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Induced Lactation: The Milk Making Newman-Goldfarb Protocols

Induced Lactation Information Lenore Goldfarb, B. Comm, B. Sc.

Dear Mother-to-be,

Congratulations on your impending arrival! If you are committed to breastfeeding your adopted baby or your baby born via surrogacy, you can do it. Any amount of breastmilk you are able to provide for your baby is a precious gift. I am not the first to try this. I personally know of at least 40 other mothers who were successful at inducing lactation. Induced lactation is more commonly known as "adoptive breastfeeding" and refers to the ability for a woman to breastfeed without going through a pregnancy. I'm very proud of my ability to breastfeed and you too will find that it is well worth the effort.

Please be aware that I am not a doctor thus the information and recommendations that follow are from my own experience with induced lactation. I highly recommend that you consult a doctor who is familiar with lactation as well as an internationally board certified lactation consultant (IBCLC) IBLCE.org and forward this information to them so that you can acquire the medications that you will need and have access to follow-up medical and technical support. Contact the hospital where your baby is to be born and let them know that you are planning to breastfeed. They may have a lactation consultant who can help you. You may also wish to make copies of this information to give to any family members, friends, or medical staff, who may be unfamiliar with induced lactation and who may try to discourage you from giving your baby this precious gift.

First, My Story: After several failed pregnancies my husband and I decided to explore the option of "gestational surrogacy". This is a procedure where our baby is carried by a surrogate mother impregnated with our embryo. Since I've always believed in the importance of breastfeeding, I was determined to find out how I could breastfeed my baby without having gone through the pregnancy. I contacted La Leche League and read their information on adoptive breastfeeding. I found a lactation consultant through La Leche who had successfully breastfed her adopted child.

I searched the internet and found Dr. Jack Newman in Toronto, Canada, who was helping women who were having trouble with their milk production after undergoing a normal pregnancy. I asked him if he would be willing to help me to bring in my milk without a pregnancy. I discovered that he had a lot of experience helping adoptive mothers and so my treatment began. I was treated with special birth control pills, a medication called Domperidone, and was required to use an electric breast pump.

In my case, our baby was born two months prematurely. I had only three weeks notice to accelerate my medication and pumping (see my protocol below). I pumped every three hours around the clock to catch up. Ultimately I was successful and provided breastmilk for my son from his second day of life. Still, because he was a preemie, it was nearly 10 days before he was able to nurse. Initially my son had some digestive problems and so I was told by the doctor that my son could only take my "premilk". This is milk that I pumped for only 5 min. After a couple of days he was able to consume a full breast. At that point the hospital insisted that he have human milk fortifier mixed in with my breastmilk, telling me that he needed this because he was premature. I have since found out that this is not necessarily true. A 32 weeks gestation baby does not necessarily need fortifier. I have also since found out that the "premilk" vs. all my breastmilk should not have been an issue.

Now that I look back on the situation I realize that out of all the preemie babies in that ward, mine was the ONLY breastfed baby. This leads me to believe that although for the most part the staff at that hospital was very supportive of my efforts to breastfeed, the hospital itself was not "breastfeeding friendly". I spent about two weeks after that, breastfeeding my son exclusively, overruling the objections of the hospital, following which we decided to supplement about an ounce of iron fortified preemie infant formula with each feeding. I was told by the hospital at that point that the formula was necessary in our case because our son was born premature and severely anaemic. I have since found out that this is also not necessarily true either. If he was iron deficient, he could have had just plain iron. Not all premature babies need fortifier or supplements in addition to breastmilk. Ask your baby's doctor to advise you. Although I did supplement, I made sure to give my son breastmilk with every feeding and continued until he was eight months old and 20 pounds.

Why Breast is Best

First and foremost, human milk is for human babies. There are at least 100 biological ingredients in breastmilk that cannot be duplicated with the use of formula. The most important of these ingredients are the numerous protective antibodies, growth factors, and enzymes that are present in breastmilk. The baby absorbs the iron and fat that are present in breastmilk much more efficiently than the iron or fat from formula. Breastmilk constantly changes to meet the needs of the baby and there is never a concern about allergy to breastmilk as there is with formula.

Along with the nutritional benefits, there is the unique bonding benefit that occurs when a mother breastfeeds her infant. Babies breastfeed for milk and comfort. As a mother who was unable to carry her infant, I must tell you that breastfeeding eliminated the "void" that I felt when I learned that I would not experience a natural pregnancy and birth. The feelings of helplessness, and inadequacy vanished the moment I held my newborn son to my breast. I felt that the preparation and actual nursing experience were essential in helping me to bond with my baby. There is something about giving something to your baby that only you can provide that will make you feel really good about yourself. Do it yourself, and you'll see what I mean.

The Biology of Induced Lactation in a Nutshell

It is not necessary to have been pregnant in order to breastfeed. During pregnancy a woman's body produces increasing amounts of progesterone, estrogen, and prolactin. These hormones ready the breasts for breastfeeding. Once the pregnancy is completed, progesterone and estrogen levels drop and prolactin levels increase resulting in lactation. The protocols outlined later in this document are designed to mimic what happens during and after pregnancy. I go into more detail about this later on in the "Introduction to the Protocols".

Once your milk supply is established it works on a "supply and demand" basis under your baby's control if you are nursing and under your control if you are pumping. The more often and the more efficiently a baby nurses (or you pump), the more milk will be produced by the breast to meet the baby's demand. Once the baby (or pump) is put to the breast, a signal is sent to the brain from the breast that causes the release of oxytocin initiating the milk ejection (or letdown) reflex causing the milk to flow. The release of oxytocin coupled with the draining of milk from the breast, causes the breast to produce more milk. (Riordan p. 277). This is one of the reasons for the use of the double electric breast pump during the protocols. The double pump actually fools your body into thinking your are nursing twins.

Introduction to the Newman-Goldfarb Protocols

Until recently, the only advice that lactation consultants and members of the medical profession could tell women who were interested in adoptive breastfeeding was to do nothing before the baby arrives, just put the baby to the breast when you pick him/her up at the hospital and in a while you'll have milk, that milk isn't the most important thing, that there is more to breastfeeding than milk supply. That's fine, except it usually doesn't really work out and you end up feeding your baby formula. If you're lucky, you'll have a few drops of breastmilk per feeding and it will take weeks or months to achieve it. By then you may be so frustrated that you will most likely go for the bottle. Think about this...it takes a woman 40 weeks to gestate a baby and all the while her breasts are being prepared for nursing. How can anyone expect milk to miraculously arrive without either a pregnancy or medications to simulate a pregnancy? It is true that there is more to breastfeeding than breastmilk. There is the intimacy and the bonding and the development of the baby's jaw and jaw muscles and so on. The reason that most lactation consultants and medical personnel are not aware of the protocols is because they were only published in Dr. Jack Newman's book in 2000 and I only published my guide on the web in July 2001. The nice thing about these protocols is that they are easy to do and the results are often miraculous to say the least.

I was the first to try the regular protocol. In early 1998, I contacted Dr. Jack Newman and asked him to help me to bring in a milk supply without a pregnancy when I learned that I was expecting a baby via gestational surrogacy. Since my success with the protocol, I've been working under Dr. Newman's supervision to help other mothers to bring in their milk supplies. Dr. Newman is one of the foremost lactation experts in North America. Together we worked out a milk making protocol that works. At my peak, was able to bring in 32 oz a day! I did the regular protocol and at the time I didn't know about herbs or pumping schedules. I just muddled along. I was very lucky to find a board certified lactation consultant (IBCLC) who had done adoptive breastfeeding the old fashioned way, with the Lact-aid and tubes to her breast to "simulate" breastfeeding. She was very helpful. Since that time I've worked with over 40 adoptive breastfeeding moms to help them bring in a good milk supply (always under Dr. Newman's supervision).

