Last week I got a letter from Erica asking my advice on re-establishing breastfeeding for her 4 month old who stopped at six weeks due to GERD. This was my very long response. In a nutshell, if you have stopped nursing but actually want to breastfeed your baby, YOU CAN!! This post will help you achieve your goal.

The vast majority of women who wean prematurely do so out of fears of inadequate milk supply. New mothers are in an incredibly vulnerable state and tend to blame every hiccup, every cry, and every fussy baby on herself and her milk supply. This often leaves new mothers feeling that they are failures because they were unable to breastfeed their babies and guilty because they are giving their baby formula which is known to increase the risk of countless childhood diseases. Fortunately, the perception of inadequate milk supply is often more of a misperception rather than a physiologic fact. That means that most women who wish to breastfeed after weaning can relactate and resume breastfeeding with the proper support and coaching.

Most women who have prematurely weaned and wish to relactate are good candidates for success. There is a small pool of mothers who find breastfeeding nearly impossible due to physical factors. Those with developmental abnormalities affecting the glandular tissue of the breast, endocrine disorders (disorders of the thyroid or pituitary gland), mothers of premature infants, and mothers who have never nursed may find re-lactation difficult. Most women however are healthy, have healthy, term infants, and are likely to succeed, particularly if they have successfully nursed in past. Indeed there is even evidence suggesting that breast development during the first pregnancy and breastfeeding attempt is enhanced following the birth of a second child, even if the mother did not successfully breastfeed her first child.

Keys to successful re-lactation include:

Realistic Goals: Re-lactation can be time consuming and stressful and it may take several weeks to reach exclusive breastfeeding. While many women can successfully re-establish exclusive breastfeeding there will be women who are unable, for myriad reasons, to exclusively breastfeed. I encourage women to set realistic goals on how long it will take to achieve success and what success will mean to her but to never give up. After all, a mother who is partially nursing while supplementing is still breastfeeding her child, whereas the mother who quits entirely is not breastfeeding at all. Success in re-lactation however, must be determined by the goals set by mothers, not lactation professionals.

Support: Lack of support leads to lack of confidence; lack of confidence leads to infrequent suckling; infrequent suckling leads to breastfeeding failure. All three are associated with less successful re-lactation. Breastfeeding mothers who suffer with feelings of inadequacy due to milk supply problems must be supported by their family and social groups if they hope to successfully re-lactate. Breastfeeding cannot be one of the many chores a woman must do each day; it must be the priority of the entire family. Mothers who find themselves trying to work pumping, SNS use, and breastfeeding into their already full schedule will often find themselves unable to overcome the challenges of re-lactation and will fail.

Nipple Stimulation: There are several techniques for nipple stimulation, perhaps the most successful is direct infant suckling. However the mother can augment that with hand expression, breast massage, warm compresses prior to stimulation, and mechanical pumping. Some studies have shown that combinations of these techniques enhance success.

Milk Removal: Since the breasts synthesize milk based on the degree of emptiness, breast drainage must be a part of nipple stimulation. The mother may find that a period of trial and error is needed to determine the best strategy for breast emptying (infant suckling, hand or pump expression, etc…).

Galactogogues (medications or herbal supplements that increase milk production/synthesis): The two most common medications used to augment milk synthesis are Metaclopramide (Reglan) and Domperidone. Both are anti-nausea medicines which increase Prolactin production. Unfortuantely, scientific evidence demonstrating the effectiveness of galactogogues is weak. Both Reglan and Domperidone have been shown to increase Prolactin levels and milk production. However, the studies demonstrating this, lack credibility in the scientific community. As such, it is important that women who take these medication understand that while they may be helpful, they are by no means a magic bullet that will increase milk synthesis. The evidence in support of Mother’s Milk Tea, Fenugreek and Milk Thistle (all common herbal galactogues) is even more questionable. Given the subjective way that milk production is measured (see previous articles on Sage Homme), it is possible that many galactogogues work through the placebo effect rather than by actually increasing activity at the molecular level. That said, the point is moot; the goal of relactation is to empower a mother to breastfeed her child and the exact physiology behind her success is not as important as her success. I therefore support safe and responsible galactogogue use under the supervision of a competent IBCLC.

