A precious opportunity: supporting women with concerns about their breastmilk supply.
Premature cessation of breastfeeding is associated with numerous health risks for mothers and children in both economically-advantaged and disadvantaged countries (see Table 1). By protecting the breastfeeding relationship the child and mother are protected from numerous acute and chronic diseases as well as mental health problems. Health professionals' knowledge of breastfeeding and the degree of support and encouragement they provide are key factors determining a mother's decision to initiate and continue breastfeeding (Feldman-Winter 2010, Labarere 2005). Some have argued that health professionals have a duty of care to ensure parents are informed of the potential risks associated with premature cessation of breastfeeding (Miracle 2007). Ensuring adequate breastfeeding support and sensitivity with the way this information is communicated are obvious co-requirements.
Data collected over the last decade showing that premature cessation and insufficient exclusive breastfeeding are associated with increased risk of child mortality, severe infection and hospitalisation in countries such as Australia, the United Kingdom and the United States of America has dispelled the myth that insufficient breastfeeding is only life-threatening in developing countries (Bartick 2010, Chen 2004, Ladomenou 2010, Ma 2013, Quigley 2007, Smith 2002).
The World Health Organisation (WHO) recommends six months exclusive breastfeeding, followed by continued breastfeeding for at least two years. Exclusive breastfeeding means oral ingestion of only breastmilk with the exception of required medications. No water, juices, breastmilk substitutes or solid foods are given (WHO 2009). The WHO estimates that globally only 38% of infants are exclusively breastfed for six months (WHO 2013). Data from the 2011-2012 national health survey indicates that only 17.6% of Australian babies were exclusively breastfed for six months with only 38.6% being exclusively breastfed for four months (49.8% of babies 6 to 9 months were receiving no breastmilk). Further, only 13.4% of children were still receiving breastmilk after their 12 month birthday and less than 5% were still receiving any breastmilk at 24 months (ABS 2013).
Distinguishing True Lactation Insufficiency from Perceived Lactation Insufficiency
Careful history and assessment is required to distinguish true lactation insufficiency from perceived insufficiency. Many women will assume there are problems with their milk supply when their baby is unsettled and/or cries, when their baby wants to feed more often, when their baby wakes more frequently in the night, when their breasts feel smaller or softer, and/or when minimal milk can be expressed (Amir 2006). While some of these things may be present when milk supply is low, none of these signs is a clear indicator of low milk supply. Some of these factors may be present when babies are unwell, in pain, and/or in a period of accelerated growth. Changes in breast fullness are often associated with the normal change, from oversupply to supply matching the need of the baby that frequently occurs when the baby is 2-4 months old. The milk ejection reflex (MER) is often reduced for a pump, so pumped milk volume often does not represent milk available to a breastfeeding baby.
Unfortunately inappropriate management of perceived lactation insufficiency often leads to true lactation insufficiency. For example, concern about milk supply will often lead to the use of supplementary artificial feeds (Gatti 2008). Giving supplementary feeds satiates the baby so the baby takes less milk from the breast and consequently breastmilk production declines (Riordan 2010). When the supplement is given in a bottle exposure to the artificial teat often leads to nipple confusion resulting in breast refusal, which further compounds the problem.
When responding to a mother's concern about milk supply it is important to understand why she feels her milk supply is low, and to find out key information to assess her individual case. Firstly it needs to be determined if her baby is receiving sufficient milk, through careful assessment of the baby's stool and urination history, as well as assessment of growth and development (see Table 2). How often and for how long is her baby feeding? Is her baby having night feeds (which are important for maintaining supply)? Has she seen a qualified and experienced lactation consultant? Has there been an assessment of the baby's latch and other baby-related health issues (such as tongue-tie) that may impact milk transfer?
Table 3 gives a summary of the possible causes of lactation insufficiency. In the case of true low milk supply all efforts to avoid exposing the baby to artificial teats should be made. In most cases any necessary supplementation can be administered via a lactation aid which allows babies to receive this additional milk at the breast, keeping them accustomed to receiving milk at the breast and ensuring some breast stimulation. Cup feeding is another method used that avoids the use of artificial teats (WHO 2009). When supplementary feeds have been deemed necessary, it is important that strategies are in place to resolve breastfeeding challenges, improve maternal milk supply and phase out supplementation whenever possible. All health professionals should be aware of the WHO's order of preferences for supplementary feeds. The first preference is the mother's own expressed breastmilk, the second is donor milk (screened and from a well-known trusted source or a milk bank), and finally, only when these options are not available is the third preference, using an artificial breastmilk substitute, acceptable (WHO 2009).