There are basically two ways to go about this. There is the regular protocol and the accelerated protocol. As a rule, the longer you can be on the protocol, the more milk you'll end up with. In both cases you'll need to take a monophasic large dose birth control pill non-stop, only active pills, no sugar pills (Ortho 1/35 or Necon 1/35) together with a medication called domperidone. (see the medications and herbs 1,2,3 below).

Domperidone is an anti-emetic or anti-nausea drug that was initially prescribed for people with upper gastrointestinal problems. Domperidone is not a hormone but it has a side effect that results in an increase in prolactin levels. It was discovered that when some women would take the drug this increase in prolactin levels could in turn cause lactation. As with most drugs, very little of the Domperidone ends up in the milk. The baby gets only very tiny amounts. There is another drug that is found in the US called Reglan (Metoclopramide). We do not recommend the use of Reglan. It crosses the blood-brain barrier and can cause neurological problems and depression. It is not recommended for long-term use. Domperidone is not known to cross the blood brain barrier and is used to treat chronic conditions that require it's long-term use. It is not known to cause depression. Note that Reglan is not approved by the American Academy of Pediatrics for use in breastfeeding mothers (Hale p 442).

Since domperidone does not cross the blood brain barrier it is much safer for mother and baby. They even give domperidone to babies in Canada suffering from projectile vomiting. Right now domperidone is not widely available in the US but domperidone has been approved for use in breastfeeding moms by the American Academy of Pediatrics. (see below). We wish the FDA would get with it and approve it. Unfortunately that costs money and since the same pharmaceutical co makes both Reglan and domperidone, they didn't see the need to spend the money or the effort to continue to try to get domperidone approved by the FDA after Reglan was approved even though Reglan is associated with lots of side effects, severe depression among them. Thus, domperidone was placed on the back burner so to speak.

Domperidone is widely available in every country in the world except the United States (except at certain compounding pharmacies). We are very lucky here in Canada that domperidone was approved more than 20 years ago. This made it possible for a generic version to come onto the market enabling Canadians to obtain this medication economically.

Note that: It is perfectly legal for a US doctor to prescribe domperidone even though it isn't available in the US. And it is legal for a US citizen to bring domperidone into the US for personal use provided it is accompanied by a doctor's prescription, a letter stating that the medication is for the patient's personal use, and the shipment does not exceed a 3 month supply. (see FDA regulations below). Here is what Dr. Thomas Hale says about domperidone in his book "Medications and Mother's Milk, 2000", Pharmasoft Publishing, p. 217 Note: Please check with your doctor before beginning any medication.

1) "Domperidone

Trade name: Motilium Can/Aus/ UK: Motilium Uses: Nausea and vomiting, stimulates lactation AAP: Approved by the Academy of Pediatrics for use in breastfeeding mothers

Domperidone (Motilium) is a peripheral dopamine antagonist (similar to Reglan) generally used for controlling nausea and vomiting, dyspepsia, and gastric reflux. It is an investigational drug in the USA, and available only for compassionate use. It blocks peripheral dopamine receptors in the GI wall and in the CTZ (nausea center) in the brain stem and is currently used in Canada as an antiemetic [anti nausea]. Unlike Reglan, it does not enter the brain compartment and it has few CNS effects such as depression. It is also known to produce significant increases in prolactin levels and has proven useful as a galactagogue (lactation inducer). Concentrations of domperidone reported in milk vary according to dose but following a dose of 10 mg three times daily; the average concentration in milk was 2.6 ug/L. The usual oral dose for controlling GI distress is 20-40 mg three to four times daily. The galactagogue [milk making] dose is suggested to be 20-40 mg orally 3-4 times daily. At present, this product is unavailable in the USA.

Lactation Risk Category L2….Drug which has been studied in a limited number of breastfeeding women without an increase in adverse effects in the infant. And/or, the evidence of a demonstrated risk which is likely to follow use of this medication in a breastfeeding woman is remote.

Adult Concerns: Dry mouth, skin rash, itching, headache, thirst, abdominal cramps, diarrhea, drowsiness. Seizures have occurred rarely.

Pediatric Concerns: None reported.

Drug Interactions: Cimetidine, famotidine, niztidine, ranitidine (H-2 blockers) reduce absorption of domperidone. Prior use of bicarbonate reduces absorption of domperidone.

Adult dosage: 20-40 mg 3-4 times daily" (end of quote from Dr. Hale's book)

Note: for best results it's a good idea to take domperidone 1/2 hour before meals and at least 1 hour before pumping or nursing.

FDA regulations state that the following criteria must be met to import medications into the US. It is legal for US residents to import medications from outside the US provided the following conditions are met. a) The product was purchased for personal use and does not exceed a 3 month supply. b) The product is not for resale. c) The intended us of the product is appropriately identified. d) The patient seeking to import the product affirms in writing that it's for the patient's own use. e) The patient provides the name and address of the doctor licensed in the US responsible for his or her treatment with the product. f) The medication is not a controlled substance, e.g. sleeping pills, Valium, narcotics.

Although domperidone is not readily available in the US, you may still obtain the medication as follows:

Any Canadian pharmacy can send you Domperidone if you get a prescription from your doctor. Note: It is perfectly legal for a US doctor to write a prescription for domperidone even though it isn't widely available in the US. Murray Shore Pharmacy has experience with this. Tel: 1-800-201-8590, Fax: 1-800-201-8591 or visit their website at http:/www.mshorepharmacy.com. Simply fax your doctor's prescription along with your name, address, phone number, and social insurance number. There is a one time US$10 set up fee and then it costs approximately US$98 for a bottle of 500 Domperidone 10mg and US$18 for FedEx. You will need approximately 3 - 4 bottles. They will ship anywhere in the world.

Domperidone is available in the US with a prescription at several compounding pharmacies. Lloyd Center Pharmacy in Oregon is one of them. You can reach them at Tel: (503) 281-4161. Domperidone is available without a prescription, COD from Mexico. For best results you should fax your order. Just fax them your name, address, telephone number, and how many boxes of pills you would like and whether you want overnight delivery or two days and they will send them FedEx, C.O.D. You will need to prepare a money order or cashier's check made out to KCR, Inc. It's a good idea to write in block letters on the fax so there is no chance of error with your name and address. The minimum order is 8 boxes. There are 30 pills in a box. That makes 240 pills. The price is US$112. FedEx 2 days is an additional US$20 or FedEx overnight is US$30. To Fax from the US dial exactly this: 011-526-654-5522. It's a good idea to back it up with a telephone call. There is a person there that speaks English. To call from the US dial exactly this: 011-526-654-1834. It may take a while to get through. They have been very reliable to deal with.

There are several online sources for domperidone. Some of these include the following:

At 1onlinepharmacy.com they ship domperidone anywhere in the world without a prescription. Look for the generic brand (variable sources) US$18 for 100 tabs (10 mg). Shipping is free if shipped by regular airmail. Delivery in 10 -30 days. They also offer express shipping but they don't recommend it because it can take up to 21 days with new customs regulations in place.

At 1drugstore-online.com you can get domperidone without a prescription. Look for the generic brand by Jassen-Cilag which is domperidone maleate (Motilium) They sell 100 tabs (10 mg) for $25. The minimum order is US$50 but shipping is free worldwide and takes 10-15 days. If you need the medication fast, they'll ship it express for US$30. They will accept orders from everywhere EXCEPT Canada. For Canadians who can't find a doctor to prescribe domperidone, you can get it here

pharmagroup.com without a prescription. Look for Motilium 10 mg 30 tabs for US$12. This comes out to US$120 for 300 tabs. They will ship worldwide including Canada and the US under regular shipping for 6% of their order or a minimum of US$16. If you want the order within 3 business days you'll have to pay 10% of your order or a minimum of US$40.

