tumorigenic potential and their negligible ability to form teratomas, are highlighted as obvious advantages for using these cells in regenerative therapy.

Case Report: Induced Lactation in a Transgender Woman

Objective: Our report describes a case of nonpuerperal induced lactation in a transgender woman. Methods: We present the relevant clinical and laboratory findings, along with a review of the relevant literature. Results: A 30-year-old transgender woman who had been receiving feminizing hormone therapy for the past 6 years presented to our clinic with the goal of being able to breastfeed her adopted infant. After implementing a regimen of domperidone, estradiol, progesterone, and breast pumping, she was able to achieve sufficient breast milk volume to be the sole source of nourishment for her child for 6 weeks. This case illustrates that, in some circumstances, modest but functional lactation can be induced in transgender women.

The Availability of Information on Induced Lactation in Malaysia

Induced lactation is a method of stimulating the production of breast milk in women who have not gone through the process of pregnancy. Recent advances in technology have given such women the opportunity to breastfeed adopted children. Previous studies conducted in Western countries have explored the breastfeeding of adopted children, as well as the experiences, successes and challenges of this process. However, research on procedures for breastfeeding adopted children is lacking in Malaysia. The authors have therefore reviewed literature related to induced lactation in Malaysia to fill this gap. Of the 30 related articles identified, 19 described the breastfeeding practices and experiences of adoptive mothers in Malaysia. Out of 19 articles, there were four journal articles, five circulars and regulations, two books, two post-graduate theses, four blogs posts and forum discussions, and two online newspaper articles. Medical information relating to induced lactation procedures was also reviewed, showing that there was a lack of scientific studies focusing on induced lactation practices among adoptive mothers. Information on religious, specifically Islamic, perspectives on breastfeeding and child adoption laws was gathered from websites, social networks, blogs, magazines and online news sources. In consideration of recent advancements in medical technology and the dire need among Malaysians, it is crucial that evidence-based, accurate and reliable information on induced lactation is made available to professionals and other individuals in this country.

An Adoptive Mother Who Became a Human Milk Donor

Inducing lactation in the absence of pregnancy (nonpuerperal lactation) is not always successful and, in many cases, only partial breastfeeding is achieved. Different protocols have been described, but scientific evidence and research are lacking in this area. The authors describe the case of a woman with a history of a miscarriage, for whom the lactation induction process was so effective that she became a milk donor even before she received her adopted child. She had not previously used hormone treatment. She was given domperidone as a galactogogue for 1 month. The pumping protocol began with a double electric breast pump combined with manual pumping 6 months before her child was delivered, and 3 months later, she was accepted as a donor by our milk bank. This highlights the importance of regular stimulation as a milk production mechanism. This is the first case of human milk donation in an adoptive mother described in the literature.

Induction of Lactation in the Biological Mother After Gestational Surrogacy of Twins: A Novel Approach and Review of Literature

One of the important challenges in surrogate pregnancies is the early bonding of genetic mother with her infant and the establishment of breastfeeding. A combination of pharmacological and nonpharmacological methods is often used for the induction of lactation. Reports of induced lactation in surrogacy are limited and scattered. In this report, we present a case of induced lactation and initiation of breastfeeding in preterm twins by the genetic mother, through her novel approach after a gestational surrogate pregnancy. Thematic approach of maternal account is summarized with context and rigor. We reviewed the reported literature of induced lactation in similar cases with an aim to address the various methods adopted.

Methods of milk expression for lactating women

BACKGROUND

Breastfeeding is important, however not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and costs of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2016), handsearched relevant journals and conference proceedings, and contacted experts in the field to seek additional published or unpublished studies. We also examined reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

