border enzyme but is adsorbed to the cell
membrane following secretion from some other locus in the intestine. However, normal values of
enterokinase in patients with CD could also be
accounted for by the fact that part of the enzyme
activity is found in a fraction of miicosal
homog-enate containing only small amounts of brush
border. This is especially plausible since whole
honiogenates were used in the measurement of
enterokinase activity in this study as well as in the others mentioned.”’5
CLAUDE L. M0RIN, M.D., M.Sc.
MICHELINE VAN CAILLIE, M.D.
CLAUDE C. ROY, M.D.
ROGER LASALLE, M.D. Division of Gastroenterology, Department of Pediatrics, Sainte Justine Hospital,
and the University of Montreal
Montreal, Quebec, Canada
1 1. Caspary WF, Winckler K, Lankisch PG. Creutzfeldt W: Influence of exocrine and endocrine pancreatic function on intestinal brush border enzymatic
activ-ities. Gut 16:89, 1975.
12. Seetharam B, Grimme N, Goodwin C, Alpers DH: Differential sensitivity of intestinal brush border enzymes to pancreatic and lysosomal proteases.
Life Sci 18:89, 1976.
13. Woodley JF, Keane R: Enterokinase in normi#{238}alintestinal biopsies and those from patients with untreated coeliac. Gut 13:900, 1972.
14. Rutgeersts L, Tytgat C, Mainguet P, Eggermont E: Enterokinase activity of normal and flat duodenal niucosa. Acta Gastroenterol Beig 36:449, 1973. 15. Lebenthal E, Antonowicz I, Shwachmiian H: The
inter-relationship of enterokinase and trypsin activities in intractable diarrhea of infancy, celiac disease, and intravenous alimnentation. Pediatrics 56:585, 1975.
Supported by Medical Research Council of Camiada gramit MA: 3320, the Canadian Cystic Fibrosis Foundation, and the Justine Lacoste-Beaubien Foundatiomi.
ADDRESS FOR REPRINTS: (C.L.M.) Sainte Justine Hospital, 3175 St. Catherine Road, Montreal H3T 1C5,
Q
nebec, Canada.REFERENCES
1. Hadorn B, Tarlow MJ, Lloyd JK, \Volff OH: Intestinal emiterokinase deficiency. Lancet 1:812, 1969. 2. Nordstrom C, Dahlqvist A: Rat enterokinase: The effect
of iomis and the localization imi the intestine. Biochem Biophs Acta 242:209, 1971.
3. Schmitz J, Preiser H, Maestraci D, et al: Subcellular localization of enterokinase in human small intes-tine. Biochem Biophys Acta 343:435, 1974.
4. NordstrOmii C: Enzyniic release of enteropeptidase from isolated rat duodemial l)rush borders. Biochem Biophys Acta 268:71 1, 1972.
5. Nord.strOm C: Release of enteropeptidase and other brush border emizymes from the small intestinal wall in the rat. Biochem Biophys Acta 289:367, 1972. 6. Morin CL, Roy CC, Bonin A, Lasalle R: Small bowel
dysfunction in cystic fibrosis. J Pediatr 88:213, 1976.
7. Newcomer AD, McGill DB: Disaccharidase activity in the small intestine: Prevalence of lactase deficiency in 100 healthy subjects. Castroenterology 53:881,
1967.
8. Louvard D, Maroux S, Baratti J, Desnuelle P: On the distribution of enterokinase in porcine intestine and on its subcellular localization. Biochem Biophys Acta 309:127, 1973.
9. Lebemithal E, Antonowicz I, Shwachmami H: Enteroki-miase amid trypsin activities in pancreatic insuffi-ciency and diseases of the small intestine. Castroen-terolog 70:508, 1976.
10. Alpers DH, Tedesco FJ: The possible role of pancreatic proteases in the turnover of intestinal brush border proteimis. Biochemn Biophs Acta 401:28, 1975.
Relactation: An Overview
Relactation refers to the physiological process
whereby human lactation is initiated at a time
unrelated to the postpartum production of milk.
