What is Relactation? Starting Breastfeeding Again After a Gap

When Brittany Gerald's daughter came three weeks early in 2019, breastfeeding got off to a rocky start. The doctors worried the baby was too young to latch and insisted on formula feeding. The hospital lactation consultant also told her not to pump so the baby could establish the appropriate supply.

Formula is a safe and nutritious alternative to human milk, but Gerald wanted to breastfeed. Her baby could not establish supply. Why? Because milk supply is established through demand—or removal through nursing, pumping, or a combination of the two. Since Gerald wasn't removing milk, she didn't have an abundant supply when it was OK for her daughter to latch. She saw multiple lactation consultants until one told her to give up.

But after stopping, Gerald did some research and realized she had been given bad advice from the start. She also learned that it was possible to try breastfeeding again through a process called relactation.

So what is relactation? It's "the process of re-establishing lactation after stopping for someone who has been previously pregnant," says Norma Escobar, IBCLC, the lactation program coordinator for New Hanover County Health and Human Services. For Gerald, relactating involved pumping every two hours. It was daunting and exhausting.

"It was a lot of work," admits Gerald, now a certified breastfeeding specialist who went on to start a podcast and company, My Lactation Navigation. "She was sleeping through the night. You'd hope you would be too. I was pumping while working, too."

But Gerald did it and was able to pump 20 oz. per day. She fed her child human milk until she turned 2 years old.

Gerald wanted to undertake relactation. But amidst a nationwide formula shortage, some parents feel they have to. Escobar used to only get one or two inquiries about relactation per year. These days, she gets one or two per week. Aunchalee E.L. Palmquist, Ph.D., MA, IBCLC, is also noticing an increase and isn't surprised. "We see an interest in relactation after every kind of disaster in families with children," says Dr. Palmquist, an assistant professor in the Department of Maternal and Child Health at the UNC Gillings School of Global Public Health and an affiliate of the Carolina Global Breastfeeding Institute (CGBI).

It's possible to relactate and even induce lactation in individuals who were not previously pregnant. But the processes require careful attention not just to the physical health of the lactating person but also to their mental state. Experts discussed relactation and inducing lactation.

Who Can Relactate?

Anyone who has previously been pregnant and lactated can relactate, notes Lydia Boyd, IBCLC, CBE, CLE, BPC of The Lactation Network and The B.L.A.C.K Course. But Boyd notes some factors can impact the process.

• Oral anatomy issues in the baby. Tongue ties, recessed chins, and cleft palates can make it more challenging for a baby to latch.
• The health of a lactating person. Conditions like diabetes, hypothyroidism, and polycystic ovary syndrome (PCOS) can affect hormones and hinder milk production. The person may still produce some milk, but the supply could be lower. Insufficient Glandular Tissue (IGT), which occurs when the breasts do not fully develop milk-producing tissue during puberty, can also limit supply.
• Access to a pump. Under the Affordable Care Act, birthing people are entitled to one free breast pump. But data shows that one in nine women of childbearing age is uninsured. Breast pumps can cost more than $400, a roadblock for parents without financial means.
• Time. Boyd understands time is a finite resource. Lactating people may have another child and/or job. Though employers are required to give lactating people time and space to pump, those breaks can be unpaid. And employers may not be supportive, despite the legal requirements. Removing milk every two to three hours may not be feasible for everyone."It's manual labor, and the person needs the time and space to do it," Boyd says.

How Late Can You Relactate?

This answer varies depending on the lactating person. "We've heard stories of grandmothers doing it," Boyd says. "I'm pretty sure those are outliers, but if you are still of reproductive age and haven't hit menopause yet, you can be a great candidate."

In a best-case scenario, individuals hoping to nurse the baby at the breast will have a child three months old or younger. "They have a strong sucking instinct and can be brought back to having a latched feeding," Dr. Palmquist says. But she qualifies that it's possible for older infants to come back to breast, too.

The Process of Relactation

Before relactating, Boyd advises people to speak with a health care provider. The lactating person should be assessed for:

• Sufficient glandular tissue
• Thyroid issues
• Inverted or flat nipples
• Medications (Not all are breastfeeding safe)

The baby's oral anatomy—including lip, tongue, and buccal ties and suck strength—should also be assessed by a lactation consultant and pediatric dentist or ENT. From there, it's about milk removal.

"If you have a baby who can latch and is interested in latching...we would recommend nursing the baby as much as possible," Dr. Palmquist says.

Though the lactating person may not have a full supply, they can comfort nurse. Dr. Palmquist also suggests using a supplemental nursing system (SNS), which allows caregivers to put the baby at the breast and have nutrition coming through a tube often taped near the nipple. Feeding the baby by the nipple with a syringe is also possible. The skin-to-skin contact relieves stress, which can affect supply, and stimulates a hormonal response that triggers milk production. It also promotes bonding.

