RELACTATION AT THE AGE OF COMPLEMENTARY FEEDING

By: Dr. Devi Farhana, CIMI

 

Breastfeeding is a physiological process of providing nutrition in the form of breast milk to the baby. The purpose of breastfeeding is not only related to the baby’s satiety, but also contribute to the bonding and emotional nutrition development of the baby’s. These mutual interactions become the baby’s fundamental growth and development as social creatures.  The breastfeeding process does not only involve the mother and baby, but also the father, the extended family and their environmental support. Maximum support from the health workers and surroundings will benefit mothers and babies in maintaining a successful breastfeeding process.

Breast milk is one of the God’s gifts that has been known since the ancient times as a special food and still remains as an irreplaceable nutrient for babies. The composition of breast milk remains the best among all. In addition to that, breast milk contains immune and anti-germ substances that could not be found in any other milk. Some literatures mentioned that 100% of babies’ needs could be fulfilled by breast milk alone, 6 months and above 12 months by 50% and 30% while the rest are obtained from complimentary food. This shows a baby can survive the first 6 months only from nutrition provided by the mother.

The countless benefits of breast milk for the health of the mother and the baby not necessarily make the breastfeeding practice any less hard, especially in Indonesia.

 

CASE STUDY

Mrs. NL (a mother) came with Baby A together with her husband to lactation clinic at Permata Bekasi Hospital. Mrs. NL wanted to try breastfed baby A (9 months old). Mother lives with her husband in Bekasi.

 

Pregnancy and Labor History

Baby A was female and the first child, with birth weight of 2730 grams. There was no complication during pregnancy and was born through spontaneous vaginal delivery with the help of midwife.

 

Nutrition Intake During the first 6 Months

During the first 6 months, Baby A got exclusive breastfeeding. Breast milks were obtained by direct breastfeeding and through bottle (expressed breastmilk). In the first days after giving birth, Mrs. NL pumped approximately 200 ml of breast milk per breast per 2 hours of pumping sessions and baby A was able to consume approximately 60 ml of expressed breast milk with bottle. Mrs. NL felt that the baby struggle to breastfed directly, caused by the shortness of her nipple.  Therefore Mrs. NL took some initiative to use nipple shield as supporting tool.  However the nipple shield was not really solving the problem, as the baby did not want to breastfeed directly from Mrs. NL’s breast. In the end, Mrs. NL gave up direct breastfeeding infant A but still provide it through bottle-feeding.

Baby A’s weight gain was good in accordance with the growth chart, the mother keep expressing the breast milk with a breast milk pump. Entering the fifth month, the mother’s milk production began to decrease to 60 – 80 ml each breast. On the other hand the baby A’s milk consumption was simultaneously increased along with her age, which was worrying for Mrs. NL. Infant A’s grandmother then reminded Mrs. NL that the breast milk production would decrease caused by breast pumping in opposed to direct breastfeeding.

 

Nutrition intake over the age of 6 months (MPASI)

Entering the sixth months, baby A was introduced to complementary food in accordance with the recommendations of the World Health Organization (WHO) while still continuing breast milk. Baby A was able to consume 100 ml breast milk while the mother’s milk production decreases to 60-80 ml per breast. Through the development of anxiety in regards to the feeling of breast milk insufficiency, Mrs. NL’s breast milk’s production decreased even more. The mother then began to look for information to fulfill baby A’s increasing need of breast milk. All types of commercial milk production booster (Breast milk Booster) were consumed but the production of breastmilk still did not increase. Finally one of Mrs. NL’s friends suggested relactation.

 

“Your breast milk production will be reduced if you only pump it” – Infant A’s Grandma

 

Relactation Process

Entering the age of 7 months 14 days, baby A was brought to Bekasi. As recommended by her friend, Mrs. NL immediately contacted the Praborini lactation team over at Permata Bekasi Hospital.

 

“Tomorrow we want to go to the hospital, baby A wants to learn breastfeeding” – Mrs. NL to her husband

 

Retrieval of information about the family background and family support was performed. There were no internal or external conflicts (household/social) that could potentially hamper the relactation process. A thorough physical examination was performed on the mother and the infant to identify the relactation problems. Maternal breast and nipple shape obtained within normal limits and breast milk production also within normal limits. Baby’s nutrition status was good (7720 grams) at the age of 9 months and 6 days, but tongue-tie and lip-tie grade 3 were found and there were no other complications found in the oral cavity. The other physical examination turned out to be normal. Direct breastfeeding observations were undergone and the baby refused to feed from the mother’s breasts. With the aid of supplementation tools, breastfeeding observations were made and the baby began occasionally to feed from breast directly. Both the Mother and father agreed to do a further relactation process.

