I. What is foster breastfeeding/ wet nursing?
1.(Abejide et al in Nigeria, 1997 ), and (Banapurmath 1993) and Seema (Seema
1997) in India,
identified the childs health as the principle motivating factor for mothers and foster mothers. ( to relactate). The infants
were already ill when relactation was suggested by a health care provider. In Papua New Guinea
(Nemba 1994), foster mothers who requested prescriptions for a feeding bottle were motivated to relactate when the
hazards of bottle feeding were explained to them. In these situations, the amount of milk produced and the extent of relactation
were important outcomes. ( WHO, 1998)
2.Over time, many changes have evolved in adoptive and foster care policies. For ages, motherless
infants had to be placed with lactating women in order to insure their survival. Once formulas could be made from relatively
safe animal milk, artificial feeding allowed institutions to care for babies until more formal arrangements could be made.
Today emphasis is placed on uniting children with their adoptive family as quickly as possible to insure positive emotional
bonding. Foster placement may allow for reunification or alternative permanent living through adoption. (Sutherland, Ann H,
Breastfeeding: An Adoption Option, A Foster care Workers Review, ISBN#0 96559 20-6-5)
3.Grandmothers in Africa (Slome 1956) produced milk when they put
infants to their breast to soothe them in the absence of their mothers, without any intention to relactate.
4. Wet nursing was the norm among European based cultures for centuries and was seen in all cultures
throughout recorded history. Before technology and milk surpluses created the mass production of, and market for, artificial
baby foods, wet nursing was the only option for infant survival if the birth mother was unable to nurse. ( Wight, 2004)
B. Foster breastfeeding in America
1. Cross-nursing is breastfeeding of a child by a woman other than their mother. In the West,
prior to the 20th century a form of cross-nursing called wet nursing (where a woman is paid to breastfeed a child)
was common( Golden 1996)
. 2. The decline in cross-nursing in the West paralleled a general decrease in breastfeeding resulting
from the ready availability of artificial infant milks. ( Golden 1996 )
3. However, the situation is different in many non-industrialized societies where breastfeeding
is ubiquitous and it is relatively common for children to be breastfed by other than their mother. ( Riordan 1999)
4. In 2001 there were 542, 000 children in foster care in the United
States ( US Dept of Health and Human Services, the AFCARS Report www.acfhhs.cov/programs/cb. ). All of these children have emotional special needs and a proportion also have physical special needs ( Halfon
1995) (McIntyre 1986) 23, 000 were babies under a year of age10. Despite breastfeeding being
universally recognized as the desired form of nutrition for babies, providing breast milk and/or breastfeeding for babies
in foster care is usually not considered.
II. Who can foster nurse?
A. County Regulations
1. Each state and county has differing regulations, many or perhaps even most do not address the
issue of foster breastfeeding. You must have the consent, in writing preferably, of your social worker in order to protect
yourself, the infant, and the foster family agency.
B. State regulations
1. I have copied the Wa state code here : What I have found is that most states follow this protocol,
if any at all. WAC 388-148-0395 What requirements must I meet for feeding babies? You must meet the following requirements
for feeding babies:
(1) In group care settings, all formulas must be in sanitized bottles with nipples and labeled with
the child's name and date prepared if more than one child is bottle-fed.
(2) You must refrigerate filled bottles if bottles
are not used immediately and contents must be discarded if not used within twenty-four hours.
(3) If you reuse bottles
and nipples, you must sanitize them.
(4) If breast milk is provided by anyone other than a baby's biological mother,
approval must be obtained from the child's social worker.
(5) Infants who are six months of age or over may hold their own bottles as long as an adult
remains in the room and within observation range. You must take bottles from the child when the child finishes feeding or
when the bottle is empty.
[Statutory Authority: RCW 74.15.030. 01-18-037,
§ 388-148-0395, filed 8/28/01, effective 9/28/01.]
C. Foster moms should/must meet these criteria: (suggested by
1. Be HIV negative. The only definite exception to the above is HIV infection in the mother. Until
we have further information, it is generally felt that the mother who is HIV positive not breastfeed, at least in the situation
where the risks of artificial feedings are considered acceptable. There are, however, situations, even in Canada,
where the risks of not breastfeeding are elevated enough that breastfeeding should not be automatically ruled out. The final
word is not yet in. Indeed, recently information came out that exclusive breastfeeding protected the baby from acquiring the
HIV better than formula feeding and that the highest risk is associated with mixed feeding ( breastfeeding + artificial feeding).