This phenomenon has also been referred to as
induced lactation or, in some instances,
inter-rupted lactation in women who have weaned
their infants and wish to resume breast-feeding.
The relactation process can also be used to
promote an increase in the milk supply of women
who are already lactating.
Although relactation is an accepted fact in many cultures, even well-trained pediatricians in
both the developed and developing countries may
be unaware of the potential relactation has in
good infant care.
BACKGROUND
The following are examples of successful
relac-tation in different parts of the world.
In the Bangladesh rehigee camps,
gastroenter-itis was one of the main causes of death among
young infants. The immediate therapy was to
maintain the infant’s hydration while
breast-feeding was discontinued. By the time the
diar-rhea and vomiting had stopped and the infant was
ready to resume oral feedings, the mother’s breast
milk had dried up; consequently the baby had to
Unfortu-nately, as is common in many developing
coun-tries, the water used for preparation of formula
was contaminated, causing a recurrence of
gastroenteritis. In search of a solution, women
who had temporarily discontinued breast-feeding, due to intercurrent illnesses in their infants, were
induced to lactate within a few days by merely
putting the infants to the breast.’ It was
recom-mended to the government of India as well as to
the World Health Organization that in order to
avoid the use of contaminated local water,
wide-spread relactation should be adopted as a
preven-tive measure. If the infant’s mother were not
available, a. relative or friend could be induced to
lactate and serve as a surrogate mother. This
recommendation was under consideration when
war broke out and such proposals could not be
given priority. Although a field trial was not
feasible at that time, the theory was considered
implementable and practical. On an individual
basis successful relactation was easily
ac-complished in a score of documented cases.
While in Uganda I admitted a starving teenage
mother and her 2-month-old marasmic infant to
Mulago Hospital. The mother had not been
producing breast milk for several weeks, which
caused severe protein-energy malnutrition in the
infant. In such cases, the infant would customarily
be given formula to sustain its life while no
thought would be given to the reestablishment of
milk production in the mother.
From the time of admission, this mother was
maintained on a high-protein, high-calorie diet
and was encouraged to suckle her infant even
though the infant’s dietary requirements were
provided by formula. Within a few days milk
production was reinstituted, and the infant was
fed breast milk alone. Relactation can only be
successful if emphasis is placed on the mother’s
nutritional status.
In 1974 there were approximately
100,000
orphaned children in the city of Saigon; many of
these were newborn infants. To feed these infants
a plan was developed in several orphanages to
hire local women as wet nurses. The women were
given three meals daily and low doses of
chlorpro-mazine (Thorazine) for approximately one week.
Any healthy woman interested in providing
breast milk could be induced to lactate. Once her
milk supply was reestablished, each woman
provided milk for two young orphans. A complete
record was maintained to include heights and
weights and data related to intercurrent medical
problems, particularly respiratory and
gastroin-testinal infections. These records were to be
compared with infants matched for age and sex
who were fed with bottled formula. Relactation
was established in a number of women;
unfortu-nately, the study had to be interrupted due to
pressures related to the war.
REQUIREMENTS FOR RELACTATION
How is the process of relactation or induced
lactation implemented? The requirements for
relactation are identical to those for successful
lactation, namely, (1) an adequately nourished
woman interested in nursing; (2) a baby with a
good sucking reflex; and (3) some sort of support
system. The third aspect of the nursing triad miiay
include the father, a grandmother, the midwife or
nurse, an interested physician, neighbor, relative or friend, or any combination. ‘ The mother,
although healthy and desirous of breast-feeding,
may have some difficulty at the onset and her
success in relactation depends on the supportive
network in the immediate environment for
encouragement, instructions, assistance, and ad-vice to make the nursing experience a positive
one.
In some cultures there is a special individual
who assumes the responsibility for helping a neW
mother initiate nursing, or there may be a group
of women who have had a previous experience
with successful lactation. Reports from many
parts of the world describe relactation initiated in
nonlactating, nonpostpartum women merely by
putting the infant to the breast and allowing him
to suckle.” “ Suckling stimulates nerve endings
that cause the anterior pituitary gland to produce
prolactin, a hormone that acts directly on the
breasts to stimulate the secretion of milk.”
