Relactation after Breast Cancer: A Case Study
Segrate Milan Italy
From: LEAVEN, Vol. 43 No. 2, April-May-June 2007, pp. 27-29
I encountered a very special case that I wish to share with you. It began late on an autumn evening in 2001 when a new mother contacted me.
She told me that six years ago, she'd had surgery on her right breast due to cancer, and one-fourth of her breast was removed. During surgery, the nipple was repositioned, and the nerves and ducts were cut. She also underwent radiation therapy.
Four years after her first surgery and treatment, a malignant tumor was detected again, this time in her left breast, and unfortunately the mother had a mastectomy to remove her whole breast. About one year after this second surgery, the mother became pregnant and had her first baby (a girl). The baby was six weeks old when the mother called me on the phone.
During the pregnancy, her remaining right breast had increased in size and felt fuller. The mother wanted to breastfeed her baby, but the comments of various health specialists had been very discouraging and negative.
According to the surgeon, the breast was completely destroyed due to the previous surgery and radiation therapy.
According to her gynecologist, milk not passing through the damaged ducts could cause inflammation in the surrounding breast tissue and consequently create a risk for formation of a new cancer for the mother and of a malignant tumor for the baby.
According to the radiation therapist, the right breast was "poor" because it had been completely burned by radiation therapy, and the milk produced would be nutritionally poor and inadequate for the baby.
After hearing such declarations, the mother, even though her milk had "come in" two days after the delivery, took a medication to suppress lactation. At home, some days later, she was curious and used a breast pump. She was surprised to see some drops of milk come from her breast.
She passed the first month and a half of the postpartum period full of frustration and suffering and she cried often for the missing breastfeeding experience with her baby. It must have been hard trying to accept such a cruel destiny!
But one day she read about La Leche League and supplemental nursers. She thought a supplemental nurser might be a good solution for her to experience breastfeeding contact with her baby. This is why she came to me for help.
My first feelings were of great emotion. I immediately asked her several questions and discovered that she thought she had good feeling in her nipple and areola. I said that I would have to do some research on her situation and call her back. I really wanted to help her.
I read all the information offered by THE BREASTFEEDING ANSWER BOOK (BAB, 1997 edition) and THE WOMANLY ART OF BREASTFEEDING (WAB, Italian translation of the 1987 edition). Since her breast had changed during the pregnancy, some milk drops had come out from her nipple, and there was feeling in her nipple and areola, I imagined that the use of a supplemental nurser could help encourage milk production.
I found the following information in THE BREASTFEEDING ANSWER BOOK that was helpful to this mother's situation (Editor's Note: The page numbers for the BAB in the following sections reflect the 2003 edition.):
1. Factors influencing milk production and ejection after breast surgery:
The cutting of nerves influences the breast's ability to send the signal from the nipple to the pituitary gland, which releases the hormones prolactin and oxytocin that are necessary for milk production and let-down. "Whenever surgery is performed on the breast, loss of sensation is common. Typically, most of the feeling comes back to the breasts within six months to two years after the surgery" (BAB 2003, p. 517). Cutting milk ducts may make it difficult or impossible for the milk to flow through them. "If the nipple is removed entirely [and repositioned to make the breasts look more symmetrical], all milk ducts and major nerves are cut." But "there are women whose milk ducts have 'recanalized,' or grown back. In one reported case (Marmet and Shell 1987), a woman who had breast reduction surgery and whose nipples were removed and repositioned went on to fully breastfeed her baby, but this is rare" (BAB 2003, p. 520). The amount of mammary gland removed may affect the ability of the mother to fully breastfeed.
2. Possible treatments for engorgement caused by duct damage:
"Within a few days, the engorged areas should return to normal even if the mother continues to breastfeed. Since the milk is not emptied out, milk production will stop in these areas and the milk will be reabsorbed by the mother's body" (BAB 2003, p. 521).
If the mother is uncomfortable, she can use cold packs between feedings to help reduce swelling and ask her doctor to recommend pain medication that is compatible with breastfeeding.
3. The consequences of radiation therapy on breastfeeding:
"Radiation of the breast...damages a woman's breast tissue, which may affect breast development and lactation in that breast at the time of treatment and with subsequent pregnancies (Neifert 1992). One study showed that breast radiation causes 'ductal shrinkage, condensation of cytoplasm in cells lining the ducts, atrophy of the lobules, and perilobar and periductal fibrosis'" (David 1985; BAB 2003, p. 532). "In one study of 13 pregnancies, the treated breast produced milk in four cases and failed to produce milk in six cases; milk production was suppressed with drugs in the other three. All reported little or no change in the treated breast during pregnancy (Higgins and Haffty 1994). In another study, 18 of 53 women (34 percent) reported some milk production from the irradiated breast and 13 (24.5 percent) breastfed, with five (nine percent) describing their treated breast as smaller...." (Tralins 1995; BAB 2003, pp. 532-33).