This work needs to be confirmed. ( Newman 2003)
2.Be hep b and c, syphilis and recreational drug negative
3.Be otherwise healthy and committed.
Siskiyou County has suggested the following
protocol, written by Patty Shackleton, PHN: This is included for discussion only and has not been approved by Siskiyou County Council.
MILK AND BREASTFEEDING FOR FOSTER BABIES
Philosophy: Breastfeeding has been widely over-looked in foster care. Some California counties have been practicing and advocating breastfeeding in foster homes for a few years, hence precedent
and standards have been developed. Some foster mothers have believed that it was not permitted or would complicate reunification.
There are no laws or licensing policies opposing breastfeeding by caregivers. Breastfeeding should be encouraged and training
made available to foster parents, social workers, and biological mothers. Basic to the responsibilities of foster care are
modern health care and nutrition; breastfeeding is the best single source of nutrients and prophylaxis against many illnesses.
milk is uniquely suited for human infants. As we see more high-risk infants becoming the responsibility of the courts, it
is very important to provide these children maximum opportunity to thrive. Mother's milk or banked breast milk are options
that shall be accommodated when conditions exist to do such.
Purpose: The purpose of the protocol is to allow distribution
of a county wide standard to foster family agencies, licensing authorities, social services, and the courts regarding health
and safety measures to be taken by foster families that are able to use human milk or breastfeed foster babies. Public Health
nurses will be responsible for maintaining and updating this protocol which will incorporate guidelines and recommendations
from the American Academy of Pediatrics ( AAP) and the California Department of Health Services (DHS)
AAP and DHS currently promote the following:
. Human milk is easy to digest and contains all the nutrients that babies need in the early months of life.
Factors in breast milk protect infants from a wide variety of illnesses.
. Fatty acids, unique to human milk, may play
a role in infant brain and vision development.
. In several large studies. Children who had been breastfed had an advantage
over those who had been artificially fed when given a variety of cognitive and neurological tests, including measures of IQ
. Infants who are exclusively breastfed for at least four months, are half as likely to have ear infections in the first
year of life.
. Breastfeeding reduces the incidence, and lessens the severity of a large number of bacterial infections,
. Breastfeeding protects against a variety of common illnesses, such as diarrhea and infant botulism.
of breastfeeding is a risk factor for sudden infant death syndrome (SIDS)
. Human milk may protect premature infants from
life-threatening gastrointestinal diseases.
> Breastfeeding has recently been identified as an intervention for infants
at risk for reactive attachment disorder.
Wet nursing has been
almost unheard of in this country. In other cultures it has been assumed that women of the community should nurse a child
whose mother is unable to nurse him. Through most of human history, childcare has included breast-feeding by the women of
the community. Foster care is a natural place for breastfeeding and wet nursing. The many benefits to child and parent are
all in accordance with the principles of foster care. The risks to the infant are minimal and can be eliminated by screening
of the foster mother.
FOSTER FAMILIIES WHO ARE APPROVED TO BREAST -FEED FOSTER BABIES MUST ADHERE TO THE FOLLOWING:
1. The foster
homes' licensing agency must have acknowledged the parents intent to breast-feed. A statement in the service plan for the
foster family should clearly state that breastfeeding is available to the babies placed in their home.
2. The foster
mother will have on record testing results for HIV Hepatitis B and C, syphilis and recreational drugs current every two years.
3. The foster mother 's physician must agree that this mother is suitable for breastfeeding.
4. The health care provider for the
child must be aware of the use of breast milk and assist with direction of quality, frequency and duration.
foster home must follow safe and appropriate sanitary practices.
Foster homes willing to feed foster babies breast
milk from other sources may receive milk from:
1. The biological mother. *
2. A licensed breast milk bank.
3. A source determined
to provide screened milk that is recognized by the family's health care provider, and approved for the baby by the family's
* follow rule #4 above
should we have foster nursing moms?
