Guide to co-nursing and induced lactation

To become and be a parentSofia Klittmark, leg. barnmorska

This is a guide for people who want to breast/chestfeed a child they haven't given birth to, and for people who are to co-nurse one child (or more). The first part is about co-nursing and how you can approach nursing together. The second part is about how to induce lactation. The guide ends with some advice on how you can create a safe place for co-nursing in a society where this is norm-breaking.

Contents of this article

  1. Co-nursing
  2. Induced lactation
  3. When the baby is born
  4. Using a supplementary nursing system
  5. Creating a safe space
  6. More resources and support about nursing

Induced lactation means nursing a child you haven’t given birth to. It may be that you are the only parent who is to nurse the child, or that you nurse along with the gestational parent. We call that co-nursing.

There are strong norms surrounding nursing and therefore we want to remind you that:

  • You can choose to nurse, whether you are a cis- or a trans person, and regardless of if you are the gestational parent or not. However, the preconditions for establishing milk production vary, for example depending on your hormone levels.
  • It’s not a necessity to nurse your child to fulfil the child’s basic needs of comfort, closeness and consolation. You can be proud and satisfied as a parent no matter how your child is fed.

Individual counselling based on your needs is preferred. You may need support and practical advice from competent professionals. Many factors are individual, for example how you and your child are feeling after delivery. Try to find a midwife who can follow you through the process and help you make decisions about your situation and support you if there are any problems. Medical guidance should always be given by healthcare professionals.

Many rainbow families have witnessed that there’s a lack of knowledge in caregivers, or that norms surrounding breast/chestfeeding have complicated getting good advice. Sometimes it takes time to find the right person, but don’t give up. You have the right to individual support from healthcare staff. We have written this guide with the hope that it will complement the support you receive from healthcare.

Co-nursing

The basis of well-functioning co-nursing is the relationship between those who breast/chestfeed, and your relationship with the child. When you co-nurse you need to work together and be supportive of one another since it’s about calibrating the child’s nutritional intake and your milk production.

You can co-nurse with or without induced lactation. To nurse regardless of milk production can also be an alternative. Because of the norms surrounding nursing, there’s not a lot of information about this: Nursing doesn’t have to be about nutrition and milk production but can be about closeness and creating a bond. Nursing can be shared so that the non-gestational parent offers the breast/chest for closeness and comfort, regardless of milk production. Reflect upon how much time you have and want to spend trying to start a milk production. If you have nursed an older child and still produce “a little” milk, you don’t necessarily have to strive for an increased production. Then the child nurses with the one that has milk when it’s hungry and can, for example, lie at your breast/chest afterwards; sucking to fall asleep or cuddle. When you offer your breast/chest as comfort you can have the child with you when it’s not hungry but is trying to seek closeness or is anxious. During some periods, night time anxiety  is common. In such a situation it is also possible to give the baby pumped milk or infant formula via a supplementary nursing system. But co-nursing can also be about starting a milk production and thereby sharing the feeding.

To increase the chances of carrying out the nursing you wish for it’s a good idea to study the following topics before the baby is born:

  • how milk production and nursing works
  • how children signal their needs (for example, hunger or tiredness)

When the baby is born you can develop a sensitivity to how and what the baby is communicating. You can sit together and observe when the child is being nursed, regardless of who nurses, and that way learn how the child shows hunger, satisfaction, worry, stomach ache, need for closeness, etc.

Make a plan and prepare with the goal to be a good team and find a co-nursing situation that works for you. And as with all planning for parenthood, it’s good to maintain an openness about that things don’t always turn out the way you wish. Maybe everything feels different when the baby has come. That’s OK. But it’s good to have planned, as a foundation.

Talk through how you can support each other if it’s the first time for both of you or one of you to learn how to breast/chestfeed. Share thoughts about nursing during pregnancy, and how nursing and parenthood relate for you. Is there worry, thoughts, gender dysphoria? What is your relationship with your breasts/chest today? What stories of nursing do you carry with you from your relatives/parents and how do they affect you?

Sometimes there is conflict around nursing and feeding. The non-gestational parent may want to nurse or give pumped milk in a bottle, while the gestational parent is worried that this may disrupt their nursing or has a wish to be the only one that nurses. Both stopping nursing or having to give it up can be a great sorrow. This includes  planned co-nursing or induced lactation, and can be connected to a worry about how the bonding with the child is affected, or not feeling as valuable as a parent. It may affect your relationship and create feelings of being an outsider or jealousy towards the other parent. Try to tune in to each other by listening to each other with humbleness and respect. You need each other. How can you find ways to support each other, regardless of where you end up with nursing and feeding?

