Adoption universally involves loss. Babies recognize their mothers at birth and at delivery healthy babies placed on the abdomen of their mother will crawl up onto her chest and, locating the nipple via its familiar smell 63, will attach to her breast and suckle 6465. Newborn infants desire to remain with their mother and if removed from skin-to-skin contact with her will give a specific "separation distress cry/call" as an appeal for reunion 66. Maternal separation is stressful for infants 2566676869, and all adopted children have experienced the loss of their birth mother. Some believe that this loss can impede the development of later relationships even where the birth mother is quickly substituted with another caregiver 70. Nonetheless, children whose birth mothers are immediately replaced by adoptive mothers are not at as great a risk of experiencing difficulties with relationships as children whose histories include protracted relational trauma.

Some children placed for adoption do not have a smooth transition from loving care by their birthmother to loving care by adoptive parents; it is these children who are most at risk of difficulties with building relationships and may benefit most from adoptive breastfeeding. While children adopted as newborns may certainly be assisted by breastfeeding, the following discussion will focus on the most vulnerable children, those adopted from institutions or foster care after a history of abuse or neglect.

The number of children adopted worldwide via intercountry adoption is increasing each year and 20 000 children were adopted to the United States alone in 2004 71. Based on what is known of the practices in the countries from which children are adopted it is likely that a large proportion of intercountry adopted children lived in institutional care prior to adoption 72. Although institutions vary widely in the quality of care they provide, they are often lacking in heating, cooling, space, toys or nutrition, and provide a restricted and regimented environment 72737475. Institutions usually have high child to caregiver ratios, which do not allow for individualized attention 7476, and children are generally cared for by many different adults 72. The physical and emotional deprivations of institutionalisation can result in a raft of problems including physical and developmental delays, and language and sensory integration issues 74777879. However, it can be argued that the most serious deprivation of institutionalisation is the lack of a consistent and sensitive caregiver whom a child can trust and form a healthy attachment to. Absence of a responsive primary caregiver is a type of relational trauma that alters and retards brain development 8081, reduces capacity to deal with stress 81 and makes it more difficult for children to form close and trusting relationships 82.

A proportion of children placed for adoption have spent significant periods of time in hospital because of prematurity, illness or disability. Short-term hospitalisation with parental contact may be relatively benign 83; however, long-term hospitalisation can have a sustained negative impact on children 84858687. Children adopted after long-term hospitalisation have often spent critical months of infancy or toddlerhood without the care of a parent or other primary caregiver 87 and while hospital staff may meet the physical and medical needs of children they may not be able to provide for their emotional needs 8788. Under these circumstances, long-term hospitalisation is a form of institutional care in which children experience institutional neglect.

In all developed countries there are a large number of children who cannot be cared for by their parents and are therefore placed in foster care 89909192. Children adopted from foster care often have a history of abuse or neglect 93949596 and many have also experienced multiple foster care placements 97. Children adopted from foster care are vulnerable to having difficulty developing healthy relationships because of their experience of relationship failure 9899100.

A history of abuse or neglect negatively affects the ability of children to trust and form relationships with their adoptive parents. Such children are said to be at risk of having attachment difficulties. Attachment is a close affectional bond, a reciprocal relationship that endures over time 101. Ideally, a child will develop a secure attachment with a primary caregiver through mutual interaction in which the caregiver repeatedly gratifies his or her needs in an appropriate manner, resulting in reduction of anxiety/discomfort and in feelings of relaxation and relief 102. This repeated gratification in response to need is called the attachment cycle 103. The primary attachment relationship forms a base from which children explore themselves, others and the world; thus, the quality of attachment can impact the emotional, social and even physical development of children 104. Children who have experienced consistent, responsive caregiving develop a positive internal working model of relationships and a high level of personal value, both of which are building blocks for success in future relationships 103105106. Such children view the world as a safe place and are likely to cope well with confronting situations, confident that assistance, nurturance and protection will be available if and when needed 105.