What affects the success of relactation:
- The cooperation of the baby. "If a baby has been receiving bottles regularly, he may be reluctant to take the breast" (BAB 2003, p. 399). "In one survey of 366 women who relactated, 39 percent reported that their baby nursed well on the first attempt, 32 percent said their babies were ambivalent about breastfeeding, and 28 percent refused the breast. But within a week, 54 percent of the babies had taken the breast well, and by 10 days the number rose to 74 percent. Although babies younger than three months and those who had previously breastfed tended to be more willing, the most crucial factors were time, patience, and persistence" (Auerbach and Avery 1980; BAB 2003, p. 399). In the same survey (Auerbach and Avery, 1980), "the majority of mothers were able to successfully relactate. More than half of the mothers established a full milk supply within a month. It took another 25 percent of the mothers more than a month to fully relactate. The remaining mothers both breastfed and gave supplements until their babies weaned" (BAB 2003, p. 387). Some other conclusions of this survey are: "Mothers who attempted relactation within two months of childbirth reported greater milk production than those who attempted it later on. Although every situation is unique, many women have found that the length of time it takes to relactate fully...is about equal to how long it has been since breastfeeding was discontinued" (BAB 2003, p. 387).
- The frequency and effectiveness of breast stimulation.
- The mother's response to breast stimulation (very individual).
- The time and energy the mother can dedicate to the relactation.
- The amount of external support she receives from family and health care providers.
There is no possibility for breast cancer to be passed in human milk from mother to child. This risk had been considered in the past as a result of a study on mice, in which a cancer virus had been detected in the mouse mother's milk and connected to breast cancer in her female children. This kind of transmission was disproved in humans (WAB 1991, p. 382). (Editor's note: Although this information is not included in the WAB 2004 edition, it remains accurate.) On the contrary, according to THE WOMANLY ART OF BREASTFEEDING (2004 edition, pp. 382-83), we now know that breastfeeding protects the mother against cancer, and according to L'allattamento moderno ("Modern Breastfeeding," issue number 37), human milk prevents some kinds of tumors in the child.
In spite of the positive information I had gathered and given to the mother, she needed a "green light" from a physician. The mother found a researcher working in the Istituto per lo studio e la cura dei tumori of Milan, Italy (a cancer research institute) who confirmed all the information I found. He ruled out all the risks connected to lactation induced by the use of a supplemental nurser. He also said that in case of bad engorgement caused by an interruption of a milk duct, the milk could be removed from the breast by a syringe.
So, this mother decided to give breastfeeding a try. She bought a supplemental nurser (and informational video) and tried for the first time.
It was very emotional for her to see that her nearly two-month-old baby managed to latch on immediately and suck very well on her breast and didn't want to stop sucking. The baby girl emptied the entire supplemental nurser bottle immediately and when she finished the milk, she started to cry. It was clear that suckling at her mother's breast had been an extremely pleasant experience for the baby and she would have liked it to continue! But trying to latch her on without any supplement in the bottle appeared frustrating because she continued crying. The mother was quite worried by this reaction. "I cannot continue giving her formula all the time -- maybe trying this supplemental nurser was a huge error!" she said to me.
I suggested she use the smallest tube (instead of the medium tube she had been using) in future nursings in order to encourage the baby to suckle for as long as possible. This also increased breast stimulation by keeping the baby at the breast longer. This was successful for both mother and baby.
The day after the very first nursing with the supplemental nurser, I went to meet with the mother and baby. It was amazing to see how this completely bottle-fed child got excited at the sight of her mother's breast (she started shaking her little arms) and then very naturally latched on. She suckled until she fell asleep, and a blissful smile appeared on her little face. Both the mother and I shed tears of joy.
I shared with the mother the magazine Da mamma a mamma ("From Mother to Mother," issue number 51), a special issue on using a supplemental nurser. It contains experiences of mothers who have used a supplemental nurser for various purposes. The most important thing that came to our minds based on these accounts was that a supplemental nurser can be difficult to use at the beginning, and that it is easy to lose faith. With patience and determination, however, in four to seven days one gets more skillful with it and starts seeing results.
In spite of all the positive factors, the mother was sensitive and felt confused and a bit guilty. She felt she was doing all this because of an egotistical will of her own. She was afraid of causing psychological trauma to her baby due to this sudden change from the bottle to the supplemental nurser. So in the days following her first two attempts at nursing her daughter at the breast, we spoke a lot about the importance of accepting one's own needs and about the ability of babies to adapt to new situations.