Many can nurse, but it’s not uncommon to experience some difficulties, even for the gestational parent. Many things matter here, for example the baby’s ability to latch on to the breast/chest, and the opportunity to get support if there are complications. Through hormones, the gestational parent has an easier time starting milk production than the non-gestational parent. Starting to nurse varies in difficulty between people. If you as parents feel that it’s important that the child is able to nurse with (at least) one parent, it may be wise to focus on the establishment of a well functional nursing and milk production in the gestational parent first. The gestational parent needs to feel secure about nursing and milk production, and how long that takes differs. Nursing is done with the body, and milk production occurs in it, and it’s partly about self-reliance and self-confidence. You as a non-gestational parent can be a priceless support. The process of learning how to nurse you can do together, regardless of who nurses. In parallel, you can focus on starting the nursing in the non-gestational parent (see below). The non-gestational parent needs to become confident in nursing and milk production too. Since nursing as a non-gestational parent is norm-breaking, it may make it harder to feel self-reliance and self-confidence. Sometimes you need to focus on one parent first, then the other, sometimes you can do all at the same time. It’s teamwork, which is promoted by openness and good communication.

Nursing is part of bonding, but is not the determining factor in bonding. Nursing is closeness, comfort, joy and nutrition. Bonding can happen in closeness, comfort and joy but without nursing. It’s an important fact to carry with you into  parenthood.

Inducing lactation

The gestational parent is helped by the hormones of pregnancy, which start the production of colostrum already in the middle of pregnancy. At birth, there is a huge hormone adjustment, which prepares the body for milk production. When the breasts are then emptied of colostrum this starts hormonal changes which in turn leads to milk production. The milk production of the gestational parent also requires that nursing is started. Mostly, the child contributes to this by starting to nurse. It takes time to produce enough milk and to adjust the quantity of milk to the baby’s needs. If the baby for some reason can’t lie by the breast/chest as a new-born, it’s a good idea that the gestational parent stimulates the breasts/chest through hand expression and pumping.

Nursing is controlled by hormones, stimulation and emptying of the breast/chest (the request for milk). When nursing a child you haven’t given birth to, it is the request for milk that leads to signals that stir the body’s hormones. It is possible to do that. It can take anything from four days to six weeks to start producing milk in that way. It may be easier to get milk production going if you’ve had a milk supply before (relactation), but you can do it even if you haven’t nursed before and never have been pregnant.

The breasts/chest are/is stimulated by your hand expressing/pumping the breasts/chest. Even if at first, there is no milk, it’s the same movement as in an emptying of the breast/chest. You can extract milk by hand, with a manual or electric pump. Preferably start with hand expression. If you use a pump it’s a good idea to also use the hand to learn how the breasts/chest feel/s and work/s. Don’t be discouraged if there is no milk. Every time you hand express or pump, nursing promoting signals are sent to the brain, and in time the production starts.

Here you can watch films that show how to hand express:

When you are to pump or hand express you should start by gently stroking across the breast/chest with your fingertips; you start far from the nipple and stroke towards the nipple to stimulate it to release milk, which is called milk ejection reflex. Relaxation and peace and quiet helps the milk ejection reflex which is driven by oxytocin, the body’s “peace and quiet” hormone. Some don’t release that much to a pump, but more milk comes when the baby is sucking. Because of that, it’s not reliable to measure how much milk there is by pumping or hand expression. You can practice releasing milk to a pump. It can help to look at cute pictures or clips of babies, meowing kittens or something else that triggers caring feelings at the same time as you’re pumping. Make sure you’re as comfortable and peaceful as possible.

You can benefit from starting to hand express and/or pump one-two months before the baby is born, but you can also start after delivery, depending on your goal concerning milk production. The more you stimulate, the stronger the signal becomes. Generally, it’s better with several short stimulation periods than one long. Pump as often as you can. If you want a bigger milk production you need to stimulate the breasts about every three hours, up to eight times per day. You can pump for 5-10 minutes per sitting and side (there are pumps for one side at a time and for both sides), and always stimulate both sides. If you use a pump for one side, or hand express one side at a time, you may switch side every few minutes. When you have milk , the flow of milk rather than the clock can determine how you switch. When the flow decreases, you switch sides.

