Adoptive, surrogate, and transgender breastfeeding

Can I make milk without giving birth?

Some mothers wish to breastfeed their adopted, surrogate, or fostered baby for both the closeness and in order to provide the baby with milk. Alternately, the mother may be transgender. If a mother chooses to breastfeed, ideally the baby is willing to latch and suck onto the breast. If there is little or no milk, the baby may quickly lose interest; a tube-at-the-breast system can prevent this. Milk production can be increased by preparing the breast by using birth control pills, medication to increase prolactin, and breast stimulation with expressing and breastfeeding. The amount of milk produced varies. Adoptive mothers who have given birth have more success at inducing lactation and are more likely to produce more milk.

A) Goals of adoptive breastfeeding

Mothers of adoptive babies may wish to:

  • Breastfeed for the closeness.
  • Undertake steps to produce milk for the baby (induce lactation) and give this to the baby by:

1) Closeness

All babies benefit from being physically close with their caregivers. There are additional benefits from the act of breastfeeding, even without milk present.

Sucking at the breast can:

2) Inducing lactation

Providing breast milk is less certain. Mothers who have had a previous baby tend to make more milk (Auerbach 1981) but this is no guarantee of being able to exclusively breastfeed (Banapurmath 1993; Lopez-Bassols 2021)

There are a number of ways to induce lactation but very little research to identify the most effective or safest approaches (Bryant 2006; Mohd 2021). Most information about inducing lactation concerns individual mothers (case reports) who use a variety of methods (Saari 2014). Some of the better-known protocols are on the website of the Canadian Breastfeeding Foundation (CBF).

There are various reports of mothers creating a milk supply for an adopted, fostered, or surrogate child, even without ever having been pregnant (Cheales-Siebenaler 1999; LeCain 2020; Nemba 1994; Szucs 2010).

There is a report of a transgender mother who, after using a combination of domperidone, birth control pill hormones (estradiol and progesterone), and breast pumping, was able to exclusively breastfeed her adoptive child for six weeks (Reisman 2018). Breastfeeding continued with small amounts of milk supplements (120 to 250 millilitres) for a further six months. Another transgender mother was able to produce 90 to 150 millilitres (3-5 U.S. fluid ounces) each day by manual expression after nine months of treatment (Wamboldt 2021).

There may be slight differences in the components of their milk compared with the milk of mothers breastfeeding babies born to them (Perrin 2015). These have not been reported to negatively affect the baby's growth or development.

B) Breastfeeding the adoptive baby

Breastfeeding provides both closeness between mother and baby and stimulates and maintains milk production.

To breastfeed, the baby needs to be able to latch onto the breast. A younger baby is generally more able to latch than one who is more than eight weeks old (Auerbach 1981). If the baby cannot latch, nipple shields and other tools to help babies accept the breast and breastfeed can be helpful.

Once latched, the baby must also be willing to suck. If there is little or no milk, the baby will quickly lose interest in sucking. A tube-at-the-breast system can keep the baby interested in sucking, as it brings milk right into the baby’s mouth while breastfeeding.

In this way, the baby:

  • Receives the benefits of sucking at the breast.
  • Takes in any milk that is in the breast.
  • Stimulates further milk production.

C) How to induce lactation

Breast stimulation is the cornerstone of inducing lactation (Cazorla-Ortiz 2020).

Birth control hormones can be used before the birth of the baby to mimic pregnancy.

Mothers can take medication (domperidone or metoclopramide):

  • Before the arrival of the baby to increase prolactin and stimulate breast development.
  • After the arrival of the baby, until breastfeeding is established and the medication is no longer helpful
  • If they are not experiencing side-effects.

It is important to ensure the baby is getting enough milk and that the benefits of any approaches outweigh the risks, particularly when using medication. Please work closely with your health-care providers.  

1) Stimulating breast development with hormonal contraceptives before the baby’s arrival

Mothers can take combination (containing both estrogen and progesterone) birth control pills (hormonal contraceptives) daily to cause breast development and stop them abruptly to simulate giving birth. These can be started up to six months before the arrival of the baby:

  • Pills with higher progesterone activity are preferred.
  • Hormonal contraceptives are taken every day. The inactive, or sugar pills, present in some pill packs and taken on Days 22 to 28, are discarded.
  • Six weeks before the arrival of the baby, the hormonal contraceptives are abruptly stopped to simulate birth.
  • Hormonal contraceptives should be stopped before expressing and medication is started. 

2) Increasing milk production before the baby’s arrival

Ideally, mothers start breast stimulation seven times each day to simulate breastfeeding before the arrival of the baby.

This can be done by using one or more of the following:

  • Pumping with a double electric pump (Wittig 2008)
  • Stimulating the nipple (Auerbach 1981)
  • Using breast massage (Auerbach 1981)

Some authors recommend expressing with a double electric pump over manual expression (Wittig 2008) and over using a hand pump (Auerbach 1981).