Domperidone is available here canadameds.com with a prescription, for CAN $82.29 (about $54 US, depending on exchange rate) for a bottle of 500, 10 mg tablets. They ship anywhere in the world for CAN$18 shipping fee (about US$12). Delivery within 21 days.

Note: Domperidone used to be available from New Zealand without a prescription but as of Nov. 3, 2001 the pharmacies there are no longer able to do this because of a new law that was passed stating that a doctor must have at least one face-to-face visit with a patient before writing a prescription. This law put www.pharmacycare.com out of business. However, Pharmacycare is still supplying domperidone without a prescription only to the US via email or telephone. Here are the instructions. Current price is US$54 +US$7 shipping fee. Pharmacy care instructions: Subject: Motilium orders "Dear Customers We have sort legal advice regarding Motilium orders to the States, the good news is we can resume shipping this product, but this product only. Re: Motilium Motilium 10mg 100 tablets USD12.00 Motilium 10mg 300 tablets USD28.80 Motilium 10mg 600 tablets USD52.80 shipping USD7.00

Please note that the site is still closed. We accept orders via telephone, fax, or email. I have included our details below: Phone +678 27282 Fax: +678 26389 Free calling number from USA: 1 (877) 271-6591 Regards The Team at Pharmacycare Pharmacycare sales@pharmacycare.co.nz

The maximum dose for Domperidone is 20 mg four times per day. Don't rush to get to that dose, always increase the medication gradually. I never stopped the medication while I was nursing. I discovered that when I forgot a dose, my milk supply would decrease. At its peak, my output was 4 ounces per feeding. For more information on Domperidone visit the "Bright Future Lactation Resource Center" website.

2) Special Birth Control Pill. (please check with your doctor before beginning any medication)

You will need to find a birth control pill that is equivalent to Ortho 1/35 (1 mg norethindrone + 0.035 mg ethinyl estradiol).

Acceptable birth control pills include: Ortho Novum 1/35, Necon 1/35, Demulen 1/35, Norethin 1/35E, Norinyl 1 +35, and Zovia 1/35. Note: It is extremely important that your doctor understand that the birth control pill is not being used to control menses but rather to develop the milk making apparatus of your breasts. This is why your bcp must contain at least 1 mg of progesterone and no more than 0.035 mg of estrogen. You can get the bcp online without a prescription at getthepill.com

Begin taking the birth control pill 6 months before the baby is due (the longer the better, if you can start as soon as you know a baby is on the way it would be great) and continue without stopping (active pills only) until 2 months before the baby is due. Do not be alarmed if you do not get your period for the duration of your breastfeeding experience. I did not have a period for 1 year. After you stop the birth control pill you should continue to use an alternative method of birth control if you are fertile and sexually active. Breastfeeding and/or lack of a period do not guard against pregnancy.

Note: For the accelerated protocol we now highly recommend Diane 35. It has 2 mg progesterone as opposed to the 1 mg in the Ortho 1/35. The estrogen content is the same. Diane 35 is currently available in Canada, Mexico, Thailand and NZ. You can find it at one of the sites mentioned above. Note "getthepill" does not carry Diane 35.

3) Herbs In addition to the medications described above, I recommend the following herbs that have been consistently helpful in increasing milk supply: Fenugreek seed - 3 capsules (580-610 mg each) 3 times a day with food Blessed Thistle herb - 3 capsules (325-360mg each) 3 times a day with food You'll know that you are taking enough herbs when you begin to smell like maple syrup.

The Most Frequently Asked Question is this: "Why the need for the birth control pill non-stop (only active pills) and domperidone for the adoptive breastfeeding protocol?"

Answer: During pregnancy several changes take place in the breasts that are hormonally driven. Estrogen and Progesterone exert specific effects. Estrogen causes the proliferation and differentiation of the ductile system and progesterone causes the lobes, lobules and alveoli of the milk making apparatus of the breasts to increase in size. In addition, prolactin is released by the anterior pituitary gland and plays a significant part in increasing breast mass. Without prolactin, lactation does not occur. (Riordan & Auerbach p. 98)

We can produce these breast changes to a large extent in a non-pregnant woman artificially by the use of medications. A birth control pill containing at least 1 mg of progesterone and approximately 0.035 mg estrogen ( i.e. Ortho 1/35 or Necon 1/35,) together with domperidone 80 mg per day will cause significant breast changes that result in lactogenesis. The birth control pill is taken once a day non-stop, only active pills for several months. The reasoning behind taking the birth control pill non-stop is to simulate a pregnancy and cause breast changes. Ceasing the birth control pill for even a few days will inhibit this effect. Once significant breast changes have occurred the birth control pill is discontinued while maintaining the domperidone. A pumping schedule then begins as often as possible, usually every three hours, using a double electric breast pump. (Newman p. 252-253)

If you are in the position where you have just found out that a baby is available and you have no time to prepare you can still do this. Although the best results are obtained using a sustained protocol, there is a newly developed accelerated protocol based on the same principles as above (see the accelerated protocol below). The adoptive breastfeeding protocol and the reasoning behind it, is outlined in Dr. Jack Newman's book "Dr. Jack Newman's Guide to Breastfeeding", Harper Collins, 2000 on pages 252-254. This is called the Ultimate Breastfeeding Book of Answers in the US (Prima Publishing).

The anatomy and physiology of lactation is fully explained in a book by Jan Riordan and Kathleen Auerbach entitled "Breastfeeding and Human Lactation", 2nd Edition, Jones and Bartlett, 1998 on pages 98-101.

Another Frequently Asked Question is: "Someone told me that my milk will not be the same as a birthmother's milk and that the hormones resulting from the medications are dangerous…is this true?"

Answer: There is no known difference between the breastmilk that is produced via the protocols and the breastmilk produced by a birthmother. However, women who do the protocols are unable to produce colostrum. Colostrom is a specialized breastmilk that is produced by birth mothers prior to their breastmilk coming in. The protocols do not cause the production of colostrum to occur. (Riordan, p 280) The reason that colostrum is not produced using the protocols is that in order to produce colostrum you need "human placental lactogen" which is only available with a placenta which in turn is only available with a pregnancy. As for the hormones being dangerous, this is simply not the case. The hormones that a woman's body generates while pregnant are so much higher than we can ever hope to achieve with medications. Oral contraceptives are approved by the American Academy of Pediatrics for use in breastfeeding mothers. (Hale p 503). Neither the hormones nor the medications nor the herbs are a problem.

The Newman-Goldfarb Protocols:

The Regular Protocol (suitable for intended mothers expecting a baby via surrogacy or adoptive mothers with a long lead time)

Most of the women who follow this protocol are able to bring in 50% to 100% supply of breast milk and sustain until weaning.

1) Six months (the longer the better, if you can start as soon as you know a baby is on the way it would be great) before your baby is due, take an "active" birth control pill each day + 10 mg Domperidone three times a day . Your breasts will swell. This is normal. The birth control pill actually suppresses your milk supply mimicking what happens during pregnancy. No pumping or herbs please until 6 weeks before the baby is due.

2) Five months before your baby is due, take an "active" birth control pill each day + increase the Domperidone dosage to 10 mg four times a day. Your milk supply will still be suppressed. Still no pumping or herbs.

3) Four months before your baby is due take an "active" birth control pill each day + gradually increase the Domperidone dosage to 20 mg four times a day over the course of a week. Do not exceed this dosage. Your milk supply will still be suppressed.