However, children who are institutionalised, hospitalised, neglected or abused by caregivers or have experienced multiple placement often have a greatly reduced or disrupted experience of the attachment cycle. Children who are institutionalised do not have the attachment cycle completed frequently or consistently because of the ability of too few caregivers to meet the individual needs of many children 82. This does not constitute a single stress but is repeated, prolonged and chronic traumatic stress 107. Institutionalised children are also hampered in development of attachment security because they have multiple caregivers 82108 and children can only build attachments with a small number of caregiving adults 109. Similarly, children who are hospitalised long-term may not have individualised care or a primary caregiver 82. In addition, a proportion of hospitalised children experience chronic unrelieved pain and such children cannot have the attachment cycle completed because the source of their distress cannot be removed 110. This places them at even greater risk of being unable to trust a caregiver 111.

Children who are neglected may not have the attachment cycle completed or may have it completed inconsistently preventing them from trusting their caregiver and developing a secure attachment 112. Those children who are abused by their primary caregiver have the attachment cycle disrupted by abuse and, in consequence, closeness with their caregiver results in fear rather than safety or comfort 82112. Children born drug addicted have experienced prenatal abuse 111, which can result in neurological impairment and cause irritability, pain and hypersensitivity to touch 113 making it difficult for the attachment cycle to be completed. The multiple placement that is experienced by many children in the foster care system hampers attachment security development because children lack a consistent caregiver. The more placements and changes in caregivers that children experience the more difficult it is for them to believe that they are not going to be abandoned again 114.

A child's preplacement experience will affect the development of the relationship between child and mother after adoption, because of the effect of past relationships on the child's internal working model of relationships. Children whose caregiving has been neglectful (including institutional neglect) or abusive (including multiple placement) have experienced relational trauma and are likely to have a negative working model of relationships, have low self worth and consider the world an unpredictable and hostile place 103105106. Children with a history of relational trauma may experience lifelong difficulties with feeling empathy, trusting others and developing intimate relationships 81115 as their internal model of relationships tells them, "Do not let us care too much for anyone. At all costs let us avoid any risk of allowing our hearts to be broken again" [116, p124].

For parents who have adopted a child with a history of abuse or neglect, the need of their child to protect themselves from further hurt can prove a challenge to the development of the parent-child relationship and a barrier to healing. This need for self-protection is manifest in various behavioural strategies that are adaptations to the child's life experience 7882100 including: exhibition of indiscriminate affection, avoidance of physical touch or eye contact, seeking to control relationships, premature independence and resistance to nurturing.

Children who have been institutionalised or who have experienced multiple placement are commonly indiscriminately affectionate and seek to engage and show physical affection to strangers 7495117. In post-institutionalised children this behaviour may arise out of the experience of needing to be proactive in seeking scarce adult attention 74118; in children with a history of caregiver loss, it may be an indication of their expectation of future loss and a mechanism of seeking an alternative caregiver. Indiscriminately affectionate behaviour is problematic because it is often at the expense of interaction with parents 103. It is not uncommon for children to refuse to make eye contact with parents, avoid physical contact or be stiff while being held 103. Also, while children have experienced limited human touch or physical abuse and are in particular need of nurturing touch, many are touch adverse 98103.

Children may also seek to control the relationship with their parents, particularly their mother 100103109 and will reject affection when the mother seeks to provide it but demand affection on their own terms 103. For these children, keeping in control is a way of feeling safe because they have understandably come to believe that they cannot rely on others to look after them 100. Similarly, children may be prematurely self-reliant and self-contained and not seek comfort or assistance from parents 82109119. When distressed, such children may suppress the external manifestations of their disturbance 120 because they do not expect that anyone would respond to their cries or because they do not want to risk being rejected 109. Thus, for example, some young children will quietly lie in bed after wakening and will wait (up to several hours) until someone comes to attend to them 78121. They may also exhibit self-soothing behaviours such as rocking, finger sucking, head banging or masturbation 103118. Self soothing behaviours are common in the general population; however, in children who have been abused or neglected, self soothing is more frequent 118 and in preference to comfort that their primary caregiver might seek to provide them with. Some children aggressively avoid intimacy with their mother and actively reject her 109111 and they may consistently act in such a way as to attempt to make themselves undesirable to their mother 103. Thus, children's past experiences of hurt in relationships result in them seeking to resist nurturing care from their mother 98. There are other behavioural symptoms that children with a history of relational trauma may exhibit such as excessive clinginess 109, seeking to control their environment 103 or night disturbance 122 However, these symptoms are less problematic in terms of directly placing a barrier to the mother building a trusting relationship with her child and so will not be discussed.