Nipple stimulation includes rolling the nipple between the thumb and index (pointer) finger and stretching it. Nipple stimulation can also include stroking it before breast massage (Auerbach 1981). 

Breast massage is not well-described in these studies. We recommend that it should not cause any pain or redness of the breast. It may include: 

  • Circular motions around the entire breast. 
  • Length-wise stroking towards the nipple. 
  • Compression of the breast between the fingers and thumb or between the palms.
  • A light coating of cooking oil to allow the hands to glide more easily. 

Mothers may use herbs in addition to medication. These are continued until they are no longer helpful.

Mothers should not combine hormonal contraceptives to induce lactation and breast stimulation. Rather hormonal contraceptives, if used, should be stopped before breast stimulation is started.

3) Breastfeeding and increasing milk production after the baby's arrival

Breastfeeding starts as soon as the baby is present and ideally, mothers breastfeed at each feed. They:

  • Often benefit from the use of a tube-at-the-breast system if milk supplements are required.
  • Should express for each of the baby's feeds if the baby is not able to latch and suck effectively.
  • May express after the baby has breastfed to increase breast stimulation. 
  • Should stop any medication or herbs once they are no longer helpful. 

4) Support

Other factors that increase success include (Nemba 1994; Saari 2014):

  • Motivation
  • A positive attitude
  • Support from partners and family members

References

Auerbach KG, Avery JL. Induced lactation. A study of adoptive nursing by 240 women. Am J Dis Child. 1981 Apr;135(4):340-3

Banapurmath CR, Banapurmath S, Kesaree N. Successful induced non-puerperal lactation in surrogate mothers. Indian J Pediatr. 1993 Sep-Oct;60(5):639-43
 
Biervliet FP, Maguiness SD, Hay DM, et al. Induction of lactation in the intended mother of a surrogate pregnancy: case report. Hum Reprod. 2001 Mar;16(3):581-3
 
Bryant CA. Nursing the adopted infant. J Am Board Fam Med. 2006 Jul-Aug;19(4):374-9
 
Canadian Breastfeeding Foundation (CBF) [Internet]. Toronto: Canadian Breastfeeding Foundation; [date unknown]. Introduction to the Protocols for Induced Lactation. [cited 2018 Sep 20]
 
Cazorla-Ortiz G, Galbany-Estragués P, Obregón-Gutiérrez N, et al. Understanding the Challenges of Induction of Lactation and Relactation for Non-Gestating Spanish Mothers. J Hum Lact. 2019 Jun 25:890334419852939

Cazorla-Ortiz G, Obregón-Guitérrez N, Rozas-Garcia MR, et al. Methods and Success Factors of Induced Lactation: A Scoping Review. J Hum Lact. 2020 Sep 14:890334420950321

Cheales-Siebenaler NJ. Induced lactation in an adoptive mother. J Hum Lact. 1999 Mar;15(1):41-3

LeCain M, Fraterrigo G, Drake WM. Induced Lactation in a Mother Through Surrogacy With Complete Androgen Insensitivity Syndrome (CAIS). J Hum Lact. 2020 Jan 2:890334419888752 

Lopez-Bassols I, Duke LO, Subramaniam G. Three Continents, Two Fathers, One Donor: A Non-Puerperal Relactation Case Study. J Hum Lact. 2021 Apr 22:890334421999327

Mohd Hassan S, Sulaiman Z, Tengku Ismail TA. Experiences of women who underwent induced lactation: A literature review. Malays Fam Physician. 2021 Feb 1;16(1):18-30

Nemba K. Induced lactation: a study of 37 non-puerperal mothers. J Trop Pediatr. 1994 Aug;40(4):240-2

Perrin MT, Wilson E, Chetwynd E, et al. A pilot study on the protein composition of induced nonpuerperal human milk. J Hum Lact. 2015 Feb;31(1):166-71

Reisman T, Goldstein Z. Case Report: Induced Lactation in a Transgender Woman. Transgend Health. 2018 Jan 1;3(1):24-26

Saari Z, Yusof FM. Induced lactation by adoptive mothers: a case study. Jurnal Teknologi 2014: 68(1); 123-132

Szucs KA, Axline SE, Rosenman MB. Induced lactation and exclusive breast milk feeding of adopted premature twins. J Hum Lact. 2010 Aug;26(3):309-13

Wamboldt R, Shuster S, Sidhu BS. Lactation Induction in a Transgender Woman Wanting to Breastfeed: Case Report. J Clin Endocrinol Metab. 2021 Jan 29:dgaa976

Wittig SL, Spatz DL. Induced lactation: gaining a better understanding. MCN Am J Matern Child Nurs. 2008 Mar-Apr;33(2):76-81

Zingler E, Amato AA, Zanatta A, et al. Lactation Induction in a Commissioned Mother by Surrogacy: Effects on Prolactin Levels, Milk Secretion and Mother Satisfaction. Rev Bras Ginecol Obstet. 2017 Feb;39(2):86-89