4) 6 weeks before your baby is due, stop the birth control pill and continue the Domperidone dosage of 20 mg 4 times a day. You may experience vaginal bleeding, this is OK. Over the next two weeks, start pumping for 10 minutes on the low or medium setting three times a day, gradually increasing to 20 minutes on the medium setting three times a day. If you can pump more often than this, even better. Note: Stopping the birth control pill should cause your milk supply to come in, mimicking what happens after birth. This is normal.

5) One month before your baby is due, continue the Domperidone dosage of 20 mg four times a day. Pump for 20 to 30 minutes on the medium setting of the Pump n Style every 3 hours and once during the night. Again, the more often you pump, the more milk you can store, and the better your supply will be. Pump with a double electric breast pump. A hand pump is just not up to the job. The double electric pump fools your body into thinking you have a really hungry set of twins at the breast and is the fastest way to increase your milk supply. The most reliable pumps are the Medela Pump n Style (buy) and the Medela Lactina Select (rent).

Once you've started pumping you can add the herbs Blessed Thistle herb (390 mg per capsule) and Fenugreek seed (610 mg per capsule). Take 3 capsules of each 3 times a day with your meals. Take your domperidone ½ hour before meals for best absorption. Try to eat oatmeal for breakfast at least 3 times a week and drink 6 glasses of water a day but don't make yourself sick. You can expect clear drops, which become more opaque. Then spray, then stream. It may take a few days, a week, or two, or more for you milk supply to come in. Everyone is different.

6) Once your baby arrives, continue the Domperidone dosage of 20 mg four times a day and do not stop until you are ready to wean your baby off the breast. Put your baby to your breast as soon as possible, in the delivery room if you can. Feed your baby "on demand" as often as possible. Pump for 10 minutes after each feeding, to help increase your milk supply, until it is well established. Maintain the herbs fenugreek and blessed thistle and continue until your milk supply is well established and throughout the entire time you are breastfeeding if necessary. If your milk supply is well established it might be possible for you to slowly decrease the domperidone and even eliminate it completely. See the section on "stopping the domperidone" below. The Accelerated Protocol (suitable for intended mothers or adoptive mothers who have little time to prepare, or for women who wish to relactate) Most of the women who follow this protocol are able to bring in 1/4 to 1/2 supply of breastmilk. Relactating mothers are often able to bring in 50% to 100% supply of breastmilk and sustain until weaning.

Diane 35 is taken for 30-60 days non-stop, only active pills, no sugar pills, together with the domperidone 20 mg 4 times per day. If significant breast changes occur within 30 days, the birth control pill is stopped while maintaining the domperidone, and the pumping schedule of 15-20 min every three hours begins. Significant breast changes include an increase in breast size (1 cup) and breasts that feel full, heavy and very painful. Note: stopping the protocol before these breast changes occur is not recommended. Milk production is not as great on the accelerated protocol but the supply is usually sufficient to provide 1/4 to 1/2 of the baby's needs. You can use the Lact-aid filled with either breastmilk or formula to breastfeed your child while you are going through the protocol. There are milk banks and milk exchange services that can provide you with breastmilk if it is not feasible for you to ask the birthmother to provide breastmilk. It is worth a try to ask though…you would be surprised at how many birth moms are willing to provide the child with a healthy start in life.

If you have 4 weeks or less or if your baby has arrived and you suddenly decide that you want to do the accelerated protocol, you can still do this. Start the Diane 35 ( see the section that describes the medications above) together with 20 mg of domperidone 4 times a day immediately. You can expect to feel tired as your prolactin level rises. If you can be on the Diane 35 together with the domperidone for at least 30 days you will have a better result. Once you have completed at least 30 days on the combination of Diane 35 (once a day) and domperidone (20 mg 4 times a day) and have experienced significant breast changes you can stop the Diane, maintain the domperidone and begin pumping with a double electric breast pump. A hand pump is just not up to the job. The double electric pump fools your body into thinking you have a really hungry set of twins at the breast and is the fastest way to increase your milk supply. The most reliable pumps are the Medela Pump n Style (buy) and the Medela Lactina Select (rent). Significant breast changes include an increase in breast size (1 cup) and breasts that feel full, heavy and very painful. Note: stopping the protocol before these breast changes occur is not recommended.

You'll need to pump every 3 hours and once during the night. Once you've started pumping you can add the herbs Blessed Thistle herb (390 mg per capsule) and Fenugreek seed (610 mg per capsule). Take 3 capsules of each 3 times a day with your meals. Take your domperidone ½ hour before meals for best absorption. Try to eat oatmeal for breakfast at least 3 times a week and drink 6 glasses of water a day but don't make yourself sick.

You can expect clear drops, which become more opaque. Then spray, then stream. It may take a few days, a week, or two, or more for you milk supply to come in. Everyone is different. Remember that if you are fertile, you must use an alternative method of contraception. Store as much milk as you can. Once your baby arrives, or if your baby is already here, feed him/her on demand and supplement if necessary using the supplemental nursing system or Lact-aid filled with either your stored milk, donor milk from a milk bank or milk exchange service, or formula until your milk supply is well established. Remember, not all the milk has to come from you. Whatever amount of breastmilk you provide to your baby is a precious gift. Note that the birth control pill and domperidone are both approved by the American Academy of Pediatrics for use in breastfeeding mothers.

The Menopause Protocol If you are in menopause due to surgical removal of your reproductive organs or naturally occurring menopause, you can still breastfeed and bring in your milk supply. You do not need a uterus or ovaries in order to breastfeed. All you need are breasts. The first step is to stop your hormone replacement therapy and replace it with Diane 35. The Diane 35 contains enough estrogen and progesterone to keep your menopausal symptoms at bay while at the same time developing the milk making apparatus of your breasts. You also need to take domperidone (10 mg 4 times a day for the first week and then increase to 20 mg 4 times a day). It is a good idea to stay on the combination of Diane 35 and Domperidone until you experience significant breast changes. We usually recommend at least 60 days for menopausal ladies. Significant breast changes include an increase in breast size (1 cup) and breasts that feel full, heavy and very painful. Note: stopping the protocol before these breast changes occur is not recommended.

Once you have completed at least 60 days on the combination of Diane 35 (once a day) and domperidone (20 mg 4 times a day) and have experienced significant breast changes you can stop the Diane, maintain the domperidone and begin pumping with a double electric breast pump. A hand pump is just not up to the job. The double electric pump fools your body into thinking you have a really hungry set of twins at the breast and is the fastest way to increase your milk supply. The most reliable pumps are the Medela Pump n Style (buy) and the Medela Lactina Select (rent).

You'll need to pump every 3 hours and once during the night. Once you've started pumping you can add the herbs Blessed Thistle herb (390 mg per capsule) and Fenugreek seed (610 mg per capsule). Take 3 capsules of each 3 times a day with your meals. Take your domperidone ½ hour before meals for best absorption. Try to eat oatmeal for breakfast at least 3 times a week and drink 6 glasses of water a day but don't make yourself sick. You can expect clear drops, which become more opaque. Then spray, then stream. It may take a few days, a week, or two, or more for you milk supply to come in. Everyone is different. Please do not resume your hormone replacement therapy but rather eat Soya products to control your symptoms. Soya milk and/or Soya butter are good choices because they contain phytoestrogens but eat only enough to stop hot flashes because too much will decrease your milk supply.

My Protocol

Five months before our baby was due, I started to take 1 active birth control pill and 10 mg of Domperidone three times a day. Four months before our baby was due, our surrogate mom was diagnosed with placenta previa and I began to pump three times a day: in the morning, dinnertime, and bedtime. Although I had some milk within 10 days, I did not understand that the birth control pill was actually suppressing my milk production thus giving my breasts an opportunity to fully mature. One week after I began pumping, our surrogate mom went into preterm labor. She was only at 29 weeks, less than 7 months pregnant. I took immediate action and put myself on an accelerated protocol. I stopped the birth control pill, increased my Domperidone dosage to 20 mg three times a day, and began pumping four times a day: in the morning, at lunch time, at dinner time, and at bedtime (I would watch TV to alleviate the boredom). One week later I began to pump four times a day and once during the night for 20 min on "medium".