Mother and the infant are doing relactation by the hospitalization method (Praborini method) and the provision of complementary foods was given in accordance to the WHO recommendation. During relactation, a lactation visit was carried out daily by the lactation doctor to assess the progress of the relactation process.

First day of treatment, the mother was very happy and optimistic that she can finally breastfeed her baby back. With the help of supplementation tools, several observations were made by the doctor and the baby can feed directly from the mother.  However the baby seems to have difficulties in maintaining a continuous suction. The infant was easily distracted while undergone breastfeeding that made the process become inefficient. The mother was very focused in undergoing a relactation process.

Second day of treatment, the infant’s weight rose significantly to 8060 grams, the mother and the infant started to breastfeed comfortably and enjoyed the process, although the baby was still refuse the breast occasionally. Frenotomy (incision of the frenulum tissue) of the tongue tie and lip tie was done to help the baby maintain its suction from the breast. Then mother and father were taught about the tongue and lip exercises to practice the mobility of the baby’s tongue and reduce the likelihood of frenulum to sticking back. The mother looked really focused and was confident that the infant would feed from her breast.

Third day of treatment, the baby’s weight increased to 8075 grams, the infant started to suckle directly to the breast without the help of supplementation tool. Through the physical examination on the mother, it was found that the breast milk was dripping on both breasts. When breastfeeding observation was done without the help of supplementation tools, the baby feed directly from the mother’s breast, resulted in a deep and continuous suction. The baby releases the breast by herself when she felt full and the breast of the breastfeeding mother felt softer. Mother was very enthusiastic to learn to feed babies on both breasts. The mother tried to hold the baby while raising her right breast and the baby smiled at the mother and kissed the mother’s breast, then she begun to suck. Baby and mother look very comfortable finally being able to perform a direct breastfeeding. The relactation process was rated as successful, mother and baby were allowed to go home and follow up on schedule.

During the follow up, it was found that the mother milk’s production increased and breast emptying was good. The infant’s weight increased 460 grams in 7 days (65,7 gram/day) to 8380 grams. Post-frenotomy treatment was good. Following the last frenotomy, the infant’s weight gained 32 grams per day to 9000 grams. During the follow up, the mother was always accompanied by the father and Mrs. NL looked more cheerful and confident. Baby A was also still able to direct breastfeed from the mother even in crowded place.

 

Relactation

Definition

Relactation is an attempt to restore the baby’s ability to feed directly from the breast, either because the baby stopped breastfeeding for various reasons or the mother, who previously done breastfeeding, quit along the way. Relactation is not easy. Mothers who want to regain an emotional benefits (bonding) with the baby through relactation, would be more successful in their breastfeeding process, than those that focus on increasing the production of the breast milk. In several surveys, 75% of mothers said relactation gave positive results.

 

When is Relactation necessary?

• Baby/Mother who is ill and requires separate treatment.
• Baby with a low birth weight who has not been able to suck effectively in their early days of life.
• Baby experiencing breastfeeding problem, especially those under six months.
• Mother with reduced breast milk production due to the lack of proper breastfeeding technique or lack of proper lactation management.
• Adoption case, in order to form a bonding and get the benefits of breastfeeding
• A case where the mother can not breastfeed their baby because she is suffering from a virus that attacked the body’s immune system like Acquired Immunodeficiency Syndrome (AIDS) or a case where the mother has died. One of the family member like the grandmother can do relactation for the baby.
• In case of emergency such us natural disaster

 

 

When does relactation start?

Younger babies have a better desire to breastfeed from their mothers. Infants under 3 months have a better success ratio and so do the infants who had breastfeed experience before. Infants over 6 months have a strong tendency to refuse relactation.

 

The Key to Successful relactation

Babies and mothers should enjoy the process of relactation, especially the babies should feel comfortable around the mother. It is important to avoid everything that makes the breast become the most undesirable place for babies.