Skin-to-skin can also be achieved through babywearing and simply placing a baby in only a diaper on the lactating person's bare chest. Boyd says any time the baby receives a bottle—be it for a full feeding or supplement after nursing—the lactating person should remove milk by pumping or hand expression to signal to the body to make more.

Additionally, like Gerald, people can relactate through hand expression or pumping only. "If you can do it every two to three hours during the day and every three to four hours per night, that's great," Boyd says.

Milk supply can also be increased with medications, such as Reglan and Domperidone. The latter is not FDA-approved in the U.S. Boyd advises people to speak with their health care providers before starting any medication or herbal regimen. Once a person begins making milk, Boyd says it's essential to protect their supply to maintain it. "Make sure you are consistent," Boyd says. "If you can get the baby back to breast, make sure you are removing milk for every feeding that that baby gets."

How to Induce Lactation

During pregnancy, the breasts change to prepare for breastfeeding, most importantly the development of glandular tissue and milk-producing cells, Dr. Palmquist says. The removal of the placenta after birth triggers a hormonal response that begins milk production.

"The hormonal response is an abrupt drop in progesterone when there is elevated prolactin, cortisol, and insulin," Dr. Palmquist says. But people who have never experienced pregnancy—even if they no longer have a uterus, ovaries, or a menstrual cycle—can still produce milk for a child. Dr. Palmquist says individuals can go on a birth control pill with higher levels of progesterone to mimic pregnancy. The person should be on it for at least 16 weeks, though Dr. Palmquist says guidance varies.

"There are different protocols anywhere from starting at six months prior to the expected arrival of a baby to accelerated protocols," she says. "Individuals should develop a plan that is right for them and their situation and health status."

The person may also be prescribed medication, such as Domperidone or Reglan, to establish supply. From there, the process is similar to relactation—supply and demand through nursing or a regimented pumping schedule. Creating a full supply is possible, but not everyone will. "Most people can make some milk," Dr. Palmquist says. "In many cases, it requires some supplementation, but it varies."

Managing Expectations and Emotions

Regardless of what method a person uses to relactate or induce lactation, results will not be immediate. "It's going to be different for everybody and situation-dependent," Dr. Palmquist says.

According to the Centers for Disease Control and Prevention (CDC), "Milk production can start as early as a few days after beginning nipple stimulation, but may take weeks to months. The start of relactation will depend on the length of time that has passed since lactation stopped previously and the age of the baby."

Hormonal issues may also play a role in how fast someone can re-establish supply and how much milk they can produce, Dr. Palmquist says. In the meantime, it's essential to continue to feed the child through other means, such as donor milk or formula.

The process can get frustrating, and people can get discouraged. What's more, it's been a difficult two years to be pregnant or a parent. Current lactating people may have gone through pregnancy at the height of the Omicron variant. They may have had another child earlier in the pandemic. There aren't COVID-19 vaccines available to children under 5 years old, and child care has been hard to navigate. Now, there's a formula shortage.

"Stress is high," Dr. Palmquist says and adds that it's essential to have supportive providers, such as lactation consultants, who are attuned to the trauma parents have experienced. Boyd agrees. "We need to give parents permission to do what they need to do for their well-being, however that looks for you," she says.

Structural Support for Lactation is Needed

Relactating can be a rewarding process, but Gerald wishes she didn't have to do it in the first place. "With breastfeeding, they treat it like it's going to be this perfect journey," she says. "I remember being told not to pump right away or give a bottle right away. That's not necessarily helpful."

Dr. Palmquist believes there needs to be systematic changes to help individuals who want to lactate succeed when physically and mentally possible. These changes include:

• Paid leave. "We absolutely need to have paid family leave, especially for people who have just given birth," Dr. Palmquist says. "It is inhumane to make people return to work two weeks to three months postpartum and expect them to follow the recommended guidance." The guidelines from the American Academy of Pediatrics are to exclusively breastfeed for six months and for at least a year after the introduction of solids. One study showed that women with at least 12 weeks of paid leave were more likely to initiate breastfeeding and still be breastfeeding at six months than those without it, a benefit underserved families do not always have.
• The Baby-Friendly Hospital Initiative (BFHI). Launched by World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), this initiative gives individuals the education and confidence to initiate breastfeeding from birth.
• Training for health care providers. Sometimes, providers like the ones Gerald encountered are not informed about breastfeeding. They don't get appropriate advice on supply management or overcoming latch difficulties. Dr. Palmquist says more skills and evidence-based training are necessary to help individuals who want to and can lactate reach their goals.
• Support. Lactation consultants, doulas, and midwives can help families not only with lactating but with managing emotions during the postpartum period. Dr. Palmquist feels it is essential to increase access to them for families, regardless of race or socioeconomic status.

Bottom Line

It's possible to relactate and induce lactation. Though feeding a baby human milk is not the be-all-end-all of parenthood, experts share it's essential caregivers understand all of their options. "Anyone should be able to make an informed decision," Boyd says. "For specific groups that have lower breastfeeding rates, part of the issue is they don't know all of the options. If they knew, they could make an educated decision on what works best for their family."