If you pump during pregnancy and haven’t breast/chestfed before it can be difficult to know what it should feel like. If a child has a good latch and sucks actively it is generally more effective than a hand or pump. When the baby is born you will experience what it feels like when it has a good latch and sucks actively. In that way, the child can teach you how it should feel in order for the milk to come. This will make it easier to hand express or release milk to a pump. Then you can also pump while the child is laying skin to skin. All tips to increase the milk production also apply to those who are inducing lactation. Do look up “power pumping” and breast compressions. Power pumping is a pumping schedule designed to increase milk production. Breast compressions can be done both in pumping and nursing. You then empty the breast/chest more effectively, which gives a stronger signal to increase milk production, and gives the baby more milk if done while nursing.

When the baby is born

When the baby is born, co-nursing needs to be adjusted based on your specific situation, among other things on how the gestational parent feels, how the baby is feeling, and if the baby needs extra feeding for medical reasons. Do take help and support from your midwife at the birthing ward about how you can handle your situation. If the midwife isn’t experienced in/has no knowledge about co-nursing you can mention this guide, which can also support healthcare staff.

Both who are to nurse can have the baby skin to skin as much as possible from the time it’s born. Skin to skin releases nursing promoting hormones, among others oxytocin. Nursing and milk production is promoted by peace and quiet and the minimising of physical and mental stress, worry and pain.

The new-born’s stomach is the size of a cherry (5-7 ml) and the colostrum of the gestational parent usually provides enough nutrition for the first few days. After having rested after delivery, the baby usually wants to be, more or less constantly, by the breast/chest for the first few days. You might want to prioritise the gestational parent’s milk production at first; the gestational parent can have the baby by the breast/chest for the most part, but the non-gestational parent can also try and have the baby by the breast/chest on some occasions already at the birthing ward, also keeping on stimulating by hand expression and pumping. It can be good for both of you to receive nursing support from a midwife at the birthing ward about, for example, what nursing positions work and how the baby latches on each one of you. After the milk has started to come in the gestational parent and as the confidence in nursing increases, you can start switching to letting the baby lie by both parents’ breasts/chests. You can also choose to let the baby nurse equally from day one, where both of you are complementing by pumping and hand expression to stimulate milk production. Regardless of with whom the baby nurses, you can combine the baby’s sucking with hand expression and pumping, so that both parents’ milk supply can be promoted and stimulated from the beginning.

Letting a healthy and alert child lie by the breast/chest of the non-gestational parent on some occasions during the first few days is mostly nothing that gets in the way of the gestational parent’s nursing, especially if the non-gestational parent has no milk. But if you have been pumping during pregnancy and already have a milk supply , you need to think about that a well-fed baby is less interested in sucking, and that the sucking is part of starting the milk production in the gestational parent. That is why there is advice about avoiding supplementary feeding of babies during the first few days, if possible. Some babies are fed for medical reasons, and then the milk of the non-gestational parent can be very valuable! If your baby needs supplementary feeding for medical purposes you can use your milk instead of infant formula. If there’s reason to believe that your baby needs supplementary feeding after birth, you can freeze the milk you pump during pregnancy and bring it to the birthing ward. The advice given to pregnant people with diabetes type 1, whose children need supplementary feeding after birth, is to start pumping at week 36 to be able to bring milk to the birthing ward. If you are expecting twins, both pumping during pregnancy and co-nursing can be extra valuable.

Using a supplementary nursing system

If you want to nurse but haven’t got enough milk, you can have the child by the breast/chest and give nutrition through a technical device called a supplementary nursing system. A container is then filled with pumped milk/formula, and a thin tube is attached to the breast/chest right by the nipple, so that the tube provides milk when the child latches. In that way you can stimulate or induce the body’s own milk production at the same time as the baby is fed.

A supplementary nursing system can be used to increase milk supply and promote nursing in the gestational parent, if the baby is ordered supplementary feeding after birth. If the non-gestational parent already has milk, their pumped milk can be used for supplementary feeding at the same time as it helps the milk production of the gestational parent. Routines differ between hospitals. Feeding by cup is the most common way of doing supplementary feeding during the first days, if exclusive breast/chestfeeding is the goal. Both cup and supplementary nursing systems are good methods if you want to avoid a bottle, which can complicate nursing.

A supplementary nursing system can also promote nursing and stimulate milk production in the non-gestational parent. The baby can be fed infant formula or pumped milk from the gestational parent, if possible. Sometimes the baby doesn’t want to latch on if there is no milk, or if the flow is low. Then the system can be a way to help the baby to want to lie by the breast/chest by providing milk at the same time. It can also be a way to nurse for a longer period of time, for example for people who have had breast surgery. Sometimes it’s hard to make the milk last, regardless of if you’ve given birth or not, and then it can be a way of giving nutrition directly by the breast/chest to stimulate or uphold existing milk supply.