Oxytocin (OT): OT is the hormone that causes the Milk Ejection Reflex (MIR), also known as the “Let Down” effect. OT surges in response to nipple stimulation, and during pleasurable experiences (skin to skin contact, infant snuggling, and affectionate attention from a loved one). It is therefore, no surprise that stress, anxiety, fear, and pain all decrease OT release. OT is also released due to conditioning responses, meaning that OT release is enhanced when mothers do things that remind them of breastfeeding. For example if you always sit in the same chair to breastfeed, the act of sitting in that chair will increase your likely hood of having an OT surge. I often suggest that pump dependent mothers cover their breasts and pump with the baby’s blanket. Not only does this hide the pump and keep mothers from stressing over the actual movement of milk, but it also triggers a conditioned response to breastfeed due to the smell of the baby on the blanket. The important thing about OT is to relax and enjoy the time spent breastfeeding, and as much as possible, the time spent pumping, hand expressing, massaging the breasts. Synthetic OT is available in some areas through compounding pharmacies and can enhance the let down response.

So, in a nutshell, yes, you can relactate but you and your loved ones have to commit to it. The key physical factors needed for relactation are nipple stimulation and milk removal. I can’t stress enough that in order to enhance the success of nipple stimulation and milk removal the mother must be confident in her abilities, comfortable and relaxed while nursing, and must have realistic goals. The mother must be supported and able to prioritize relactation. I strongly recommend that any mother having difficulty with milk production see a lactation consultant immediately to avoid weaning however, weaning does not have to be permanent. If you have stopped nursing and want to relactate, you can.

In the words of Winston Churchill “Never, Never, Never, Never, Never, Give Up!” You can do it!

References:
Thorley, V. (2012) Induced Lactation and Relactation. In Mannel R., Marten, P.J. and Walker, M. Core Curriculum for Lactation Consultant Practice 3rd Ed. Jones and Bartlett Publishers. Burlington MA.
Academy of Breastfeeding Medicine Protocol Committee. (2011). ABM Clinical protocol no. 9: Use of galactogogues in initiating or augmenting the rate of maternal milk secretion (first revision January 2011). Breastfeeding Medicine, 6, 41-49.
Agarwall, S., & Jain, A. (2010). Early successful relactation in a case of prolonged lactation failure. Indian J of Pediatrics, 77(2), 214.

Cow's Milk Protein sensitivity and Buffalo Milk

Jamie asked me, what is perhaps the most interesting question I have ever been asked. 

“Do u know of any cross reaction between breast milk protein, cow milk protein and buffalo milk protein.”

As it turns out she has a client who is traveling to a country where drinking buffalo milk is rather common and the client has a nursing infant who is sensitive to cow’s milk proteins.  She wanted to know if buffalo milk would be the same.  I have never in my life considered buffalo milk and so it took some digging.  I was interested to discover that in general buffalo’s milk has a lower risk of causing problems through breast milk than does cow’s milk and that Indian buffalo bred for dairy production are better than wild-type buffalo (Sodhi et al., 2012).  I was also turned on to a new interest, and that is the study and diagnosis of Cow’s Milk Protein Allergy (CMPA) and Cow’s Milk Protein Insensitivity (CMPI).  It would appear that “lactose intolerance” is frequently over diagnosed when in fact the real problem is A1 β-casein intolerance.  Who knew?  Now I do, and I will share this with you.

In a rather complicated and technical paper on the specific components of milks commonly found in India, Islam and colleagues analyzed the chemical make-up of Buffalo, Holstein hybrids, Red Chittigong cattle (RCC) and “indigenous cattle” that are commonly found in India.  They found that Buffalo milk and that of the RCC was nutritionally better than Holstein cow’s milk (HC).  When compared to HC, buffalo and RCC are higher in fat and protein and lower in A1 β-casein (Islam et al, 2014).  So to answer the question, the breastfed infant is likely to be fine if his mother drinks buffalo milk while outside the U.S.  But that wasn’t enough for me.  I, like you, had never herd {VBG} of A1 β-casein, so I had to look it up and figure out why it mattered. 

As it turns out there are two primary milk protein in mammalian milk, particularly among dairy animals.  They are A1 β-casein and A2 β-casein.  A1 β-casein (A1 from now on please) is the primary source of irritation in non-human milk intolerance and it is predominantly found in European cattle breads (Holstein and other “black and white” cows).  A2 β-casein (A2) is not known to cause milk intolerance (Pal, 2015).  A2 comes from Asian, African, and American cattle breeds that are brown i.e. Jersey cows and other “southern breeds” (Snowville Creamery, 2016).  That may be enough for many of you out there but if you are really interested, I will carry on.