The prolactin reflex is related to production
and secretion of milk. Suckling indirectly
stimu-lates the posterior pituitary gland, causing the
release of oxytocin, which passes through the
bloodstream to the breasts to act on the small
muscle cells surrounding the m ilk-producing
ducts. This action forces milk into the terminal
ducts and is known as the “letdown reflex” or the
ITlilk ejection reflex.
DRUGS IN RELACTATION
A variety of chemicals has been used to
promote relactation, either in the nonpostpartum
woman or in the lactating woman whose milk supply has been interrupted or is insufficient.
Both estrogen and progesterone, the main
compo-nents of contraceptive pills, stimulate the
prolif-eration of breast alveoli and ducts.’2’ However,
these hormones are contraindicated for
relacta-tion purposes because they may be secreted into
the infant, in addition to which they may inhibit lactation.’ ‘
Oxytocin stimulates the milk ejection reflex
and aids in emptying the ducts during
breast-feeding; it also assists in the release of pituitary
prolactin necessary for milk production.
Oxyto-cm, in nasal spray or in oral tablet form, has been
employed with variable success to induce
relacta-tion. However, large dosages of oxytocin, or
prolonged use, have been reported to exert an
inhibitory effect. ‘ ‘ 6. 1 7
Reproducible data indicate that
institutional-ized mental patients, both males and females,
who receive large doses (1,000 mg or more) of
chlorpromazine may begin to lactate
sponta-neously. It seems that chlorprolnazine acts both as tranquilizer and as galactagogue. In
conjunc-tion with strong positive reinforcement, a sound
maternal diet, and a hungry suckling infant,
chiorpromazine has been a useful adjunct in the
induction of lactation.M In the Bengali refugee
camps in India, and in Vietnam, low doses of
chlorpromazine, 25 to 100 Iig given three times daily for periods of seven to ten days, helped
initiate milk production in nonlactating women.’
It is possible that chlorpromazine and other chemicals, as well as certain herbal agents, work
both physiologically and psychologically to
promote the letdown reflex and lactation.’’
In recent reports, several authors describe their
experience with metoclopramide, a drug known
as a potent stimulator of prolactin release when given intramuscularly, intravenously, or
oral-If 10 mg of metoclopramide is
adminis-tered by mouth, the level of prolactin is increased
froni three to eight times normal within five
niinutes and the effect lasts up to eight hours.
Metoclopramide should be administered every
eight hours for seven to ten days to stimulate an increased milk supply. In one study this agent was employed when a spontaneous decrease in milk
volume could not be reversed merely by putting
the infant to the breast more frequently.
Metoclo-pramide in low doses is considered safe, with no side effects noted in either mothers or infants, but
the amount secreted in breast milk was not
measured. The reported clinical trial was not
controlled and the sniall group studied was not randomly selected, definitely limiting widespread
application of the results.
In considering the beneficial potential of any
medications employed to induce lactation, gener-ally there is an enthusiastic physician, nurse,
midwife, or a team of such persons who reinforce,
support, and encourage the mother, leading to the
conclusion that it is due to their combined efforts
that relactation is achieved, rather than because
of the drug alone. This potential placebo effect
always must be taken into account in the
evalua-tion of such trials. Such a trial would be
scientif-ically acceptable only if it were organized under
double-blind conditions for documentation of the
effect, or lack of effect. Otherwise, we can only
interpret such results as additional evidence for
the necessity of the nursing triad’s support system in lactation inducement.
POTENTIAL FOR RELACTATION IN
DEVELOPING COUNTRIES
The provision of breast milk in developing
countries becomes a matter of survival. Without this source of high-quality protein, the infant
generally does not survive.2’ The questions can
be posed, is nursing a problem for women in
developing countries? Is it not customary for all
women in poor countries to breast-feed their
infants? Why even discuss the topic of relactation
when it is usual, customary, and, for the most
part, expected that all women breast-feed?