It is important to recognize that the time of placement in an adoptive family is extremely stressful for children. Children form attachments to their caregivers even if they are abusive or neglectful and so loss of any caregiver is stressful 123. Newly adopted children have not only lost previous caregivers and familiar environments but have also gained new caregivers and a new environment in which they have to learn to live. For children with a history of abuse or neglect, dealing with this stress can be particularly difficult, since not only are they likely to have an impaired regulatory system that disorganizes under stress 107 they also have not developed an attachment to the new caregiver to assist them in dealing with this stress 98.

It is vital for a child who has not developed a healthy attachment in infancy or whose attachment has been disrupted to become attached in order to heal and grow 124. For a newly adopted child with a history of relational trauma, assisting them to trust and to build a secure attachment relationship with their mother can be a challenge. Nonetheless, adoptive parents are motivated to help their children with the hope that they can reverse damage and enable their children to achieve good outcomes in adult life 100. This hope is well founded since there is evidence that early difficulties can be overcome 7476125 and that even the stress physiology of child can be altered by appropriate parenting 126. In this context, breastfeeding is a parenting tool that may be used to assist child-maternal relationship development.

LiJun was adopted from China at the age of three years. She had been abandoned as a young baby and placed in an orphanage where she lived until adoption. Staffing levels in the orphanage were low and while it appeared that the carers had a genuine affection for LiJun they could not provide individual care or a stimulating environment. Thus, at placement LiJun was developmentally delayed and exhibited other symptoms associated with long-term institutionalisation. The transition to her adoptive family was abrupt and LiJun was overwhelmed and very distressed by what was happening to her. However, the morning after placement she started interacting with her new family showing an immediate preference for her adoptive father. While LiJun appeared generally happy during the day she had great difficulty going to sleep and would also frequently wake during the night at which time she expressed anger or sadness in her cries. During her night distress she vehemently rejected her mother but would accept comfort from her father.

Upon return home, her mother began to attempt to transfer LiJun's preference to herself. She persisted with initiating physical closeness with LiJun and carried her in a sling, co-slept, co-bathed and hand fed her and slowly LiJun warmed to her mother. However, LiJun's night distress remained. It would take up to three hours for LiJun to go to sleep and during the night she would wake 6–12 times. Often her mother needed to take LiJun from the bed and walk and carry her in order for her to go back to sleep.