Our son was born at 32 weeks and was immediately placed in the neonatal intensive care unit, on a respirator, with intravenous lines. At the time of our son's birth, I increased the Domperidone to 20 mg 4 times per day, began pumping every three hours around the clock, and froze my breastmilk. After 24 hours, my son was weaned from the respirator and I began to hold him skin to skin. This is called "Kangaroo Care" and is one of the best things you can do for a premature baby. I held his head next to my breast each day. Two days after our son was born, the hospital began tube feeding him with my breastmilk. I know now that I probably should have put a few drops of my breastmilk to my son's lips those first few days, even while he was on the respirator, to help him to develop digestive enzymes. This would have helped him to tolerate his feedings much easier. My output was two ounces per feeding which was more than he needed. I found that if I pumped next to his incubator my output was greater. I continued to hold our son for many hours each day, and from time to time, holding his head next to my breast. After a few days, I began to slowly train our son to breastfeed. It was nine days before he was able to get the hang of it and take a full breast.

I cannot tell you how profoundly grateful I was that I was able to do this for my son. Breastfeeding my premature baby was absolutely, without question, the best thing for him. Although I was able to keep up with our son's demand, the hospital strongly encouraged me to supplement his feedings with a special infant formula designed for preemies because the doctors said that his needs were different than a full term newborn. Our baby was very pale when he was born and required two blood transfusions so the doctors told me that his iron requirements were more than I could give him with my breastmilk. If I could do this over again, I would have breastfed exclusively and given my son an iron supplement instead of a formula supplement.

While our son was in the neonatal intensive care unit (6 weeks) I pumped after every feeding to increase my milk supply. I stored all my excess milk and supplemented with it when I could avoid giving him the special preemie infant formula. When our son came home, I was advised by my pediatrician to supplement with regular iron fortified infant formula to increase his iron consumption once again. To solve the iron problem and to avoid a decrease in my milk supply, I started to give my son infant vitamin drops with iron. Most feedings he would take only breastmilk and other feedings, I would give him an ounce of iron fortified formula if he was still hungry and had fully depleted my breastmilk.

As time went on and my son's demand for breastmilk began to exceed my output, I would supplement 50:50 breast and formula. At my peak, I was giving him 4 ounces of breastmilk per feeding. When he was 8 months old I started to wean him from the breast but continued with a bottle and pumping. He was given 6 -7 ounces per feeding and of that, 2 ounces were breastmilk, the rest was iron-fortified formula. I continued this way throughout his eighth month until he was on formula alone and my breastmilk output had decreased to 1 ounce per feeding. At this point I stopped pumping. I did not experience any discomfort when I stopped. I have since learned that babies of 8 months do not need formula. They can eat food and drink regular milk. They also don't need to be weaned at that age. You can go on breastfeeding for as long as you and your baby are both willing to continue to enjoy your nursing relationship…years in fact.

How to Decide Which Protocol is Right for You

Depending on when you expect your baby to arrive you have to think like this...you'll need to pump for at least a month. You need to be off the bcp when you start pumping, you will need to be on the bcp-domperidone combination for at least 30 days non-stop. The longer you can be on the combination the better. So if you have three months...you'll be on the combo for 2 months straight. If you have 2 months...you'll be on the combo for at least 1 month straight. After you're off the bcp and still on the domperidone, you'll begin to pump. You'll need to use a double electric breast pump like either the Medela Pump n Style or Medela Lactina Select (hospital pump). And then you'll need to take herbs...fenugreek and blessed thistle.

What to do if you do not experience "significant" breast changes: Significant breast changes include: Breasts increasing in size by at least 1 cup size. Breasts full, heavy, and very painful.

If you do not experience significant breast changes within 15 days of beginning either of the protocols, you may want to consider increasing your progesterone intake. There are two reliable ways to do this. 1) Replace your current birth control pill with Diane 35. This medication has twice the amount of progesterone that is in the "1/35" type birth control pills. 2) Continue on your current "1/35" birth control pill and add 1 mg of progesterone another way such as by adding 1/2 a pill of Provera 2.5. Adding progesterone usually solves the problem.

A word of caution about creams. Creams do not provide the needed level of progesterone in a reliable manner. You are much better off with an oral form of progesterone.

It is very important to follow the protocols as written. If you leave out any of the ingredients for success, you can be sure to have problems with your milk supply. Each element of the protocol serves a specific function.

Breast Pump

You will need to acquire a breast pump. I felt that the "Pump n Style" by Medela was the best one for me. It is a double electric pump and has a special cold-storage space with ice packs for the milk. There is also the Medela Lactina Select double electric pump that can be rented from either your lactation consultant or your local hospital. Start by pumping three times a day for 5 min on the low to medium setting, increasing to 20 min on the medium setting. You should have milk within 10 days to three weeks. At the beginning, I pumped once in the morning, once at dinnertime, and once before bed. I took my medication about an hour before I pumped. I also learned to "hand express" for the times when I could not pump due to lack of electricity or privacy.

Supplementary Nursing Systems

There are two basic types of supplementary nursing systems on the market. They are the SNS by Medella and the Lact-aid. Basically, this is a bottle or bag filled with formula that is worn around the neck or clipped to your clothing or hidden in a shirt pocket. Thin tubes leading from the bottle or bag attach to both breasts. The baby then nurses from the breast normally. This is an excellent way to supplement your baby's feedings until you are able to bring in your milk supply, and to take the pressure off you, if you do need to supplement your baby's feedings once your milk supply comes in. Alternatively, there is the improvised lactation aid suggested by Dr. Newman that you can find in his book on pages 80 - 81.

Once your milk supply is starting to come in or is established. The best way to use the supplementer is to allow your baby to feed on each breast with the supplementer in place but not flowing until he/she doesn't drink anymore from your breasts. You can tell because the baby will stop the suck>pause (downward motion of chin)> suck motion. Use breast compression to get as much breastmilk to your baby as possible from the first breast and when that stops working and your baby stops drinking switch sides and do the same thing. Allow the supplement to flow only when the baby has done both sides at least (not necessarily spent an hour or whatever, just as long as he's drinking). That way, if the baby doesn't want any more, he won't take any more and you'll know that your baby had as much breastmilk as possible.

What to Do With the Milk

Save all the milk you pump and freeze it in one-ounce portions. Medela makes freezer bags for breastmilk available at most baby stores. You should mark the date and time on each bag so you can use them in the order in which they were obtained. Make sure your freezer is colder than 0 degrees Fahrenheit. Use a fridge/freezer thermometer to check the temperature. I washed everything with antibacterial soap and poured boiling water through the bottles and breast attachments each time I used them to make sure they were sterile. You may want to boil them in a pot once a week. You can store your milk for a year this way. This way you can supplement your baby's feedings with your own breastmilk if you need to. You will be most successful if you use the supplemental nursing system filled with your previously stored breastmilk. If you find that you have finished all your previously stored milk, you can use formula in the supplemental system.

Lactation Consultants

I highly recommend that you contact an Internationally Board Certified Lactation Consultant (IBCLC) who has experience with adoptive breastfeeding or who is at least open minded about the protocols. You can find a listing for the US at http://www.iblce.org/us_regional_registry.htm and for the rest of the world at http://iblce.org/international_registry.htm If for some reason you are unable to find a board certified lactation consultant you can try a La Leche leader through La Leche, Tel: 1-800-La Leche. La Leche representatives have a wide variety of products available.