Without considering ideal nutrition, hygienic
milk supply, economic benefits, psychological
and contraceptive advantages, women in
devel-oping countries inherently appreciate the fact
that without breast milk babies do not live
through infancy. Until recently, mothers in most
developing countries have appreciated the
impor-tance of breast-feeding.22
In the traditional extended family there are
opportunities for relatives or even friends to serve as substitute wet nurses. Health workers should
consider the potential for relactation in times of
natural or man-made catastrophes, and in times of mass migration or relocation due to floods, droughts, or earthquakes. In addition, whenever gastroenteritis, due to contaminated water,
reaches epidemic proportions, serious
considera-tion should be given to reestablishing lactation for
infant feeding.
Developing countries have documented a high
incidence of low-birth-weight infants. If it is not
feasible for mothers to be admitted to newborn nurseries to provide expressed breast milk, relac-tation could be employed to provide such infants
with breast milk upon discharge from the
hospi-tal. In the case of infection, either of infant or mother, it may be necessary to interrupt
lacta-tion, which can readily be reestablished once the
infectious process has run its course.
Should a mother die during childbirth, an all
the surviving infant customarily is given to a
female relative to rear and feed. If the relative is
nonlactating, the infant is put to the breast at
frequent intervals and a variety of herbal
medicines may be employed, usually with
success.
Additional arguments for the promotion of
relactation come from the finding that
maternal-infant bonding is much stronger in the breast-fed
infant, a factor associated with better growth
rates, fewer infections, and improved record of
morbidity and mortality. In conjunction with
other breast-feeding advantages, the problem
referred to as “unconscious infanticide” is less
likely with maternal-infant bonding strengthened through lactation.26
Finally, a direct correlation has been
estab-lished between breast-feeding and the
prolonga-tion of birth intervals. Studies indicate that
women who breast-feed experience a delay in the
reestablishment of ovulatory cycles in the
post-partum period. Consequently, relactation may be
considered another natural method of family
spacing with advantages for both mothers and
infants. 27-29
POTENTIAL IN DEVELOPED COUNTRIES
Every one of the above-mentioned
considera-tions is translatable with some modification for
mothers and infants in the developed countries.
The process of relactation should be considered
for infants who are prematurely born and remain
on premature units for a period of time, and for
those who are temporarily taken off the breast
during hospitalization for illness or surgery. If
breast-feeding is desired, such women can be
encouraged to relactate. Obviously, the
practi-tioner would have to be aware of the relactation
process in order to promote this as a realistic
possibility.
In addition, there have been numerous
instances of nulliparous women successfully
breast-feeding adopted infants2375’#{176} and even of
grandmothers relactating after periods of over ten
years since their last pregnancy.’03’ This may
have application in a limited number of
women.
Although it has long been common knowledge
that colostrum contains large amounts of
protec-tive antibodies, breast milk provides continued
protection with low levels of antibody content
along with the added benefit of iron-binding
proteins.32 This advantage of relactation should
be considered particularly for the prematurely
born infant,” as well as for infants suffering from
infectious or allergic processes. If the infant is too
weak to suckle, the relactation process may be
initiated with expression of breast milk, either
manually or with the use of a breast pump.
Finally, a little known but perhaps increasingly importallt consideration for relactation in
devel-oped countries is that the breast-fed infant is less
likely to be overfed and consequently less likely to
become overweight or obese.4 In addition, the
development of dental caries correlated with
artificial feeding is not a problem for the breast-fed infant.
SUMMARY AND CONCLUSION
The potential for relactation in both the
devel-oping and developed countries should be
consid-ered. On a special and individual basis relactation
is occurring every day in many parts of the world.
Mothers and health workers should be
encour-aged to attempt relactation and gain a firsthand
appreciation of the simplicity and ease with
which this process can be accomplished.
Few problems are encountered. In situations
where the infant’s own mother is not available, or
if she is physically or emotionally unable to nurse,
a substitute woman who is interested can be
induced to relactate, the process requiring a
somewhat longer period of time. Relactation is
feasible and practical and can often save an
infant’s life. Once the importance of relactation is
appreciated, health workers will employ it in
many situations for better mothering and better
infant care.
Ro E. BROWN, M.D., M.P.H.