Several weeks post-placement, LiJun's mother relactated and began offering breastfeeding. Her mother's motivation to relactate initially arose out of a desire to provide breastmilk in order to prevent illness; she was concerned that LiJun's emotional state left her vulnerable to infection and that illness would be another burden on a child who was struggling to cope. LiJun drank the milk her mother produced in a cup but attempts to introduce a bottle failed because LiJun did not appear to know how to suck on the teat. Nevertheless, her mother showed LiJun pictures of breastfeeding couples, offered the breast each day and after a couple of weeks LiJun licked her mother's nipple and then sucked very briefly for the first time. Thereafter, LiJun would suck for less than a second on her mother's nipple every few nights. Two months post-placement, LiJun's mother was carrying her in a sling as she attempted to soothe her to sleep when LiJun started sucking on her mother's neck. In response to this her mother laid her down in the sling, offered the breast and LiJun attached to the breast, suckled and fell asleep. For two months after this LiJun suckled to sleep in the sling at night on a semi-regular basis but she would not breastfeed at any other time and would not breastfeed if she had had a challenging day or was otherwise unsettled. Although LiJun was breastfeeding, it was sometimes obviously difficult for her to do. However, five months post-placement and two months after beginning to breastfeed to sleep, LiJun abruptly started to seek breastfeeding for comfort and reassurance day and night. LiJun then breastfeed up to 12 times a day and could be instantly comforted by breastfeeding on her still frequent night waking (which continued for two years post-placement). Her mother feels that LiJun used breastfeeding as a way of obtaining comfort and reassurance, as a touch point to herself and to aid self regulation when circumstances were overwhelming. Now three years post-placement LiJun continues to breastfeed to sleep at night but rarely seeks breastfeeding at other times. Her mother feels that the acceptance of breastfeeding paralleled LiJun's acceptance of herself as her mother and that it has aided her daughter in healing.

Jacqueline was adopted from China at five years of age. She had been abandoned at the age of 18 months at which time she had a life threatening congenital heart defect. After abandonment, she lived in an orphanage for 2.5 years before heart surgery was performed, involving six weeks hospitalisation without any contact with caregivers. Post surgery Jacqueline was placed in foster care for eight weeks and during this time began to talk for the first time since her abandonment. Jacqueline experienced multiple transitions and multiple separations from multiple caregivers during her first five years but after a final nine months in the orphanage she was placed for adoption. Her mother states that post-placement Jacqueline presented as a generally happy child who was energetic and eager to please; however, she was also indiscriminately affectionate and developmentally delayed, hoarded food, wanted to be self-sufficient and was afraid of and had difficulty recognizing emotions.

After placement in her adoptive family her mother sought to parent Jacqueline in such a way as to promote attachment and so kept her in close physical contact, co-bathed and co-slept with her and used massage to provide nurturing touch. Jacqueline would periodically express some of the anger she felt as a result of her past hurts in what her mother describes as a "rage." After one such "rage" she indicated a need to suck. She sucked hard on her mother's fingers, nose and face before finding her breast, latching on, suckling and falling asleep. Her mother was very surprised by Jacqueline's desire to breastfeed but perceived this need to suck as being a "primal urge" coming from deep within her, not something that was occurring at the conscious level, and felt that it would be helpful to allow her to suckle. Her mother believes that Jacqueline must have been breastfed by her birth mother because of the way she latched and suckled as an experienced breastfeeder and thinks that she was seeking to re-enact earlier times of comfort and nurture. After this incident, Jacqueline continued to initiate breastfeeding sporadically; up to several times a day and as little as once every a fortnight. Jacqueline was content to suckle without milk being present but her mother relactated after breastfeeding had continued for a few months with the aid of a breast pump. Breastfeeding was used by Jacqueline as way of finding of comfort and security and was sometimes associated with Jacqueline "playing baby." The frequency of breastfeeding generally decreased over time until weaning at 2.5 years post-placement. Jacqueline showed a dramatic acceleration in emotional, physical and cognitive development during the first two years post-placement. Jacqueline's mother views her acceptance of her child's desire to breastfeed as helpful and feels that it has promoted healing, attachment and belonging in her adoptive family and has helped her child to feel secure.