1. Factors related to the Infants
   • Infant’s desire to suckle. The relactation process will be easier for babies who suck on to the breast immediately when offered breast for the first time. However, some studies reveal 74% of babies will reject the breast for the first time if the baby had never done breastfeed again after some time.
   • Infant’s age. In general, babies younger than 3 months have a desire to breastfeed better than older babies. Adopted infants less than 8 weeks have a 90% chance of induced lactation success compared to the infants over 8 weeks, which is about 51%. Older babies still have a chance to succeed in relactation as long as the baby has the desire and initiative to suck on to the breast. All mothers are able to do relactation/induced lactation regardless of the baby’s age.
   • The time gap in doing the last breastfeeding. Relactation will be easier if the time gap in doing the last breastfeeding is short enough.
   • Providing nutrition during breastfeeding gap. Babies who are accustomed to getting nutrition through a bottle will have a different pattern of suckling, therefore the baby will prefer bottle over the breast, even if the breast has abundant milk. This condition is called nipple’s confusion. Therefore, it is very important to stop using bottle. Babies who experience nipple confusion can still suckle directly on to the breast if the mother gets the right handler. In infants with nipple confusion it takes time, stamina and professional health workers for the relactation to be successful.
   • Special conditions in infants. Evaluation on the condition that causes the baby to stop breastfeeding early, especially in terms of anatomy (tongue-tie, lip-tie,cleft lips/gums/palate), reflux disease and others.
2. Factors related to the Mother
   • The mothers’s motivation. The success rate of relactation really depends on the mother’s motivation. A greater success rate will be obtained if the mother is doing the relactation in order to increase the bond with her baby or for the baby’s health to fulfil their nutrition needs
   • The mother’s lactation gap. The shorter the time gap of the mother doing the last breastfeeding for her baby, the more likely for the relactation to success.
   • Breast condition. Some mothers have a condition that can interfere the breastfeeding process, such as flat/inverted nipples, post-surgery breast scarring and breast infection. As long as the baby is well positioned and attached, effective suckling will make relactation /induced lactation successful.
   • Mother’s ability to respond to baby’s needs. Mothers need to establish a relationship with the baby by reading the baby’s cues and desire to suckle at any time. During relactation, mothers need to make intense skin-to-skin contact in order to understand the baby’s cues. To have a maximum respond, the mother needs to take a break from daily activities and even leave work for some time. If this condition cannot be fulfilled, the mother’s concentration will be divided and the relactation will be difficult to do.
   • Family support, Environment and Health Worker. Emotional support is really needed by mothers who are breastfeeding. In developed countries (US, Sweden, Britain and others), fathers have a big role to play as the main support for mothers. Emotionally supportive father and directly participate in providing practical assistance (changing diaper, soothing the baby, burping the baby) will increase the success rate of the exclusive breast milk provision  as much as 3.737 times greater than mothers who have lack support from her husband.
   • Previous Breastfeeding Experience. Having a previous breastfeeding does not have much effect in determining the success of relactation. Several studies revealed no significant results between mothers who had never breastfeed their babies or mothers who had never been pregnant and mothers who had done breastfeed before in the success of relactation. Another study revealed that 11 of 12 women who had never done breastfeed before were able to produce sufficient milk 5-13 days after the induced lactation protocol began.

 

Things that need to be considered when doing relactation

• Reasons for breastfeeding? Mothers can consult with breastfeeding counselors or closest friends who are also in the same shoes before starting the relactation journey
• Physical changes, breasts, and menstruation will happen when doing relactation
• Mood swing. It is very important to talk with a trusted person while undergoing the relactation process.
• Relactation process will be time consuming and difficult, but it’s possible. With the right support, information and dedication, relactation can be done in every mother and will be resulting in a happy and precious experience for both the mother and the baby. Self-confident and faith will be very helpful in this relactation journey.

 

References

1. Praborini Asti, Wulandari A. Ratih. Anti-Stres Menyusui. Kawan Pustaka. Jakarta. 2018.
2. World Health Organization. Relactation; Review of experience and recommendations for practice. Geneva 1998.
3. Kayhan-Tetik Burcu, et al. A Case report of successful relactations. Turkish Journal of Pediatric [Internet]. 2013 Nov [Accessed on 2019 Oct 20^th]; 55: 641-4. From https://pdfs.semanticscholar.org/701f/f5aad32df00f3a15e2b8e35640f7d710e0b1.pdf
4. Lommen Amy, et al. Experiential perceptions of Relactation: A phenomenological Study. Journal of Human Lactation. [Internet] 2015 [Accessed on 2019 Oct 20^th ]; from https://www.researchgate.net/publication/260431059_A_case_report_of_successful_relactation
5. Association of Breastfeeding Mothers. Relactation: Restarting breastfeeding after a gap. [Internet] 2019 [Accessed on 2019 Oct 23^rd]; from https://abm.me.uk/breastfeeding-information/relactation/
6. Mehta Anita, et al. Relactation in lactation failure and low milk supply. Sudanese Journal of Paediatrics. [Internet] 2018 Apr 2^nd [Accessed on 2019 Oct 23^rd]; 18 (1): 39-47. From: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113782/
7. Seema et al. Relactation: An effective intervention to promote exclusive breastfeeding. Journal of Tropical Pediatrics [Internet]. 1997 Aug [Accessed on 30^th of Oct 2019]; 43: 213-6. From https://academic.oup.com/tropej/article-abstract/43/4/213/1661166