La Leche has a website at La Leche League . Again, it is important for you to find someone who is familiar with adoptive breastfeeding or who is at least open minded about the protocols. Breastfeeding and pumping should not be painful. I recommend someone who is experienced with "Adoptive Breastfeeding". She will teach you how to use your pump and how to "hand express" your milk. You can also buy your equipment from her. Then later on she can help to show you how to get a good latch when you're nursing your child. The most important job for the LC is to support your efforts. You should know that the vast majority of LC's are unfamiliar with the protocols and will try to persuade you to do nothing until the baby arrives. They will try to convince you that all you need to do is put your baby to the breast and this will be enough to stimulate milk production. They will tell you to use either the SNS or the Lactaid device while you're waiting for you milk. My dear, you will end up waiting a long time and you will be very disappointed if you follow this approach.

Breastfeeding Your Baby

As soon as your baby is born and you are able to hold him, put him to your breast (in the delivery room if you can). You may leave him on your breast to nurse each side at will, burping your baby between breasts. Initially, if you feed your baby on demand, your milk supply should increase to match it. This may mean feedings 1 or 2 hours apart. Within a week to ten days, your baby should be on a fairly regular schedule of his own making but don't get overly involved with this. Schedules are for trains not babies. You will need to continue breastfeeding around the clock until your baby can go four or five hours between the midnight feeding and the early morning feeding. Sleep is important for your milk supply. Try to sleep when your baby sleeps. If you can, I recommend pumping for at least 10 minutes after every feeding until your milk supply is well established. Whenever you notice a diminished milk supply, pump after every feeding and your milk supply should increase.

Breastfeeding should not be painful. If it is, most likely, your baby is not "latching on" properly. The most common problem is that the baby does not have enough of the breast in his mouth and needs to be repositioned. A common mistake is to put the baby only on the nipple when in fact the baby needs to take in the nipple and the surrounding areola as well. To begin nursing, your baby will "suck" in the breast tissue, then your baby "milks" the breast with his jaws as opposed to "sucking" only on the nipple.

The Latch

Above all, if you are nursing, the number 1 most important thing is to have a good latch. If your baby is not latching on properly, he/she will not be able to get the milk that is available as well, no matter how much milk you have. If you do have an abundant milk supply, your baby might still do well as far as weight gain is concerned, but the feedings may be long and frequent if the baby is not latched on as well as he/she could be. The key is to make sure that the baby takes in the nipple AND as much of the surrounding tissue as possible. There are no milk ducts in the nipple. They are under the areola surrounding the nipple. The baby needs to "pump" this area with his/her jaw in order to get the milk. The more efficiently your breasts are emptied either by baby, pump, or hand expression…the more milk you will have. Watch for your baby to do the following motion while on the breast…suck>chin moves downward towards baby's chest>pause>baby closes mouth. Here's a way for you to understand this. Suck some liquid from a straw and you will experience the pause in the chin. The baby does the same thing. Every time your baby's chin moves down and pauses, your baby is getting a mouth full of milk. When you see the suck, suck, suck motion or no motion at all there is no milk getting to the baby and either you'll need to adjust the latch or use breast compression to get more milk to the baby. Visit breastfeeding.com for a video clip on breast compression.

Breastfeeding should not hurt. Your baby needs to take in as much breast tissue as possible. Dr. Newman uses the "cross cradle"' hold and an "asymmetric latch". (Newman pp 53 -58). Using your left breast as an example, hold your baby with your right hand under her neck, fingers holding her head, your right forearm supporting her body. You may or may not wish to use a nursing pillow or regular pillow to help you to support your baby's weight. Then use your left hand to shape your breast. Hold your left hand in front of you, palm towards you, pinky side towards the floor and thumb pointed to the ceiling and forefinger pointed to the right. Place your hand in this position directly under your breast and use your hand to form a "c". Cup your breast, lift it and squeeze the "c" so that you have shaped your breast and have control of it. Aim for the middle of your baby's top lip (not the bottom one as some LC's suggest) so that your baby's tongue will be in the right position. As soon as she's opened up, shove your breast right under her top lip, straight into her mouth.

Once your baby is latched, remove your hand and use it to help you to support your baby. Take your other hand out from underneath and use it to thread the Lact-aid tubing into your baby's mouth (see the section on supplemental nursing systems above). If the latch is good, you will have shoved more breast tissue from the bottom of your breast than the top. "This is what is meant by the "asymmetric latch". This will better enable your baby to "milk" the milk sinuses that are located inside your breast just under the areola. You may or may not see a bit of the areola on top. All areolas are different. Some women have huge ones that a baby could never cover and some women have small ones. As long as you're not in pain, and your baby is doing the suck>pause (chin down, mouth filling with milk)>suck...you've got a good latch. The same technique applies to the right breast in reverse. If breastfeeding becomes painful after you've started, it means that your baby has adjusted the latch and you have to insert your pinky finger into the corner of his/her mouth to break the suction, get the baby off your nipple, and reposition the latch. You can repeat this as often as necessary until you're comfortable. Visit the following website for more information, illustrations, and video clips: breastfeeding.com

Common Problems and Solutions:

Breastfeeding the Premature Infant

Breastmilk is absolutely, without question, the best food you can give a premature infant. In the case of very premature infants who are unable to take the breast because they are too weak to suck and who are being tube fed, I recommend pumping your milk and having the hospital staff tube feed your infant with your breastmilk. This was the case with my son. He had to be tube fed for the first nine days until he was strong enough to breastfeed. I insisted that the tube contain my breastmilk. You may have to be insistent, not all staff in NICU's are supportive of breastfeeding or even breastmilk feeding. I advise putting your baby to your breast as soon as you are able to hold him. Have a lactation consultant show you how to train a preemie to breastfeed. It may take several days or weeks for your baby to get the hang of it. Don't despair, be patient, it's worth the effort.

Once your baby is able to breastfeed, it may take alternate feedings of breast and tube feeding until your baby is strong enough to breastfeed at every feeding. If your milk supply is low (which often happens due to the stress) you may want to use the supplementary nursing system (SNS) or Lactaid filled with either your previously stored breastmilk or special premature infant formula. As soon as your baby is established on the breast, I recommend that you discontinue the tube feedings. Many hospitals advocate the use of bottles with "preemie" nipples. This is not advisable and leads to "nipple confusion". You may end up with a baby who will reject the breast in favor of the bottle. The SNS or Lactaid is much better for your baby and for your milk supply. Cup feeding when you are not with the baby is better than bottle-feeding. If you are caught off guard and faced with an emergency premature birth or sudden adoption situation you can try the accelerated protocol below. Another option that you can explore is the use of a milk bank.

Jaundice

Jaundice is yellowing of the baby's skin and eyes caused by the normal breakdown of red blood cells in the baby's body. The blood cells release a substance called bilirubin that causes the yellow color. Bilirubin in turn is processed by the baby's liver so that it can be expelled from his body. Jaundiced babies have livers that are not able to process the bilirubin efficiently yet. This common form of jaundice, which appears within the first few days of life, is normal and usually disappears with time. In severe cases of Jaundice, the baby will need to spend some time under the "bili-lights" (phototherapy). It is not completely understood why bili-lights work but they do. There is no reason to discontinue breastfeeding. In fact, breastfeeding your infant more often will actually help the situation. If your baby has jaundice it is important to visit your doctor for a bilirubin assessment. There are some forms of jaundice, which are not normal, and in rare cases, extremely high bilirubin levels can cause problems, even brain damage if not treated. It is still not necessary to stop breastfeeding. For more information visit our website.