Healthcare staff at the birthing ward can easily produce a supplementary nursing system that can be used instead of a cup, by fastening a thin tube to a syringe. The Swedish non-profit organisation Amningshjälpen also sells this kind of simple supplementary nursing system along with a detailed instruction on how to nurse with a supplementary nursing system.

How to use a supplementary nursing system:

Creating a safe space

You will have to deal with the environment’s normative thoughts and feelings at the same time as you handle your own feelings. Nursing is surrounded by many norms, ideas and also myths. In Sweden today, the norm is that a child should only be nursed by the gestational parent, which makes induced lactation and co-nursing norm-breaking. It also means that there isn’t a lot of knowledge about, or experience of, co-nursing yet. If you want to nurse a child you haven’t carried yourself, you may be met with surprised and questioning reactions, which can lead to you devaluating yourself. Then it can be good to remind oneself that norms change over time. In historic times, some people used wet nurses – employees who nursed other people’s children – and in several other places in the world it’s less tabooed to nurse a child you haven’t given birth to, maybe nieces/nephews or grandchildren.

You might need to deal with both outer and inner resistance in order to feel comfortable about what you do and your choices. To be able to relax is a precondition both for releasing milk, feeling good and making the baby comfortable at your breast/chest. You need self-reliance and self-confidence, which can be more difficult to get in a norm-breaking situation. Otherwise it’s easy to misinterpret the baby and think that it doesn’t want to do something or that you’re doing something wrong. While in reality, the baby may have a hard time latching on, or it is or isn’t hungry and doesn’t want to lie by your breast/chest at that time for that reason. You are not doing anything wrong towards the baby, and you need to learn how to nurse in a way that suits you both.

You can choose not to be open about your nursing to not have to handle the environment’s reactions to what is norm-breaking in your decision. Some people have chosen that. Remember that you have the right to do exactly what you need in order to create a safe space for your nursing.

Many new parents are surprised and strongly affected by the feelings that surface around nursing and the ability to give (or not being able to give) nutrition to their child, both the gestational parent and the non-gestational parent. It’s sometimes difficult to decide whether to keep fighting to solve potential problems around nursing or giving it up. It’s a good idea to find someone to talk to who can understand you and your thoughts about nursing, feeding, body and parenthood, and who can be beside you through the first period.

More resources and support in nursing

Illustration: Bitte Andersson

Below are links to other websites, organisations and groups where you can receive support and information. Worth knowing is that if you read about induced lactation on American websites, many of them will speak of methods/protocols to start nursing by taking medication/hormones. This is not done in Sweden and is therefore not something we can recommend.

Nursing support for trans people

Trevor MacDonald from Canada is a key figure who has worked a lot with support for trans people who want to nurse.

Induced lactation

Alyssa Schnell from USA is a key figure who has worked a lot with support to people who want to induce lactation.

Co-nursing

Specifically about trans women’s possibilities of nursing

Facebook groups that offer nursing support

  • LLL LGBTIQA+ Families Welcome to La Leche League LLL LGBTIQA+ Families: a safe space for families who identify somewhere across the sexuality and gender identity rainbow.
  • Birthing and Breast or Chestfeeding Trans People and Allies This group is intended for sharing information and experiences about pregnancy, birth and nursing amongst trans and genderfluid/gender neutral people anywhere on the gender spectrum, at any point in transition (or pre-transition).
  • Trans Feminine Breastfeeding and Lactation Support. Please ask to join the ‘Trans Feminine Breastfeeding and Lactation Support’ group from within the ‘Birthing and Breast or Chestfeeding Parents and Allies’ group.
  • La Leche League – Inducing Lactation & Relactation This is an inclusive support group for those looking for information and support on how to induce lactation (bring in a milk supply without a pregnancy) for non-birthing parents, such as surrogacy, adoption, co-nursing, trans/non-binary chest feeding, etc; and for those who are relactating for a child they did birth after stopping breastfeeding previously for any reason.
  • Inducing Lactation – Surrogacy, Co-Nursing, Adoptive or Chest feeding This is a peer-to-peer group for those going through surrogacy, co-nursing, adoptive, or chest feeding. If you are interested in learning more about inducing lactation, are in the process of inducing lactation or have already/previously induced lactation then this group is for you.

Fact checking: Anna Maria Westlund, RNM (registered nurse midwife), IBCLC (International board-certified lactation consultant) and “support mom” at Amningshjälpen.