'Adopted, embraced and nurtured'.

A woman who wanted to give her adoptive daughter the best possible start in life by breastfeeding her, embarked on a programme to induce lactation. This is her story and those of two of the health professionals--a whanau ora nurse and a midwife--involved in helping her achieve that goal.

My husband and I are in our early 40s and have four beautiful daughters. Each of our children was whangai (adopted, embraced and nurtured). Our eldest daughter is 20, the youngest, 20 months. This story relates to our youngest daughter Tira Wahine-Kura.

Tira was born on June 13, 2003. Her birth mother and birth father are related to me by blood and we also share a friendship. The decision to adopt Tira was a collective one between her natural parents, paternal grandparents and ourselves, and was made when her birth mother was approximately two months into her pregnancy.

When Tira's birth mother was approximately four months pregnant, she asked me whether I had considered breastfeeding Tira. I hadn't, as I did not realise I could do this. To begin, with I was unsure whether this was natural or not, and I deliberated over it for some time.

The advantages of breastfeeding

During this period, I happened to see a brochure on breastfeeding at a friend's place and how important breast milk was in terms of a baby's early development. This was the deciding factor for me and so I approached the whanau ora nurse, Sue Parsons, from Te Tai O Marokura Health and Social Services in Kaikoura, where I live. She was unsure whether this was possible but agreed to make enquiries.

Sue talked to Kaikoura Hospital midwife Michelle Falloon and together they discussed whether it would be possible for me to breastfeed the baby. The whole thing was a Learning curve for all of us.

While the nurses checked out the medical requirements, I talked to my whanau. Their responses varied. My children had differing responses--some thought it was awesome, while one was quite resentful. My husband said he would fully support whatever I decided. My brothers' and sisters' responses differed from disbelief, to thinking I was nuts, to wondering how it would work and why I would want to do it, to excitement. In the end, they all supported my actions. Afterwards, the key response was fascination that I really could breastfeed, without having been pregnant.

Care plan developed

When all the information was in, Michelle, Sue and I met to discuss the information and the ramifications of what would need to happen. From here, Michelle wrote a care plan and I was monitored regularly by both Sue and Michelle. I then spoke to my managers at work, whose response was disbelief but supportive, and they agreed to allow me the time to meet the care plan requirements in relation to breast pumping every two hours.

Meeting the requirements of the care plan was extremely tiring, but I was determined to give my baby the best start in life. This, and everyone's support were what pulled me through, especially when I was feeling extremely frustrated as I was getting no results.

I was at a friend's house using the manual pump when she told me she had an electric breast pump I could use. I tried this and it really hurt compared to the manual pump, but it was the first time milk actually appeared in my bottle. From then on I used the electric pump. From my perspective, this was more effective, as it did not rely on me, thus the pressure required to fully open the milk ducts and increase my milk supply was consistent. This enabled my nipples to toughen and become Less sensitive. In terms of the medication (domperidone), this was effective in building my milk supply, both at this time and after the baby was born. A side effect of the medication was that it stimulates the appetite and I did gain weight. However, this could be due to the fact that at the time I was "nesting", especially after the baby was born.

I was also on an oxytocin nasal spray. This was a hormone taken to encourage the "letdown" process. I took this one week before Tira was born. The preparation for breastfeeding began one month before Tira was born.

Once Tira was here, I continued to take the domperidone for six months. Tira's birth mother collected her colostrum so I could feed this to Tira through a feeding tube at the same time as I was breastfeeding. She also supported me during this initial stage. Although the tube was quite small, Tira seemed to get distressed every time I used it. This in turn upset me, so after a week I stopped giving her the tube. Instead I would feed her from the breast and then give her a bottle with the colostrum in it and breast milk from her birth mother.

Was Tira getting enough?

Part of my dilemma, as a breastfeeding mother, was concern about whether Tira was getting enough nourishment, so I would give her a bottle with formula. Often she would fall asleep while I was breastfeeding, before I could give her the bottle, and this increased my worries. Although most breastfeeding mothers have the same concerns, in my case, this was magnified because of the literature I had read which stated I may not be able to provide a full supply of milk, but a percentage of it.

People telling me she was a bonnie and contented child did not allay my fears. My fears were only really allayed when Tira was weighed and I could actually see she was gaining weight. The nurses did this for me regularly. After a while I did relax and Tira would have the breast, the breast milk from her birth mother and the formula. She would have between 10-20 mls from a bottle and occasionally 50 mls. I would still, however, fill a 150 ml bottle to ease my mind. At this time, Tira's birth mother was living with me because of personal circumstances, rather than because she was the birth mother. This time gave Tira's natural brothers a chance to bond with her.