In the beginning, the mother was using the supplemental nurser about one to three times a day during a 24-hour period because the cleaning and preparation of the device seemed complicated to her. But after two weeks of regular use, a drop of milk started coming out from her breast after the feedings, and the stools of her baby had a "yogurt-like" smell. She became very enthusiastic and started using the supplemental nurser at each feeding (five to six times a day).
This increased rhythm of use brought the following results in 10 days: the baby started choking at the beginning of the feedings as if there was too much milk going into her throat, and some formula was always left in the bottle of the nurser.
Four days later, the mother managed to express some milk out of her breast easily. In the same period, the baby refused the dummy (pacifier) she had used regularly until then. After another 10 days, 30 to 40 ml of formula always remained in the bottle and the baby, for the first time in her life, started spitting up after feedings. So we had to admit that this breast, against all the negative forecasts, was able to produce milk!
The production increased gradually to reach a third of the daily need of the baby, i.e., about 250 to 300 ml. The mother never had problems with engorgement or plugged ducts, and the pediatrician always judged the baby to be perfectly healthy with regular growth. The breast itself became a bit bigger and fuller and her menses, which had returned about two months after the birth, stopped.
During all this period there were good and bad moments, and the mother called me at least every two to three days to get support. Often, when she felt that the milk production wasn't going to increase anymore, it was enough to remind her that at the beginning she wasn't interested in having full lactation, but only in being able to feed the baby at her breast with formula, and that even a small milk production would have been precious. In fact, the LLLI booklet Nursing Your Adopted Baby states that newborn babies affected by severe diarrhea have been successfully treated by giving them only 60 ml of human milk per day. (Editor's note: the English edition of this booklet is currently out of print.)
This mother and child went on breastfeeding into toddlerhood. At the age of two, the little girl was still happily nursing.
I don't know whether the mother didn't reach full lactation due to the surgery and radiation therapy, or due to the fact that the relactation was started when the baby was already two months old, or both reasons together.
After following this case, I think that the human body is much more capable to renew and "repair" itself than most people imagine. Also, psychological and practical support can make a huge difference in overcoming particularly complicated situations.
I am infinitely grateful to LLL for having had the opportunity to share this very special experience with this mother-baby couple. Rarely have I felt myself so useful in my whole life.
Anderson, K. L'allattamento al seno del bambino adottivo ("Nursing Your Adopted Baby"), La Leche League International; translation from English into Italian by Elise Chapin Arnone, Maria Teresa Lanza, and Antonella Sagone, 1998.
Da mamma a mamma ("From Mother to Mother"), La Leche League Italia, Spring 1998, issue 51.
L'arte dell'allattamento materno ("THE WOMANLY ART OF BREASTFEEDING"), La Leche League International, Italian Translation Rev. Ed. 1987.
L'allattamento moderno ("Modern Breastfeeding"), La Leche League Italia, Issue 37, December 2002.
Mohrbacher, N. and Stock, J. THE BREASTFEEDING ANSWER BOOK, revised edition. Schaumburg, IL: La Leche League International, 1997.
Additional Editors' References
Mohrbacher, N. and Stock, J. THE BREASTFEEDING ANSWER BOOK, third revised edition. Schaumburg, IL: La Leche League International, 2003; 387, 399, 517, 520-22, 532-33.
THE WOMANLY ART OF BREASTFEEDING. Schaumburg, IL: La Leche League International, 2004; 382-3.
References Cited in BAB Quotes
Auerbach, K. and Avery, J. Relactation: A study of 366 cases. Pediatrics 1980; 65:236-48.
David, F. Lactation following primary radiation therapy for carcinoma of the breast. Int J Rad Onc Biol P 1985; 11(7): 1425.
Higgins, S. and Haffty, B. Pregnancy and lactation after breast-conserving therapy for early-stage breast cancer. Cancer 1994; 73(8):2175-80
Marmet, C. and Shell, E. Breastfeeding in Unusual Circumstances: An Overview: Presented at LLLI's 11th International Conference, 1987.
Neifert, M. Breastfeeding after breast surgical procedure or breast cancer. NAACOG Clin Is Peri Wom Hlth Nurs 1992; 3(4): 673-82.
Tralins, A. Lactation after conservative breast surgery combined with radiation therapy. Am J Clin Oncol 1995; 18(1):40-43.
Special thanks to Judie Gibel, the newest technical editor for LEAVEN. Judie and Christina worked closely to ensure technical and research accuracy, including translation and/or edition concerns in the text and references. Because various editions and translations of publications were used, we offer Christina's reference list with an additional editor's reference list. The editions of WAB and BAB used by the author are noted within the body of the article, but the page numbers inserted after each quote are for the most recent English editions of these books (2004 WAB and 2003 BAB) except where noted.