This updated review includes 41 trials involving 2293 participants, with 22 trials involving 1339 participants contributing data for analysis. Twenty-six of the trials referred to mothers of infants in neonatal units (n = 1547) and 14 to mothers of healthy infants at home (n = 730), with one trial containing mothers of both neonatal and healthy older infants (n = 16). Eleven trials compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and pump types. Twenty studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols, pumping frequency, provision of an education and support intervention, relaxation, breast massage, combining hand expression with pumping and a breast cleansing protocol.Due to heterogeneity in participants, interventions, and outcomes measured or reported, we were unable to pool findings for most of the specified outcomes. It was not possible therefore to produce a 'Summary of findings' table in this update. Most of the included results were derived from single studies. Trials took place in 14 countries under a variety of circumstances and were published from 1982 to 2015. Sixteen of the 30 trials that evaluated pumps or products had support from the manufacturers. The risk of bias of the included studies was variable. Primary outcomesOnly one of the 17 studies examining maternal satisfaction/acceptability with the method or adjunct behaviour provided data suitable for analysis. In this study, self-efficacy was assessed by asking mothers if they agreed or disagreed with the following statement: 'I don't want anyone to see me (hand expressing/pumping)'. The study found that mothers who were using the electric pump were more likely to agree with the statement compared to mothers hand expressing, (mean difference (MD) 0.70, 95% confidence interval (CI) 0.15 to 1.25; P = 0.01, participants = 68). Mothers who were hand expressing reported that the instructions for expression were clearer compared to the electric pump, (MD -0.40, 95% CI -0.75 to -0.05; P = 0.02, participants = 68). Descriptive reporting of satisfaction in the other studies varied in the measures used, did not indicate a clear preference for one pump type, although there was satisfaction with some relaxation and support interventions.We found no clinically significant differences between methods related to contamination of the milk that compared any type of pump to hand expression (risk ratio (RR) 1.13, 95% CI 0.79 to 1.61; P = 0.51, participants = 28), manual pump compared to hand expression, (MD 0.20, 95% CI -0.18 to 0.58; P = 0.30, participants = 142) a large electric pump compared to hand expression (MD 0.10, 95% CI -0.29 to 0.49; P = 0.61, participants = 123), or a large electric pump compared to a manual pump (MD -0.10, 95% CI -0.46 to 0.26; P = 0.59, participants = 141).The level of maternal breast or nipple pain or damage was similar in comparisons of a large electric pump to hand expression (MD 0.02, 95% CI -0.67 to 0.71; P = 0.96, participants = 68). A study comparing a manual and large electric pump, reported sore nipples in 7% for both groups and engorgement in 4% using a manual pump versus 6% using an electric pump; and in one study no nipple damage was reported in the hand-expression group, and one case of nipple damage in each of the manual pump and the large electric pump groups.One study examined adverse effects on infants, however as the infants did not all receive their mothers' expressed milk, we have not included the results. Secondary outcomesThe quantity of expressed milk obtained was increased, in some studies by a clinically significant amount, in interventions involving relaxation, music, warmth, massage, initiation of pumping, increased frequency of pumping and suitable breast shield size. Support programmes and simultaneous compared to sequential pumping did not show a difference in milk obtained. No pump consistently increased the milk volume obtained significantly.In relation to nutrient quality, hand expression or a large electric pump were found to provide higher protein than a manual pump, and hand expression provided higher sodium and lower potassium compared to a large electric pump or a manual pump. Fat content was higher with breast massage when pumping; no evidence of difference was found for energy content between methods.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including initiation of milk expression sooner after birth when not feeding at the breast, relaxation, massage, warming the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Variation in nutrient content across methods may be relevant to some infants. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings. Independently funded research is needed for more trials on hand expression, relaxation and other techniques that do not have a commercial potential.

Methods of milk expression for lactating women

BACKGROUND

This is an update of a 2008 Cochrane review. Breastfeeding is important. However, not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and cost implications of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2014), CINAHL (1982 to March 2014), conference proceedings, secondary references and contacted researchers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trials, extracted data and assessed risk of bias.