So, A1 has a very interesting effect on the human gut.  Upon entry to the GI system A1 proteins activate BCM-7 (the real bad guy) and that protein stimulates the opioid receptors in the gut (Pal, 2015).  That’s right, I said opioid receptors. Some of you are wondering how milk can be a narcotic (it isn’t).  The opioid receptors in the brain are responsible for decreasing pain, but those found in intestine simply slow down the passage of chyme through the GI tract.  When things slow down in the gut those contents begin to irritate the lining for the intestine and you get constipation, bloating, pain, and diarrhea.  Does sound familiar to any of my “lactose intolerant” friends out there?  In infants it will also frequently cause vomiting and bloody stool.  Any lactation consultant worth her salt will tell you to remove all forms of dairy from your diet for at least 2-3 weeks to allow the baby’s GI system to heal.  If symptoms go away you know what it is and how to treat it (don’t go back to dairy).  But after reading this I hope that you will consider trying to find A2 milk and give that a try since it just might work. 

Another thing I found while researching this article was cow’s milk protein allergy (CMPA) which is far more serious than insensitivity.  It is an actual allergic reaction to cow’s milk protein (A1 and/or A2).  It usually starts with a rash in the first month of life (or the first month of formula feeding) but can also present with GI illness, and even respiratory problems leading to anaphylaxis.  In the western world 2-3% of infants will be allergic to cow’s milk protein for the first three years of life.  Oddly enough, babies tend to grow out of this allergy and 85-90% of them will be allergy free by age 3 (Host & Halken, 2014).  What was maddening for me as a lactation consultant was that while researching for this post I found several articles on the diagnosis and treatment of CMPA the authors never once recommended putting the baby on breast milk to treat or prevent the allergy.  In their excellent article “Cow’s milk Allergy: Where have we come from and where are we going” Host and Halken offer several possible treatments for CMPA.  First they offer changing to extremely hydrolyzed formula (eHF) but admit that it is rather biter and unpalatable making it difficult for an infant to tolerate and rather expensive making it hard for the parents to tolerate (2014).  Then they offer exposure therapy through an new treatment modality known as OIT (oral immunotherapy) in which they offer the infant small but ever increasing doses of the allergen over a period of time gradually making the infant immune to the allergenic effects, but they again concede that it is risky and that “a subset of patients have developed significant side-effects.”  Further they suggest that the results are transient and will fade when you stop exposing the infant to the allergen.  Finally, they recommend injectable IgE therapy with omalizumab (try saying that five times fast) (Host & Halken, 2014).  I shudder to think of the poor infant having routine injections of any medication but particularly one that will attempt to suppress the immune system at such a young age.  Why, we are left to wonder, does the author not suggest switching to human breast milk rather than doing all of this to the poor infant?  But that is a topic for another day. 

So there you have it.  If you have a baby who is sensitive to cow’s milk he is most likely sensitive to A1 β-casein and not lactose intolerant.  The primary treatment for cow’s milk protein sensitivity and cow’s milk protein allergy is the same, remove the cow’s milk from the baby’s diet.  Either remove it from the mother’s diet, effectively removing it from the breast milk (not well studied I have to admit) or if he is on artificial milk supplements (AKA Formula) then take him off the formula in favor of either breast milk or eHF (yuck!).  Finally, if you happen to have a supply of buffalo milk, give it a try, you might be happy with the results. 

References:  

Host, A. and Halken, S. (2014) Cow’s Milk Allergy: Where have we come from and where are we going? Endocrine, Metabolic, and Immune Disorders – Drug Targets.  14, 2-8.

Islam, M.A., Alam, M.K., Islam, M.N., Khan, M.A.S., Ekeberg, D., Rukke E.O., Begarud, G.E. (2014) Principal milk components in Buffalo, Holstein Cross, Indigenous Cattle and Red Chittagong Cattle from Bangladesh.  Asian Australas Journal of Animal Science V27, 6: 886-897. http://dx.doi.org/10.5713/ajas.2013.13586

Snowville Creamery (2016) About A1 and A2 beta-casein in cow’s milk.  Retrieved 18 Feb 2016: http://www.snowvillecreamery.com/a1-and-a2-beta-casein-in-cow-milk.html

Sodhi, M., Mukesh, M., Kataria, R.S., Mishra, B.P., Joshii, B.K. (2012) Milk proteins and human health: A1/A2 milk hypothesis. Indian J Endocrinology and Metabolism.  Sep-Oct; 16(5): 856.  doi: 10.4103/2230-8210.100685

Pal, S, Woodford, K., Kukuljan, S., Ho, S. (2015) Milk Intolerance, beta-casein and lactose. Nutrients, 7:7285-7297.  doi:10.3390/nu7095339