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The Difference Between the Lactational Amenorrhea Method (LAM) and Ecological Breastfeeding

The Lactational Amenorrhea Method (LAM) and Ecological Breastfeeding are sometimes mixed up and muddled, so let’s sort out the difference between the two. You might also like to read our Introduction to Fertility Tracking When Postpartum and Breastfeeding or our survey of Tempdrop users who caught first postpartum ovulation with Tempdrop.

The difference between LAM and Ecological Breastfeeding

LAM is like a form of Fertility Awareness Based Method (FABM). FABMs rest on two principles. The first is that there are naturally occurring periods of fertility and infertility in every woman. The second is that it is possible to determine whether any given woman is in a fertile or infertile period, to a certain degree of probability, by observing and interpreting the correct characteristics.

The difference between the various FABMs is which characteristics you observe and how you interpret them. For LAM, you are observing characteristics of the breastfeeding dyad, rather than just the woman, but apart from that it’s no different than any other FABM.

The characteristics for LAM include one for the woman: 
  • Has she had no bleeding since lochia (the vaginal discharge after birth) ended/56 days postpartum?

One for the child:

  • Is the child under 6 months?

And one for the dyad:

  • Has the baby’s nutrition been met exclusively or almost exclusively at their mother’s breast?

The interpretation requirements of LAM are very simple: if you can answer yes to all three questions, your probability of pregnancy is less than 2%.

Here are the three requirements of LAM laid out in point form:

  1. The mother has not had any bleeding or spotting after day 56 postpartum.
  2. The baby is breastfed at least every 4 – 6 hours day and night and not given other food, water or liquids (other than token amounts).
  3. The baby is less than six months old.

The most important of the three LAM criteria is the absence of vaginal bleeding/spotting. Generally, a first sign of returning fertility is bleeding/spotting. The second most important criteria of the LAM protocol is the breastfeeding pattern (fully or nearly fully breastfeeding). The least important of the three LAM criteria is the six months duration.

But all are required to be met to fit LAM criteria. Once a woman answers “no” to any one of these, she is recommended to determine another family planning method should she wish to avoid pregnancy.

A few points of discussion about commonly misunderstood areas:

Conflating Exclusive Breastfeeding with Exclusive Breastmilk Feeding

We must be careful not to conflate exclusive breastfeeding and exclusive breastmilk feeding. LAM has not been well tested for women who are exclusively pumping, for example, where the baby is fed entirely on breastmilk, but is not suckle directly from the mother’s breast. LAM’s efficacy is based on the baby regularly and frequently drinking directly from the mother’s breast, not pumping and feeding the baby pumped milk from the bottle.

However, it is possible to follow LAM guidelines AND pump extra in between as well! The fact of pumping itself doesn’t necessarily ring the death knell for LAM. I mention this because much of the research on LAM supports its use for fully or “almost fully” breastfeeding mothers.

Sometimes women may think they’ve dropped out of its requirements if they so much as have a babysitter give one bottle of formula one time to their baby in between their 2-4 hour daily feeds at mama’s breast, so they can go out for a weekend lunch date with their husband, or they’re pumping in between nursing sessions to store bottle-delivered breastmilk for such occasions… because it’s not “exclusive”.

Exclusive breastfeeding

But really, they still fit into the rough frequency of baby feeding at the breast that LAM instructions typically recommend. This may have implications for occasional supplementation as well.

Some research on LAM indicates that the occasional space of longer than 4 hours (but not more than 6 hours) between daily nursing and longer than 6 hours (but not more than 8 hours) at night does not negatively affect LAM efficacy, but most guidelines recommend the 4 hours (day) and 6 hours (night) minimums.

Experiencing a Return of Fertility Before 6 Months is Not a Failure

It is not a failure of LAM when a mother experiences a return of fertility before 6 months postpartum. She is simply disqualified from LAM with any bleed past 56 days postpartum. A LAM method failure is only if the mother becomes pregnant while still meeting all the criteria for LAM.

It may be possible to continue LAM past six months

There are studies on “extended” breastfeeding, lactational amenorrhea and family planning:

There is NO Requirement in LAM to Avoid the Use of Pacifiers/Binkies/Dummies/Comforters

Most large mainstream medical organizations reference the Bellagio Consensus - of the late 80’s when outlining LAM’s three requirements, for example the CDC and the Australian Breastfeeding Association. The consensus underwent much examination shortly afterward.

Using pacifiers while breastfeeding

This research from the World Health Organization began before the LAM was codified, but not completed and published until a decade after it. It supports the efficacy of LAM’s three standards, and was performed in various locations including those where pacifier use was common.

There is plenty of research published, demonstrating the well-known 98+% efficacy without any requirement in these studies to solely pacify baby at the breast, some cited by the Global Library of Women's Medicine

I like this research from the Australian and New Zealand Journal of Obstetrics and Gynecology because it addresses some of the early concerns (eg. from Trussell et al) about the Bellagio Consensus: that LAM’s effectiveness may be based on lower nutritional levels and/or different child rearing practices for women in developing countries, and that its effectiveness may be based on postpartum women not being sexually active.

These women are in highly developed nations, with modern economies and nutritional levels similar to those of the USA, Canada, the UK, etc., and were sexually active. The study made no demand to avoid the use of dummies, and the use of these comforters are common in Australian society.

The prohibition on dummy/pacifier/binky/comforter use belongs to Ecological Breastfeeding and is not a requirement of the Lactational Amenorrhea Method.
So, what are the Standards of Ecological Breastfeeding? I’m restricted by copywrite considerations, but you can find them summarized by Natural Family Planning International

As you can see, this set of behaviors includes keeping baby close and pacifying the baby at your breast by allowing comfort suckling. Ecological Breastfeeding is a set of practices designed to lengthen the period of lactational amenorrhea and infertility, for the purposes of child spacing. You can read a little more about it in these overviews from FACTS and Natural Family Planning International (note that this address is catering to a Catholic audience).

And for those interested in a more in depth read about Ecological Breastfeeding, there are some books you may like to read, like The Seven Standards of Ecological Breastfeeding and Breastfeeding and Natural Child Spacing, both by Sheila Kippley. 

Recently, Sheila Kippley has been investigating a possible increase in fertility inhibiting effects with the use of side-lying for nursing, and this is being recommended in related support groups on social media. I’m not aware of any published material on this.

Note that there are no requirements around bleeding postpartum in the use of Ecological Breastfeeding. So a woman who sees spotting or hormonal withdrawal/breakthrough bleeding in cycle 0 is not “disqualified” from Ecological breastfeeding in the way a woman using LAM is.

Ecological breastfeeding is designed to extend the time of postpartum infertility, which may continue despite spotting or hormonal bleeding in cycle 0. But because such bleeding indicates possible ovarian activity, and a possible return to fertility, in LAM it is a cut-off point for using it as a family planning method. So, these two approaches are different, even though they are both focused on breastfeeding as a natural inhibitor of fertility.

Mikayla Dalton LAM Ecological Breastfeeding ExpertMikayla Dalton is a childbirth educator and certified FABM instructor in the Boston Cross Check method, which includes urine hormone tests, cervical mucus and basal body temperature tracking in its observational toolbox. She's been working as a FABM educator since 2011, and specializes in the postpartum & breastfeeding phases of use as that's a time many women find more difficult to navigate. She's also a femtech geek whose husband once commented that she looked like the Borg Queen with all her fertility charting wearables on, and her bathroom sometimes resembles a lab. This blog post originally appeared on Fig Leaf Fertility.

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