Catherine was born full-term with a life threatening condition that had been detected antenatally. As a self-protection mechanism, her parents emotionally withdrew from her during pregnancy and although surgery post-birth was successful and Catherine was no longer at risk, her parents remained detached from her. Thus, Catherine spent the first four months of her life in hospital with minimal interaction with her parents or other adults. Catherine did not gain weight in the early weeks of life, was diagnosed as failure to thrive and had a gastrostomy tube inserted. The insertion of the gastronomy tube did not result in weight gain but reduced the amount of human contact Catherine experienced because feeding did not require her to be held. Catherine was not provided with emotionally sensitive care or affection during her time in hospital. At four months of age and weighing 3.2 kg her parents relinquished her for adoption and she was placed in foster care. At the time she entered foster care, Catherine had developed an aversion to interaction with others and would turn away if spoken to and stiffen if touched. However, her foster mother provided her with responsive care and Catherine formed an attachment to her. Catherine was in foster care for ten weeks before being placed for adoption at 6.5 months of age. Post-placement for adoption, Catherine grieved her foster mother deeply and although she tolerated her adoptive father she rejected her adoptive mother and would turn her head and push her mother away if she attempted to carry her facing towards her. Her adoptive mother had previously breastfed other adopted children placed as newborns but her early offers of breastfeeding to Catherine were strongly rejected. Catherine weighed only four kilograms at placement and had a strong aversion to bottle-feeding. She would take only small amounts of milk via a bottle and only if she was held upright and facing away from the caregiver. Sucking was not pleasurable for Catherine, she did not suck on a pacifier or her thumb and would gag and vomit if her mother attempted to reinsert the bottle teat after Catherine had pushed it out of her mouth. Catherine's mother worked towards promoting the emotional and physical health of her child by committing to carrying Catherine in a sling whenever possible, being responsive to her and always remaining close to her. Within a few weeks Catherine developed a preference for her adoptive mother and would not tolerate any physical separation from her. Her mother also worked to overcome Catherine's oral aversion and changed her infant formula to one more pleasant tasting to that previously used and persisted with bottle feeding. As a result, Catherine developed a love of sucking. At this time Catherine also began to gain weight (though her energy intake had not increased), which allowed for the removal of the gastronomy tube. When Catherine's health had improved her mother decided to reattempt breastfeeding. Catherine was being bottle-fed very frequently at this stage and her mother decided that she would always be the one to feed her and that she would attempt the transition to breastfeeding by making bottle-feeding progressively more like breastfeeding. Thus, her mother used a short bottle, which made it easier to turn Catherine towards her as she fed and would switch sides during feedings. She also allowed Catherine to suck at the bottle after all the milk had been consumed for as long as she wanted to, which was often for many minutes. Once she was bottle-feeding well her mother threaded the tube of a breastfeeding supplementer through a bottle teat and held this over her nipple while Catherine sucked and obtained milk from the supplementer. When she felt that Catherine was ready, she replaced the bottle teat with a nipple shield with the supplementer tube placed through the end and finally she removed the nipple shield so that by her first birthday Catherine was suckling direct at the breast. Once breastfeeding began, her mother noticed an increase in Catherine's confidence and security. Thus, when Catherine was hospitalised shortly after starting breastfeeding, she not only surprised her doctors by her speed of recovery but by the marked improvement in the way she coped with the stress of medical procedures. Previous post-adoption hospitalisations had seen Catherine show terror whenever she was approached by someone wearing a white coat but on her first hospitalisation after breastfeeding initiation she spent much of the time while in hospital breastfeeding and allowed herself to be examined without showing distress. Post-breastfeeding initiation Catherine also experienced acceleration in developmental progress and a detachment from bottles to which she had developed an emotional connection. By the time of weaning at two years of age, Catherine had caught up physically and developmentally and was using her mother as a secure base when exhibiting normal explorative behaviour.

John was born cocaine and alcohol addicted and expressed behaviours associated with prenatal drug abuse including: irritability, hypersensitivity to stimulation and persistent, protracted crying. On hospital discharge at six days of age, he was placed in foster care with the intention that he would eventually be placed in the care of his father. During the first few weeks of his life his foster mother reported that he was "screaming" or sleeping most of the time. Swaddling, close physical contact and sometimes skin-to-skin contact were used by John's foster mother to calm him. Many aspects of normal life were stressful to John including stimulation from noise, light or touch. Eye contact or a kiss from his foster mother would result in a bout of intense crying. When being bottle fed, John would become distressed and arch his back; however, on several occasions when his foster mother held him swaddled on her skin to sleep she awoke to find him calmly latched and suckling at the breast. His foster mother did not pursue breastfeeding at this time because she wished to support the placement of John with his father.