Sore or Cracked Nipples

The best way to avoid cracked nipples is to learn how to breastfeed your baby so that he is properly "latched on" (see "The Latch" above) and to learn how to properly use your breast pump. As you are learning, if you do experience nipple cracks use Blistex to heal them until the baby arrives. Once your milk comes in you can use a little of your milk on your nipples to heal them. Breastmilk has healing properties. When the baby arrives, you can use a product called Purlan or Lansinoh that is safe for the baby and does not need to be removed before breastfeeding. When washing your nipples, avoid soap as it has a tendency to dry out the nipples. Plain water works best.

In some cases cracked nipples can give rise to "thrush". Thrush is caused by a fungal infection (candida) and can lead to the growth of a white substance on your nipples that you can't wipe off. If you are nursing, it can appear as white patches on your baby's tongue and the inside of his/her cheeks. It is also known to cause "burning pain" in the nursing mother's nipples that persists throughout a feeding and lingers afterwards as well as deep breast pain without necessarily showing the white substance. Pain from a poor latch differs from the pain of thrush in that the latch pain stops soon after the baby begins nursing or as soon as the baby is removed from the breast. (Newman pp113-118). Dr. Newman suggests the following treatment protocol for thrush:

Dr. Newman's Candida Protocol (thrush)

Dr. Newman starts with local treatment consisting of: 1. Gentian violet (look under that title at the websites below). Once a day for 4 to 7 days.

If pain gone after 4 days, stop gentian violet. If better, but not gone after four days, continue for 7 days. Stop after 7 days no matter what. If not better at all at 4 days, stop the gentian violet, continue with the ointment as below and call.

Plus: 2. Dr. Newman's All Purpose Nipple ointment as below:

mupirocin 2% ointment (15 grams) nystatin 100,000 unit/ml ointment (15 grams) betamethasone 0.1% ointment (15 grams)

The pharmacist mixes it all together and it is applied sparingly after each feeding (except the feeding when the mother uses gentian violet). Do not wash or wipe it off, even if the pharmacist asks you to. You need a prescription for it. In Canada, Kenacomb (easier to find) or Viaderm KC (less expensive) ointment can be substituted for the above combination.

This is used until pain free and then use less frequently over a week or two until stopped. (See Treatments for Problems 1 under "all purpose nipple ointment").

3. If pain continues and it is sure the problem is Candida, or at least reasonably sure, add fluconazole 400 mg loading, then 100 mg twice daily for at least 2 weeks, until the mother is pain free for a week. The nipple ointment should be continued and the gentian violet can be repeated. If fluconazole too expensive, ketoconazole 400 mg loading, then 200 mg twice daily for same period of time (or grapefruit seed extract can be used). If Candida resistant, itraconazole, same dose and time period as fluconazole, though Candida actually is less sensitive to itraconazole, generally, than it is to fluconazole. (See handout Fluconazole). Fluconazole is apparently now available as a generic product (therefore less expensive). Fluconazole should not be used as a first line treatment or if nystatin alone does not work (which it usually doesn't).

4. Grapefruit seed extract 250 mg three times a day orally (taken by the mother), seems to work well in many cases. It can be used instead of fluconazole or in addition to fluconazole in resistant cases.

5. For deep breast pain, ibuprofen 400 mg every four hours may be used until definitive treatment is working (maximum daily dose is 2400 mg/day).

http://users.erols.com/cindyrn/newman.htm  or Breastfeeding Online or Jack Newman, MD, FRCPC Revised: October 25, 2001

Tongue Tie

The dreaded tongue tie (ankyloglossia) is easy to fix. A circumcision is so much more of a big deal. Your baby has a tongue tie if he/she cannot extend his/her tongue out past his/her bottom lip. Look underneath the tip of your baby's tongue and you'll see the short band of tissue restricting the tongue's movement. This makes nursing difficult for the baby and painful for you. The treatment for this is to clip the tongue tie…the sooner the better. Note, if the band of tissue is not at the tip of your baby's tongue and the baby's tongue can extend past his/her bottom lip, there is no tongue tie and more than likely your nipple pain is due to a poor latch. See "The Latch " above.

It's a good idea to see a pediatric dentist to clip the tongue-tie. The way it's done...(don't do this yourself because if you cut a vessel your baby will be in big trouble!!!) the dentist uses a little scissors and cuts only the band of tissue that is pearly grey with no vessels in it which is holding the tip of the baby's tongue to the floor of it's mouth. As soon as it's done, the baby is put to the breast to nurse. It doesn't hurt but it may bleed a little bit. It heals in a day or two. The breastmilk keeps it clean. Sutures are not usually needed with newborns but it depends on the thickness of the tongue tie. And it can be done right away…no need to wait for the baby to be weeks, months or a year old. The results are miraculous.

Lenore's Recipe for Increasing Milk Supply

If you are interested in increasing your milk supply and are not adverse to the idea of domperidone and herbs here is a recipe for success.

1) If you are an adoptive breastfeeding mother or an intended mother and are not already taking domperidone, it is a good idea to do so now. Take domperidone 10 mg 4 times a day for 1 week and then if you feel ok, not too tired and your stomach isn't too upset, increase the domperidone to 20 mg 4 times a day. It's a good idea to take domperidone 1/2 hour before meals and at least an hour before pumping. Don't start your herbs until you are comfortable with the domperidone…wait at least a week before you add the herbs or you can get a really upset stomach. And if you are already taking herbs…stop until you are comfortable with the domperidone.

2) For best results pumping or hand expressing every 3 hours and once during the night does wonders. Keep a cooler with an ice pack by your bed at night so you can hand express your milk into a bottle and keep it in the cooler until morning when you can transfer it into a bag and either use it in the Lact-aid if you are nursing or freeze it. You can also use this cooler idea at work if you don't have a fridge available to you. Freeze the milk when you get home or use it in the Lact-aid. Keep in mind that it may take a while for your breasts to get the message. You could be pumping and getting very little for days and then suddenly…boom you have a lot more milk!

3) When you are ready to add the herbs, take Fenugreek (610 mg per capsule) and Blessed Thistle (390 mg per capsule). Take 3 capsules of each, three times a day with food.

4) Drink as much water as you can without making yourself sick. 6 - 8 glasses would be great.

5) Eat oatmeal for breakfast 3 times a week. This is good for milk supply.

6) Above all, if you are nursing, the number 1 most important thing is to have a good latch. If your baby is not latching on, he/she will not be able to get the milk that is available no matter how much you have. See "The Latch" above. Watch for your baby to do the following motion while on the breast…suck>chin moves downward towards baby's chest>pause>repeat. Every time your baby's chin moves down and pauses, your baby is getting a mouth full of milk. When you see the suck, suck, suck motion or no motion at all…there is no milk getting to the baby and either you'll need to adjust the latch or use breast compression to get more milk to the baby.

7) If you have to supplement your baby's feedings, use a Lact-aid device. This will help your milk supply while at the same time keep your baby breastfeeding. It may seem silly to state the obvious but I'm going to say this anyway…a baby learns to breastfeed by breastfeeding. If you introduce the bottle, you will teach your baby that there is another way to get nourishment and often baby's will go for the bottle because it's less work. That doesn't mean you can't go out and leave your baby with a caregiver to handle a feeding or two…just don't make a habit of bottles at every feeding and you'll be fine.

8) Don't make yourself nuts over this. There is more to breastfeeding than breastmilk. Your baby only needs a small amount of breastmilk with each feeding in order to benefit. For more information on increasing milk supply, see "Dr. Newman's Protocol for Not Enough Milk" .

Milk Banks

Milk banks are a wonderful resource and, for a fee, will provide donated breastmilk to infants upon request. You often need a prescription and the cost is about $2 to $3 per ounce. You may want to use donated milk until your own milk comes in or as a supplement in place of formula. Milk banks screen their donors and most of them pasteurize the donor milk. Pasteurized breastmilk does not contain the same immunological benefits as unpasteurized breastmilk because the heat kills the antibodies as well as the germs but the nutritive composition is similar.