A. World Health
Organization, UNICEF, AAP, American Dietetic Association, American College of Obstetrics and Gynecology, and the Department
of Health Services for California. all recommend breastfeeding an infant for the first year .( see Welcome to California, http://www.wicworks.ca.gov/breastfeeding/resourcedocs/dhs_bfpolicy.html )
1. Where it is not possible for the biological mother to breastfeed, the first alternative, if
available, should be the use of human milk from other sources. Human milk banks should be made available in appropriate situations.
( WHO, 1998)
2. WHO recommends exclusive breastfeeding for at least the first 4 and if possible the first 6
months of an infants life, and continued breastfeeding with adequate complementary food for up to two yeas of age or more.
Yet many infants stop breastfeeding in the first few weeks or months and, as a result, are at increased risk of illness, malnutrition
and death.( WHO, 1998)
3. In emergency situations, for infants who are unaccompanied; those who were artificially fed
before the emergency; and those for whom breastfeeding has been interrupted. As many infants as possible should be enabled
to resume or continue breastfeeding to help prevent diarrhea, infection and malnutrition. A woman can relactate to feed one
or more unaccompanied infants. ( WHO, 1998)
4. Breast milk is the normal food for babies. The World Health Organization and Unicef1
state that where it is not possible for the biological mother to breastfeed, the first alternative, if available, should be
the use of human milk from other sources." Given the precarious physical and emotional health of some babies in foster care
it is possible that breast milk/breastfeeding might assist many children ( Gribble, 2003)
5.Throughout the WHO and UNICEF documentations one can find referrals to foster mothers in the
same context as the breastfeeding mother, no differences or discriminations seem to appear.
B.. Health of the infant
1.The general calming effect of breastfeeding is well known and has been measured in reduced heart
and metabolic rates of breastfeeding children (Blass, 1994).
2. Two other factors to consider are the provision of breast milk through breastfeeding and foster
breastfeeding. We have considered the emotional benefits of breastfeeding a child at risk of attachment issues, however, the
unique properties of breast milk also confer positive immune and growth factors to the breastfeeding child obtaining breast
milk. This will be of benefit to all children but may be especially significant to medically fragile infants (Arnold et
3. the lack of breastfeeding as one of the risk factors for serious RSV ( Piatak, 2003)
4. Many foster babies may benefit from breast milk/breastfeeding however, the risk of disease
transmission must be minimized. Provision of breast milk to all medically fragile foster babies is desirable. Breastfeeding
by the foster mother may be applicable in cases where the child is likely to be in care long term, has been previously breastfed
or the childs mother desires that s/he be breastfed. However, for breastfeeding of foster babies to become more common social
barriers must be overcome. ( Gribble, 2003)
5. Cases where the child is physically ill or emotionally damaged or in localities where milk
banks do not exist to supply donor milk might place a higher imperative on breastfeeding than would otherwise be the case.
C. Reunification of mom and breastfeeding infant
1. The first priority is to ensure that maternity and child care services in health facilities
and in the community provide mothers with the help that they need to initiate, establish and sustain breastfeeding. ( WHO,
2. breastfeeding may be appropriate where a mother desires her child to be breastfed. Some mothers,
as part of the process of working towards regaining custody of their child, may even maintain their milk supply with the intention
of breastfeeding their child on reunion and a breastfeeding foster mother may assist in this (although this may seem far fetched
the author is aware of one case in which this has occurred).( Gribble 2004)
D. Attachment disorders
1. Though it is likely that the skin to skin contact involved in breastfeeding may of itself be
comforting to the child and aid the transition to sleep, hormonal influences are also involved as suckling stimulates the
release of the hormone cholecystokinin in the gastrointestinal tract of breastfeeding children, inducing sleepiness (Uvnas-Moberg,
2. Although adoptive breastfeeding has been the focus of breastfeeding a child at risk of attachment
issues, it is worth note that foster breastfeeding is also practiced, sometimes with the permission and support of the relevant
authorities, sometimes without. The possibility of gaining permission to breastfeed a foster child varies widely between locations,
however, for those who are considering breastfeeding a foster child without approval they should be aware that children have
been removed from foster families because of breastfeeding. (Gribble,2003)
3. Thus, a child unable to be breastfed by their mother due to work arrangements, illness or death
may be breastfed by another woman. In these cases, cross-nursing is a convenient way to nourish and comfort a baby when their
mother is not immediately available or a pragmatic necessity in cases where alternative feeding methods are unacceptably risky.