MAIN RESULTS

This updated review includes 34 studies involving 1998 participants, with 17 trials involving 961 participants providing data for analysis. Eight studies compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and multiple pump types. Fifteen studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols (five studies), pumping > 4 times per day versus < 3 times per day (one study), provision of a milk expression education and support intervention to mothers of preterm infants versus no provision (one study), provision of audio/visual relaxation to mothers of preterm infants versus no specific relaxation (two studies), commencing pumping within one hour of delivery versus between one to six hours (one study), breast massage before or during pumping versus no massage (two studies, of which one also tested a second behaviour), therapeutic touch versus none (one study), warming breasts before pumping versus not warming breasts (one study), combining hand expression with pumping versus pumping alone (one study) and a breast cleansing protocol versus no protocol (one study).There were insufficient comparable data on outcomes to undertake meta-analysis and data reported relates to evidence from single studies.Only one of the 17 studies examining maternal satisfaction/acceptability provided data in a way that could be analysed, reporting that mothers assigned to the pumping group had more agreement with the statement 'I don't want anyone to see me pumping' than mothers in the hand expression group and the statement 'I don't want anyone to see me hand expressing' (n = 68, mean difference (MD) -0.70, 95% confidence interval (CI) -1.25 to -0.15, P = 0.01), and that mothers found instructions for hand expression were clearer than for pumping (n = 68, MD 0.40, 95% CI 0.05 to 0.75, P = 0.02). No evidence of a difference was found between methods related to adverse effects of milk contamination (one study, n = 28, risk ratio (RR) 0.89, 95% CI 0.62 to 1.27, P = 0.51), (one study, n = 142 milk samples, MD 0.20, 95% CI -0.18 to 0.58, P = 0.30), (one study, n = 123 milk samples, MD 0.10, 95% CI -0.29 to 0.49, P = 0.61), (one study, n = 141 milk samples, MD -0.10, 95% CI -0.46 to 0.26, P = 0.59 ); or level of maternal breast or nipple pain or damage (one study, n = 68, MD 0.02, 95% CI -0.67 to 0.71, P = 0.96).For the secondary outcomes, greater volume was obtained when mothers with infants in a neonatal unit were provided with a relaxation tape or music-listening interventions to use while pumping, when the breasts was warmed before pumping or massaged while pumping.Initiation of milk pumping within 60 minutes of birth of a very low birthweight infant obtained higher mean milk quantity in the first week than the group who initiated pumping later. No evidence of difference in volume was found with simultaneous or sequential pumping or between pumps studied. Differences between methods was found for sodium, potassium, protein and fat constituents; no evidence of difference was found for energy content.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.Most studies were classified as unclear or low risk of bias. Most studies did not provide any information regarding blinding of outcome assessment. Fifteen of the 25 studies that evaluated pumps or products had support from the manufacturers.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including early initiation when not feeding at the breast, listening to relaxation music, massage and warming of the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings.

A pilot study on the protein composition of induced nonpuerperal human milk

BACKGROUND

Our understanding of the components of human puerperal milk is extensive and increasing, yet the literature on nonpuerperal human milk has been limited to studies that measure the success of induced lactation.

OBJECTIVE

This study aimed to describe the composition of total protein and key bioactive proteins when lactation is induced in nonpuerperal women.

METHODS

Two women who induced lactation in the absence of pregnancy provided weekly milk samples over a 2-month period for analysis of total protein, secretory immunoglobulin A (sIgA), lysozyme, and lactoferrin. Composition was compared to the mature milk of 3 puerperal control subjects who were 11 months postpartum.

RESULTS

Median total protein for subject A was 2.30 g/dL (interquartile range [IQR] = 0.46) and showed a significant downward trend over time (P < .0001), whereas the median total protein for subject B was 2.21 g/dL (IQR = 0.18) and showed a nonsignificant decline (P = .232). Total protein in both nonpuerperal subjects was elevated compared to control subjects. Secretory IgA activity declined for both nonpuerperal subjects over time, whereas lysozyme concentrations increased over time. Both sIgA and lysozyme approached the levels seen in the puerperal controls. Lactoferrin levels remained stable for both nonpuerperal subjects and were elevated compared to puerperal milk samples.

CONCLUSION

This pilot study suggests that nonpuerperal milk has similar or higher levels of total protein, sIgA, lactoferrin, and lysozyme compared to puerperal, mature milk at 11 months postpartum, which warrants more attention as adoptive mothers increasingly choose to induce lactation.

The intricacies of induced lactation for same-sex mothers of an adopted child

The definition of a modern family is changing. In this case study, we describe the breastfeeding experience of a child receiving human milk from all 3 of his mothers: his 2 adoptive mothers, who induced lactation to nurse him, and his birth mother, who shared in his early feeding during the open adoption process and continued to pump and send milk to him for several months. We review the lactation protocol used by his adoptive mothers and the unique difficulties inherent in this multi-mother family dynamic. Both adoptive mothers successfully induced moderate milk production using a combination of hormonal birth control, domperidone, herbal supplements, and a schedule of breast pumping. However, because of the increased complexity of the immediate postpartum period and concerns with defining parental roles in a same-sex marriage, maintenance of milk production was difficult.

Methods of milk expression for lactating women

BACKGROUND

This is an update of a 2008 Cochrane review. Breastfeeding is important. However, not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on composition, contamination and cost implications of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 January 2011), CINAHL (1982 to January 2011), conference proceedings, secondary references and contacted researchers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth, and crossover trials commencing at least 28 days after birth.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trials, extracted data and assessed risk of bias. Data were checked for accuracy.