Over the next few months, John's foster mother continued to care for him in such a way as to reduce his distress as much as possible and he gradually calmed somewhat and became less unhappy. Nonetheless, he remained a tense and physically stiff baby who would not relax in his foster mother's arms and did not like facing her. When John was six months old permanency planning switched from placement with his father to adoption by his foster family and his mother decided to attempt to breastfeed him. Using a breastfeeding supplementer she offered John the breast and he accepted it immediately. His mother fed him at the breast consistently and noticed changes in his behaviour. John became much more physically relaxed and stopped holding his fists tightly clenched, he began sleeping much better and started to become more interested in what was going on around him. He also began to turn towards his mother when she held him and would physically meld into her, even falling asleep as she carried him, something he had never previously done. He commonly fell asleep breastfeeding. Within two weeks of breastfeeding initiation John also began to enjoy eating solid food, to sit alone and roll. However, most significant for his mother was that, in her words, he changed from "a rigid, screechy baby who didn't like to be held, to a calm, happy, snuggly infant" and the changes were so rapid, over a period of only a few weeks, that his mother is convinced that breastfeeding was involved.

Mothers who wish to breastfeed their adopted child are in need of support, encouragement and education. As described, it is common for children to initially reject breastfeeding and their mothers, and, particularly for women who have a history of infertility, being rejected by their long-awaited child can be devastating. Practitioners have a vital role in supporting and educating mothers so that they are able to understand and withstand rejection from their child. Such education may include informing mothers about the importance of not taking rejection personally or accepting rejection at face value and emphasising the need to avoid responding to rejection by withdrawing nurturing 9899115119. Education on the root of rejecting behaviour may also assist mothers to feel empathy towards their children 98, which will allow mothers to provide the sensitive care that enables attachment development 115154 and to persist with working towards breastfeeding. Mothers may be encouraged to be gently persistent in providing nurturing without expecting reciprocity but with the knowledge that research has found that most children will eventually respond positively to nurturing 98. Practitioners may also be able to assist mothers in locating networks that will support them in providing sensitive parenting and breastfeeding, since in a Western context parenting practices that promote attachment development are contrary to the cultural norm 155.

The issue of breastfeeding non-infant children is contentious 156. However, breastfeeding has been initiated in children up to at least four years of age at placement and, as discussed, children who have sought breastfeeding have been up to more than ten years of age. In addition, children with a history of relational trauma are likely to be much younger emotionally than their chronological age would indicate 100, and providing nurturing care and intimacy more commonly considered suitable for younger children can be beneficial 100127. It should also be considered that Western societies have a particularly short term view of breastfeeding while anthropological research suggests that breastfeeding is a normal activity for children aged up to seven years of age or more 157. Nonetheless, prevailing societal attitudes make it advisable for practitioners to suggest to parents that they need to be careful to whom they reveal that their child is breastfeeding if the child is more than two or three years of age.

The possibility and potential impact of breastfeeding is something about which few are aware; practitioners have a role in promoting and educating others about adoptive breastfeeding. It should be noted that adoptive parents are often highly motivated and committed to helping their child 72 and it should not be assumed that families will be "put off" from breastfeeding because it may be challenging. Thus, it is appropriate to discuss breastfeeding with prospective adoptive parents.

Although adoptive breastfeeding has been the focus of this paper it is worth noting that foster children are sometimes breastfed by their foster mothers. Foster breastfeeding sometimes proceeds with the permission and support of the relevant authorities 133, sometimes without 158, and the possibility of gaining permission to breastfeed a foster child varies widely between locations. However, those considering breastfeeding a foster child without approval should be aware that children have been removed from foster families because they were being breastfed by their foster mother. Nonetheless, it can be argued that breastfeeding should be considered in foster care situations where it is anticipated that the child will be in care for six months or more 133.