4. An insecure attachment (of which foster children are already at risk) results in difficulties
with self-regulation, relationships and negatively impacts many areas of development ( Drury-Hudson 1994)
E. Necrotizing enterocolitis and other health issues
1. Conversely, though it is widely unacknowledged, not breastfeeding results in retardation of
babies potential. ( Cunningham 1995)( Wiessinger 1996)( Polan 1994)
2. However, it is possible to envisage that foster babies not be further disadvantaged and that
prescription of donor breast milk, might become common. Moves towards more routine use of donor milk has begun and some US
states (California for example), the government reimburses the cost of milk
bank donor milk for foster babies with medical needs via Medi-Cal . (personal experience).
F. Benefits to the foster mother
1.Certainly mothers have described that the act of breastfeeding helped them feel closer to their
adopted child which may be at least partially due to the release of oxytocin during breastfeeding which promotes the development
of maternal behavior (Uvnas-Moberg, 1996).
2.Alternatively it may be because breastfeeding requires mothers to maintain physical proximity
to their child and to interact with them on a regular basis in a positive and intimate manner (Epstein, 1993).
3.Moreover, breastfeeding may help the mother cope with stress better as suckling at the breast
has been associated with relaxation responses that have been measured via electroencephalograph (Cervantes et al 1992)
and in decreased blood pressure and cortisol levels (Amico, 1994).
G. Benefits for Foster Family Agency and Child Protective Services
1. Financial cost to government and families is dramatically decreased with breastfeeding. The
cost to supply artificial baby milk to one child is between $1,160 and $3,915 per year in 1998. Medical expenses are an increase
of $331 to $475 per never-breastfed infant during the first year of life ( 1999 costs) (Ball, 1999). Compared to formula
feeding, breastfeeding each infant enrolled in WIC saved $478 in WIC costs and Medicaid expenditures during the first 6 months
of the infants life.( Montgomery 1997)
2. If you breastfeed for at least 4 months, your child will experience one third the risk of hospitalization
for lower respiratory disease, the protection seems to last for the first year of life. ( Dr. Virginia Bachrach, Palo
3. A pre-publication study by the Wisconsin State Breastfeeding Coalition estimated the following
health care savings in Wisconsin if Breastfeeding rates were at 7;5% at discharge
and 50% at six months.
$4,645,250/yr Acute Otitis Media
$ 758,934/yr Asthma
$578,500/yr Type I Diabetes
$30,984,432/yr Total Health cost savings
4. Listed in Outcomes of Breastfeeding Versus Formula Feeding are 19 pages of scientific studies
that prove the superiority of breast milk over formula in both economic and health issues. Every agency and breastfeeding
foster mom should obtain a copy of this for references. Most recently updated Mar 2001 by Ginna Wall,
MN, IBCLC firstname.lastname@example.org
IV. When is foster nursing applicable or desirable?
A. Drug babies
1. For the foster child it can be an extra emotional benefit as well as offer superior nutrition
to help overcome poor prenatal care. ( see article- naturalchild.com/guest/george_wootan.html from Breastfeeding New Discoveries)
2.Drug babies are often colicky or cry a lot babies. These infants are at high risk for shaken
baby syndrome. Breastfeeding foster mom can relieve the stress on the biomom, encouraging her to continue to breastfeed and
keep the infant breastfeeding until the bio-mom can get it together or overcome depression.
3. Irritability and high pitched crying is not uncommon in drug exposed infants and infants with
CNS damage. ( Archer 2003)
1. Reactive attachment disorder . At the top of the list of interventions recommended for infants
at risk for RAD is Breastfeed, if possible ( Piatak 2003)
C. Formula intolerance
1. The risk of Necrotizing Enterocolitis is so high in the premature infant, all NICU babies at
risk should have a prescription for human milk, if mother cant supply or breastfeed, then milk bank milk should be supplied.