There are 7 milk banks in the US and 1 in Canada. For the milk bank nearest to you, visit: http://www.hmbana.org/milkbanks.html

Note: Although breastmilk from the biological mother is preferred, it is not necessary. There is no known difference between biological breastmilk and induced breastmilk. According the World Health Organization (WHO), the rating of what to feed babies is as follows (Newman p10):

1) The biological mother's breastmilk via breastfeeding . 2) The biological mother's breastmilk via pumping or hand expression, provided in a supplementary feeding system, or small cup. This is second best because antibodies are created at the breast. 3) Donated milk from a breastmilk bank. 4) Formula

A Word About Bottles

It is best to avoid bottle feedings as much as possible while you are breastfeeding. The more you breastfeed, the more milk you will have. If you introduce the bottle, your milk supply may decrease. Besides hindering milk production, the use of bottles can lead to "nipple confusion" in your baby...and not in your favour. If you need to supplement with formula, use the supplemental nursing system or Lact-aid. Introduce a cup from time to time when your baby is about 6 months old. Then when you are ready to wean your baby off the breast, you can wean him straight onto the cup.

Now I know that in reality this is a hard choice. Throughout my experience with breastfeeding, my son did receive some bottle feedings either from my husband or a baby sitter when I was unavailable. And as I was weaning my son, I alternated bottle-feedings and breastfeedings and let me tell you...there is a difference. If I had it to do over again, I would have weaned my son directly from the breast onto the cup. There is more to breastfeeding than breastmilk, and when the baby is on a bottle he is not breastfeeding. The point is, keep the use of bottles to a minimum.

Stopping the Domperidone

I very slowly began to decrease my dose of Domperidone as follows. When my son was 8 months old I decreased the Domperidone to 20 mg 3 times a day for 2 weeks. Then I decreased the Domperidone to 10 mg 4 times a day for two weeks. I continued decreasing the Domperidone to 10 mg 3 times a day for two weeks. Then 10 mg 2 times a day for two weeks. Then 10 mg once a day for two weeks. Then I stopped. It is very important to stop the Domperidone very slowly. Although most women do not experience discomfort when stopping the medication, gradual weaning from the medication will help you to gradually wean your baby from the breast without frustrating him. So go slow.

Additional Tips

Rest is very important for your milk supply. Drink a lot of water, 6-8 glasses of water a day would be good but don't "drown" yourself. I found a wonderful herbal tea called "Mother's Milk" by Traditional Medicines, which is available in the health food stores in the US. I also recommend the "Olga" and "Medella" nursing bras and "Gerber" cotton nursing pads. Medella has a "hands free kit" which enables you to pump while you work or watch TV. It has elastic bands that attach the "Pump in Style" plastic parts to the Medella nursing bras. Medella also makes a cigarette lighter adapter for the car enabling you to use the breast pump on long trips while someone else drives.

Recommended Reading :"Ammunition"

This is a list of Additional Reading that I like to call "Ammunition" that you can print out and show to anyone who tries to divert you from your goal.

Breast-feeding: Unraveling the Mysteries of Mother's Milk

Outcomes of breastfeeding vs formula feeding

How Breastmilk Protects Newborns by Jack Newman MD

Why is Breastfeeding Important?

Risks of Artificial Feeding by Jack Newman MD

Cost Benefits of Breastfeeding

Breastfeeding Good for Babies, Mothers, and the Planet

Bibliography "The Ultimate Breastfeeding Book of Answers" by Dr. Jack Newman, in the USA, Prima Publishing, 2000, or "Dr. Jack Newman's Guide to Breastfeeding", in Canada, HarperCollins Publishing, 2000. (Dr. Newman is one of the foremost experts on lactation in North America. He is a Toronto Pediatrician who established the first hospital based breastfeeding clinic in Canada at Toronto's Hospital for Sick Children. He is a consultant with UNICEF's Baby Friendly Hospital Initiative and is a popular speaker at breastfeeding conferences throughout the world. His book is a wonderful guide and answers most breastfeeding questions. Dr. Newman has devoted a chapter to Adoptive Breastfeeding that is extremely helpful. The protocols are derived from information from Dr. Newman's book)

"The Breastfeeding Answer Book" by Nancy Mohrbacher and Julie Stock, 2000, published by La Leche League International. ( This book is basically exactly what the title indicates. If you have a question, this book will answer it. It is written by two IBCLC board certified lactation consultants.)

"Medications and Mother's Milk, Ninth Edition, 2000", by Thomas Hale, Ph.D., published by Pharmasoft, 2000 (Dr. Hale is an associate professor of Pediatrics and Pharmacology at Texas Tech University School of Medicine in Amarillo, Texas. His book is widely respected as being the definitive guide to medications for breastfeeding mothers)

"Breastfeeding, A Guide for the Medical Profession" by Robert and Ruth Lawrence, published by Mosby, 1999 (Both of these authors are MD's working in New York, Dr. Ruth Lawrence is a professor of Pediatrics, Obstetrics and Gynecology at the University of Rochester School of Medicine and Dentistry and Dr.Robert Lawrence is an associate professor of Pediatrics and Microbiology at New York University School of Medicine. They have written an excellent resource book for understanding the physiology of lactation and related issues. This book is required reading for the IBLCE exam)

"Breastfeeding the Adopted Baby" by Debra Stewart Peterson, 1999, Published by Corona (written by a mom who breastfed her three adopted children. Although Debra doesn't support the use of medication because the protocols were not available when her book came out, there is a lot of helpful information.)

"Breastfeeding and Human Lactation, Second Edition" by Jan Riordan and Kathleen Auerbach, published by Jones and Bartlett,1998 (These authors are both internationally board certified lactation consultants. They have written an excellent resource book for understanding in great detail the physiology of lactation and related issues. This book is required reading for the IBLCE exam)

"The Complete Book of Breastfeeding" by Dr. Marvin S. Eiger & Sally Wendkos Olds, 1998, published by Workman (this is another excellent instruction guide)

"The Womanly Art of Breastfeeding" by La Leche League International Authors, 1997, published by Penguin (this is an excellent instruction guide)

"A Practical Guide to Breastfeeding" by Jan Riordan, published by Jones and Bartlett, 1991 (excellent source of information to understand the physiology of lactation and practical instructions, there is also a chapter on induced lactation which includes a comparative study between birth mother's milk and induced milk)

"Nursing Your Adopted Baby" by Kathryn Anderson, 1986, published by La Leche League International (Publication No. 55) (Written by a mom who breastfed her adoptive baby, but again she does not advocate the use of medication because the protocols were not available when her book cam out. This guide offers a lot of helpful information. It was one of the first books published that was exclusively devoted to the topic of adoptive breastfeeding.)

Additional Information

For more information on induced lactation see the Adoptive Breastfeeding Resource Website, fourfriends.com and visit my forum "Ask Lenore" by clicking on "Ask Lenore" at the bottom of the list that appears here: fourfriends.com/board

Dr. Jack Newman's articles are available on the following websites: http://users.erols.com/cindyrn/newman.htm ; http://www.bflrc.com/newman/articles.htm http://babiestoday.com/breastfeeding/drjack;  http://breastfeed.com/resources/articles/drjack/

Questions? I hope that this information has been helpful. If you need further assistance, you can e-mail me, Lenore Goldfarb, in Montreal, Canada, at lengold@sprynet.com and I'll be happy to help. I wish you and your child a long and happy nursing relationship.

Warm Regards, Lenore Goldfarb ãLenore Goldfarb December, 2001. All rights reserved.