Importance of emotional bonds

When I decided to breastfeed, my main reason was the nutritional value of breast milk. However, once started, I could see the value of breastfeeding in building the emotional bond between Tira and me. Breastfeeding Tira definitely added an extra dimension to this initial relationship, which is difficult to explain. As I see it, with my other children, I was always able to give them to someone else to feed, while I did other chores. However, with Tira, I had to be there, and so there was more time spent with just her and me. This time allowed me to get to know her personality faster than with my other children, and it also allowed me more time to relax and just be with her. I understand it in these terms--you can see a loving embrace, but it is different when you are being embraced. If the opportunity arose to do this again, knowing what I know now, I would have definitely started breat pumping sooner. I would be much more relaxed about it and I would have breastfed for longer. I would recommend breastfeeding an adopted child to others. This experience has taught me and many other people close to me a great deal. Many people who know my story find it fascinating, as it pushes the boundaries, especially for Maori, where to whangai a child is common.

THE MIDWIFE'S ROLE

Lorraine is a mother who was committed to inducing lactation, in order to breastfeed her precious adopted baby, Tira. Induced lactation refers to the ability for a woman to breastfeed without going through a pregnancy.

Any amount of breast milk she could produce was a precious gift, and the help, guidance and support Lorraine received from myself, Sue and Lorraine's family assisted the whole process. Initial help was also offered from the birth mother's midwife, and from a lactation consultant at Christchurch Women's Hospital, Dawn Hunter.

The biology of induced lactation

During a pregnancy, a woman's body produces increasing amounts of progesterone and eostrogen via the placenta, and prolactin via the pituitary gland. These hormones prepare the breasts for breastfeeding. Once the pregnancy is completed, progesterone and eostrogen levels drop and prolactin levels increase, resulting in lactation. Eostrogen and progesterone stimulate proliferation (an increase in both the number and size) of the alveoli and ducts of the breasts, while prolactin is the milk-producing hormone. In the non-pregnant woman, or the woman inducing lactation, regular pumping with a breast pump helps to promote the growth of the alveoli and ducts, in a similar way as eostrogen and progesterone in the pregnant woman.

Once the milk supply is established, it works on a supply-and-demand basis: under the baby's control if the mother is breastfeeding; and under the mother's control if she is using a breast pump. The more often and the more efficiently the baby withdraws milk, (or the mother pumps), the more milk will be produced. As the baby suckles at the breast (or the suction of the pump begins), a signal is sent from the breast to the brain to release oxytocin, which initiates the milk ejection or let-down reflex and causes the milk to flow. (1)

The release of oxytocin coupled with the draining of milk from the breast causes the breast to produce more milk.

Several medications have, as a side effect, the production of breast milk. Domperidone is an anti-emetic drug, which is not a hormone, but a side effect is in an increase in prolactin levels. (2) Domperidone increases prolactin levels indirectly, by interfering with the action of dopamine. One of the actions of dopamine is that it decreases the secretion of prolactin by the pituitary gland. It was discovered that, when some women took this drug, this increase in prolactin levels could, in turn, cause lactation.

Domperidone is not known to cross the blood-brain barrier and is safer to use for mother and baby than some other drugs, proving useful as a galactagogue. Serum prolactin levels have been found to increase from 8.1 nanogram (ng)/millilitre (ml) to 124.1 ng/ml in non-lactating women after one 20milligram (mg) dose. In a study taken of 16 mothers, (3) the women were randomly selected and nine mothers received placebo, and seven received domperidone 10mg three times daily. (3) Milk volume increased from 112.8 to 162.2 ml/day in the domperidone group and 48.2 to 56.1 ml/d in the placebo group. Prolactin levels increased from 12.9 to 119.3 micrograms (mcg)/ litre (L) in the domperidone group and 15.6 to 18.1 mcg/L in the placebo group. No adverse effects were reported in infants or mothers. (3) The usual suggested dose for gatactogogue effects is 20-40 mg orally, three to four times daily. (2) It is advisable to continue to take the domperidone from the initiation of lactation until weaning. Most mothers find that when they forget a dose, their milk supply decreases. However, once lactation is well established and the baby is breastfeeding well, the mother may consider slowly decreasing the domperidone. If her milk supply drastically decreases, she can always increase the dose back to 20mg, four times per day.

Other side effects of domperidone include dry mouth, skin rash, itching, headache, thirst, abdominal cramps, diarrhoea, drowsiness and, rarely, seizures. (2)

Oxytocin--its role in induced lactation

The administration of oxytocin intra-nasally can be helpful in stabilising the milk-ejection reflex during the initial period of establishing and promoting increased milk yield. Oxytocin triggers the milk-ejection reflex, to assure effective emptying of the breasts at each feed. It may also stimulate the release of prolactin by the anterior pituitary, which is responsible for milk secretion. (4)

The use of oxytocin nasal spray enhances the onset of lactation, by contracting the myoepithelium cells, which forces milk from the aveolar canals into the large sinuses, where it becomes available to the suckling infant or for withdrawal by pumping.