MAIN RESULTS

We included 23 studies with 10 studies (632 mothers) providing data for analysis.Mothers provided with a relaxation tape produced more milk than mothers who were not (mean difference (MD) 34.70 ml/single expression, 95% confidence interval (CI) 9.51 to 59.89, P = 0.007). A lower milk volume over six days was reported when comparing hand expression to the electric pump (standardised mean difference (SMD) -1.00 ml, 95% CI -1.64 to -0.36, P = 0.002); other studies of the same pump using different measures did not find a significant difference (12 to 36 hours postpartum SMD -0.38 cc, 95% CI -0.86 to 0.10, P = 0.12); day five postpartum SMD -0.62 ml/day, 95% CI -1.43 to 0.19, P = 0.13). No evidence of difference in volume was found with simultaneous or sequential pumping, or between manual and electric pumps studied. One study reported a higher sodium concentration in hand expressed milk compared to a manual pump (SMD 0.59 mmol/L, 95% CI 0.22 to 0.96, P = 0.002) and to an electric pump (SMD 0.70 mmol/L, 95% CI 0.32 to 1.09, P = 0.0003), and lower potassium concentration compared to a manual pump (MD -0.37 mmol/L, 95% CI 0.00 to 0.73, P = 0.05) or to an electric pump (SMD -0.32 mmol/L, 95% CI -0.69 to 0.06, P = 0.10). No evidence of difference was found for energy content, milk contamination or adverse effects. Reports of maternal views were not comparable. Economic aspects were not reported.  

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low cost interventions including early initiation when not feeding at the breast, relaxation, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Small sample sizes, large standard deviations, small number of studies reviewed, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings.

Induced lactation and exclusive breast milk feeding of adopted premature twins

The authors report the first published case of premature twins whose adoptive mother induced lactation. Both infants are receiving exclusively human milk (adoptive mother's milk) at 2 months of age. This remarkable achievement reflects careful planning by the adoptive mother beginning in the prenatal period, her active role during the infants' hospital stay, and support from health care personnel and family members. Health care professionals are encouraged to support any adoptive mother who expresses interest in breastfeeding her infant(s).

Methods of milk expression for lactating women

BACKGROUND

Breastfeeding is important for health. However, not all infants can feed at the breast and effective methods of expressing milk have not been adequately evaluated.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, bacterial contamination of milk and cost implications of a range of methods of milk expression, including hand expression and manual, battery and electric pumps.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2007), CINAHL (1982 to July 2007), handsearched relevant journals and conference proceedings, scanned secondary references and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared one method or technique of milk expression or pumping with other(s), at any time after birth, and cross-over trials that commenced at least 28 days after birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We sought additional information from the trial authors.

MAIN RESULTS

Twelve studies met the inclusion criteria of which six (397 mothers) provided data that could be used in the analyses. Compared with hand expression, one study found a significantly greater total volume of milk expressed over six days both with the electrical pump (373.10 ml, 95% confidence interval (CI) 161.09 to 585.11), and with the foot-operated pump (212.10 ml, 95% CI 9.39 to 414.81); however, the difference found between the foot pump and the electric pump was not significant. Mothers provided with a relaxation tape produced a greater volume of milk at one expression than women not provided with the tape (34.70 ml, 95% CI 9.51 to 59.89). Simultaneous pumping took less time than sequential pumping in one study (3.50 hours/week, 95% CI 1.39 to 5.61). No evidence of difference was found in volume with simultaneous or sequential pumping, or for milk contamination, breastfeeding at discharge, fat content of milk, serum prolactin by method of pumping. Maternal satisfaction, adverse effects on mothers and economic effects of interventions were poorly reported.

AUTHORS' CONCLUSIONS

Mothers appear to obtain greater total volumes of milk in six days after birth using the electric or foot powered pump tested compared to hand expression, and a greater volume at one expression during the second week when provided with a relaxation tape. Simultaneous pumping takes less time compared to sequential pumping. Further research with larger numbers and more comprehensive reporting is needed, and mothers' reasons for expressing linked to their evaluation of effectiveness rather than market-led research on equipment performance.

Galactogogues: medications that induce lactation

Galactogogues are medications that aid in initiating and maintaining adequate milk production. Most exert their pharmacologic effects through interactions with dopamine receptors, resulting in increased prolactin levels and thereby augmenting milk supply. Metoclopramide remains the galactogogue of choice due to its documented record of efficacy and safety in women and infants. Domperidone crosses the blood brain barrier and into the breast milk to a lesser extent than metoclopramide, decreasing the risk of toxicity to both mother and infant possibly making it an attractive alternative. Traditional antipsychotics, sulpiride and chlorpromazine, have been evaluated, but adverse events limit their use. Human growth hormone, thyrotrophin-releasing hormone, and oxytocin have also been studied. Finally, a natural product, fenugreek, has been purported to be effective in anecdotal reports. Use of this agent may be warranted after considering risks versus benefits.