Departments of Community Medicine
and Pediatrics,
Mount Sinai School of Medicine
Fifth Avenue and 100th Street New York, New York 10029
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Matrix of Supportive Behavior thesis. Cohmmnbia University, New York, 1966.
3. Raphael D: The Tender Gift: Breastfeeding. Emiglewood Cliffs, NJ, Prentice-Hall, 1973.
4. Jelliffe DB, Jelliffe EFP: Doulas, confidence, and the science of lactation. J Pediatr 84:462, 1974. 5. La Leche League Imiternational: The \Vomanly Amt of
Breast Feeding, ed 7. Franklin Park, Ill, Interstate Printers, 1963.
6. Newton M: Human lactation, in Kon SK, Cowie AT (eds): Milk, The Mammary Gland and Its Secretion. New York, Academic Press, 1961, vol 1, pp
7. Newton M: Breast feeding by adoptive mother. JAMA 212:1967, 1970.
8. Cohen R: Breastfeeding without pregnancy. Pediatrics
48:996, 1971.
9. Jelliffe DB: Infant nutrition in the tropics and subtrop-ics. WHO Monogr Ser, No. 29, Geneva, 1968.
10. Jelliffe DB, Jelliffe EFP: Non-puerperal induced lacta-tion. Pediatrics 50:171, 1972.
11. Egli GE, Egli NS, Newton M: The influence of the
number of breast feedings on milk production.
Pediatrics 27:314, 1961.
12. Foss GL, Short D: Abnormal lactation. J Obstet Gynaecol Br Commonw 58:35, 1951.
13. Huntingford PJ: The inter-relationship of pituitary hormones and maintenance of lactation. J Obstet
Gynaecol Br Commonw 70:929, 1963.
14. Kaern T: Effect of an oral contraceptive immediately post partum on initiation of lactation. Br Med J
3:644, 1967.
15. Catz CS, Giacoia GP: Dnigs and breast milk. Pediatr Clin North Am 19:151, 1972.
16. Newton M, Newton N: Intra-nasal oxytocin. Am J
Obstet Gynecol 76: 103, 1958.
17. Hormann E: A Study of Induced Lactation, information
sheet 85. Franklin Park, Ill, La Leche League International, 1971.
18. Brown RE: Breast feeding in modern times. Am J Clin
Nutr 26:556, 1973.
19. Jelliffe DB: Diarrhoeal disease of early childhood, in Woodruff AW (ed): Alimentary and
Haematolog-ical Aspects of Tropical Disease. London, Edward Arnold Ltd. 1970, pp 172-173.
20. Sousa PLR, Barros FC, Pinheiro GNM, Gazalle RV: Re-establishment of lactation with metoclopramide. J Trop Pediatr 21:214, 1975.
21. McNeilly AS, Thorner MO, Volans G, Besser GM: Metoclopramide and prolactin. Br Med J 2:729, 1974.
22. Thorner MO, Volans G, Besser GM, McNeilly AS:
Antiemetics, prolactin and breast cancer. Br Med J 3:467, 1974.
23. Jelliffe DB: Breast milk and the world protein gap. Clin Pediatr 7:96, 1968.
24. Jelliffe DB: Commerciogenic malnutrition. Nutr Rev 30:199, 1971.
25. Berg A: The Nutrition Factor: Its Role in National
Development. Washington, DC, The Brookings
Institution, 1973.
26. Viel B: La Explosion Demografica. Editorial
Paz-Mexico, Liberia Carlos Cesarman, S.A., Mexico,
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27. Masnick GS: The Demographic Impact of Breastfeed-ing. To be published.
28. Perez A, Vela P, Masnick GS, Potter RG: First ovulation after childbirth: The effect of breastfeeding. Am J Obstet Gynecol 114:1041, 1972.
29. Jam A, Hsu TC, Freedman R, Chang MD: Demographic aspects of lactation and postpartum amenorrhea. Demography 7:255, 1970.
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33. Bullen JJ, Rogers HJ, Leigh L: Iron-binding proteins in milk and resistance to Escherichia coli infection in infants. Br Med J 1:69, 1972.
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