( Wilson-Clay 2002)
2. Some babies can not tolerate any type of formula.
D. Reunification with breastfeeding mom
1. Remember that stopping breastfeeding for a week may result in permanent weaning since the baby
may then not take the breast again. On the other hand, it should be taken into consideration that some babies may refuse to
take a bottle completely, so that the advice to stop is not only wrong, but often impractical as well. On top of that it is
easy to advise the mother to pump her milk while the baby is not breastfeeding, but this is not always easy in practice and
the mother may end up painfully engorged. ( Newman 2003)
E. Adoptive placement
A breastfeeding foster mother can ease an infants struggles to handle crisis and help a transition
to a permanent location. (see article- naturalchild.com/guest/george_wootan.html from Breastfeeding New Discoveries)
F. Premature infants
1. AAP guidelines acknowledge that human milk also is beneficial in the management of premature
infants. ( Pediatrics 1997)
2. Babies who are preterm are at risk of developing Necrotizing Enterocolitis, which may be prevented
by breast milk/breastfeeding. ( Wilson-Clay, 2002) In this article she lists numerous benefits of human milk for preterm
infants, and suggests ALL infants discharged form the NICU should have a prescription for breast milk or be breastfed.
3. Kangaroo care for these infants. Improves thermoregulation, regulation of heart rate, better
oxygen saturation, improved weight gain, improved bonding issues, increases in milk volumes. ( Wilson-Clay 2002)
4. Mild- and moderate-preterm birth infants are at high relative risk for death during infancy
and are responsible for an important fraction of infant deaths ( Kramer 2000)
V. What are some barriers to foster breastfeeding?
A. The woman's motivation
1. "Sometimes mothers or foster mothers are self-motivated. . . More often, mothers or prospective
foster mothers need to be counseled, informed, encouraged and supported by health care providers before they are sufficiently
motivated to relactate for an infant. This requires time, skill and patience from the counselor." (WHO 1998)
B. Some Physicians and Lactation consultants!
1.Physicians were the least supportive people and were also sometimes openly hostile. ( WHO
2.The other barrier that needs to be overcome is the view of breastfeeding special and as being
best for babies, rather than being a normal part of child care. While this attitude remains, many will deny foster children
who would benefit from breast milk/breastfeeding the opportunity because it is an added extra rather than a basic need. Breast
milk/breastfeeding may not be for every situation but lactation experts have a role to play in raising the possibility with
social workers and other health care professionals responsible for foster children. ( Gribble 2004)
3. Doctors, LLLLs and LCs are in a perfect position to provide accurate, evidence based information
and support regarding relactation. They can make or break a foster nursing relationship, so it is extremely important that
they be well-informed and up to date on this topic.
B. Social Workers
1. Social workers may have concerns about foster breastfeeding as it is uncommon in our country.
This may include that it is somehow strange or perverted, or that foster breastfeeding would interfere with the bond between
the child and the birth mother, or that foster breastfeeding represents a hidden agenda to adopt the child. ( Piatak, 2003)
2. Social workers may not be familiar with the laws and codes as they relate to breastfeeding.
Health and Safety Code Section 1647 states The procurement, processing, distribution, or use of human milk for the
purpose of human consumption shall be construed to be, and is declared to be for all purposes, the rendition of a service
by each and every nonprofit organization and its employees participating therein, and shall not be construed to be, and is
declared not to be, a sale of the human milk for any purpose or purposes.
3. The belief that breastfeeding creates a special bond that may cause trauma if broken (e.g.
if a child is reunited with birth family) does not appear to be borne out by those who have cross-nursed. Rather, women frequently
express that breastfeeding anothers child gave them warm feelings towards the child and the childs mother. ( Krantz 1981)
(Gaskin 1989) ( NMAA 1994)
4. while women have observed that some babies appeared initially surprised at being breastfed
by another woman, it has not been reported that breastfeeding interfered in any way with a childs return to maternal care.
( Krantz 1981) ( Gaskin 1989) (NMAA 1994)
C. Family members
1. In countries where breastfeeding is the norm, women usually receive more support from their
families and friends, making relactation easier. Health workers, too, may be more supportive in these settings, and may both
suggest the procedure and help her to carry it out: (Neema 1994, Abejide 1997 )
WHERE TO OBTAIN INFORMATION ABOUT ADOPTIVE/FOSTER BREASTFEEDING.
World Health Organization booklet on Relactation- the most complete summary of relactation/adoptive
breastfeeding available (also available for purchase directly from WHO)