In Lorraine's case, oxytocin spray was recommended, with three sprays into each nostril prior to feeds/pumping. Lorraine used the spray for a week prior to the birth of the baby. It has been my privilege and pleasure to be involved with these life-changing events for Lorraine, her baby and her supportive family.

RELATED ARTICLE: Playing a support role.

In my role as whanau ora nurse for an iwi health and social services provider, Lorraine approached me in April 2003, asking if I could find out if it would be possible for her to breastfeed her soon-to-be-adopted baby. I contacted a lactation consultant from the La Leche League, who suggested I contact the midwife from our local rural hospital, Michelle Falloon. I did this and an initial meeting was set up for Lorraine, Michelle and myself. At the first get-together, we talked about the expected birth date of Lorraine's baby, the preparation that would be needed, and about Michelle and my roles in helping to support Lorraine. We decided on weekly meetings, with Lorraine knowing she could contact either of us at other times if needed.

Michelle had been in contact with a lactation consultant from Christchurch Women's Hospital regarding breast pumping and medications to help induce lactation. Michelle, with guidance from the lactation consultant, wrote a care plan and we each had a copy.

Consultation with other health professionals

My role was one of support and encouragement. This was done with frequent home visits and consultation with the other health professionals involved. These included the midwife, the GP, the lactation consultant, a local pharmacist and a pharmacist from Christchurch Women's Hospital.

During my visits to Lorraine at home, I was awed by her huge commitment to this task. It was nice to see how Lorraine was getting her "nest" ready, with baby clothes, linen and kete. Lorraine's whanau was very supportive and as the birth date got closer, you could feel the excitement growing. On one of my visits, I was fortunate to meet the baby's birth mother. Tira was born on June 13, 2003, weighing 4250 grams. Lorraine and whanau were very happy about their new daughter and sister.

My weekly visits continued, along with Michelle's, who did the six-week postnatal check. Tira was given colostrum from her birth mother via a feeding tube. Lorraine felt that Tira did not feed well this way and felt more comfortable using the bottle. Tira was suckling well at the breast for the first part of the feed and then she was offered the bottle. The bottle feed was expressed milk from the birth mother for the first two weeks, and then formula was used. Although tired at times, Lorraine looked very happy and contented, as did her new baby. Tira was weighed weekly and had a dose to average weight gain.

Tira had one episode of being unwell at almost six weeks of age. She was unsettled, not feeding well and had an elevated temperature of 38 degrees C. Lorraine was worried as other members of the whanau had been unwell with a virus. Lorraine had been tepid bathing Tira. Michelle also visited and it was arranged for the GP to do a home visit. Lorraine was encouraged to keep breastfeeding Tira, to monitor intake and output and to use Pamol as instructed. Tira improved the next day, but became unwell again that night. The GP decided to send Tira to the paediatric ward at Christchurch Hospital. During this period, Lorraine experienced some difficulties with breast feeding, but she persevered through pumping and feeding and managed to keep breastfeeding going.

At six weeks of age, Tira's care was handed on to our then tamariki ora nurse, Sonia Chapman. Following Lorraine and Tira's progress had been a special time for me and I felt privileged to have been involved. With Lorraine's consent, it was decided I would continue my support visits. Tira was completely weaned by January 14, 2004, aged seven months. She is a content little girl who is bringing much pleasure to her whanau.

One of of the outcomes of this for me was the advantages of shared care with Michelle. This worked well and has strengthened our working relationship and benefitted myself, Lorraine, Tira and Michelle.

References

1) Goldfarb, L. and Newman J. (2000) The Protocols for Induced Lactation: A guide to maximising breastmilk production, http://wwwaskelenor.info/breastfeeding /print/induced_Lactation/protocols4print.html (Retrieved 4/03/2004).

2) Domperidone and Breast Feeding: Newborn Services Clinical Guidelines (2002) http://www.adhb.co.nz/newborn/Guidelines/Maternal /DomperidoneAndBreastFeeding.htm (Retrieved 2/05/2004).

3) da Silva, O.P. (2001) Effect of randomised, double-blind, palacebo-controlled trial. CMAJ. 164: 1, 17-21.

4) Barrett, P. Pharmacist, Christchurch Hospital 2004. Personal communication and Product data sheets: oxytocinon nasal spray. www.medsafe.govt.nz.