Maintenance of good milk supply
Maintaining good milk supply is dependent upon adequate removal of milk from the breast and adequate stimulation of the breast. This means frequent breastfeeds of adequate duration (and/or frequent expressing) with effective milk transfer. The breasts are under autocrine control so the rate of milk synthesis is directly affected by the rate of milk removal. The baby's latch needs to be effective to ensure adequate milk transfer. When milk remains in the breast milk synthesis inhibitory factors accumulate and decrease milk synthesis. Removal of milk from the breast removes these inhibitors thereby causing accelerated milk synthesis (Riordan 2010).
Storage capacity varies enormously between women. In a small study, Daly et al., found that breastmilk storage capacity varied from 192 to 787ml, however daily breastmilk production from women with different storage capacities was similar (Daly 1993). Women with smaller storage capacities fed their infants more frequently and milk synthesis was more rapid. This illustrates the individuality of the mother-baby dyad. Women with smaller storage capacity will need to feed more frequently to deliver the quantity of milk needed to meet their baby's needs. The mother-baby dyad is dependent on responsiveness to feeding cues (see Table 4). It is important to remember that crying is a late hunger cue which often hinders effective feeding due to the effects of exhaustion and elevated stress hormones (Riordan 2010).
How to increase supply
It is vital that the two most common reasons for insufficient milk intake and low supply are addressed. These being:
* Inadequate feeding frequency and feeding duration which commonly occur: with scheduled feeding; when feeds are terminated before the baby lets go (reduces access to caloric-dense hind milk); when breastmilk substitutes are given; or when babies are drowsy due to prematurity, illness, birth medications or exhaustive hunger crying.
* Poor latch and associated ineffective milk transfer is a commonly overlooked hindrance to supply. Hence assessment of latch by an experienced lactation consultant or breastfeeding counsellor is essential for all women with suspected low milk supply (Amir 2006, Riordan 2010).
Maximising skin-to-skin contact is also important (Riordan 2010). This can be encouraged by suggesting bath breastfeeds and cosy topless time with baby. When low supply is suspected, offering both breasts at each feed will ensure that breastmilk synthesis inhibitors are drained from both breasts.
Importance of appropriate referral
The importance of referring women who are having breastfeeding difficulties to experienced certified lactation consultants and breastfeeding support services cannot be emphasised enough (see Resources at the end of this article). When challenges are addressed and resolved quickly, breastfeeding is most likely to continue. In some cases a team approach, including the involvement of a paediatrician, paediatric speech therapist, lactation consultant, and naturopath/herbalist may be indicated. The team approach works well when practitioners are aware of their area of expertise and their limitations. One of the factors hindering effective health-professional support of breastfeeding women is the contradictory advice they receive, especially from practitioners with inadequate training in lactation physiology (Hauck 2010).
Herbal galactagogues may be used to help support milk supply. It is essential to continue to address all factors that may be impacting milk supply and specifically ensure there is frequent effective removal of milk from the breast and that the breasts are receiving adequate stimulation. Without these measures herbal galactagogues are likely to have limited impact.
Information on how herbal galactagogues work is of a preliminary nature and there are multiple theories. Tables 5 and 6 list some commonly prescribed herbal galactagogues mostly from the Western herbal materia medica. For more information on the clinical trial data for herbal galactagogues a recent systematic review is available (Mortel 2013). Table 7 provides some information on some potential anti-galactogogues.
Possible mechanisms for herbal galactagogue action include (Abascal 2008, Bruckner 1993, Humphrey 2003, Marasco 2009):
* Enhancing prolactin levels through dopamine receptor antagonism in the same way that the pharmaceutical galactagogues domperidone and metoclopramide appear to work (Capasso et al. 2009).
* Modulation of other hormone receptors, affecting sensitivity to insulin, progesterone and oestrogens (Luecha 2009).
* Reducing lactation-interfering hormone imbalances such as hyperandrogenism.
* Directly increasing the amount of functional breast tissue.
* Positively influencing infant feeding behaviour through altering the taste or exerting carminative actions via constituents transferred to the breastmilk.
* Diaphoretic action based on the concept of the mammary alveoli being a modified sweat gland.
* Improving mammary blood flow.
* Exerting anxiolytic and thymoleptic actions which may support the improvement of breastfeeding confidence and allow effective milk ejection reflex and prolactin response by reducing inhibitory stress hormones.
Nervine actions may be particularly important for breastfeeding mothers as anxiety and depression frequently occur in this population; ironically worry about milk supply may in itself inhibit MER and over time lead to poor milk supply. Education on breast physiology and the use of relaxation techniques, particularly while feeding, may be useful for some women.
Individualising herbal galactagogue treatment allows herbal treatment to be tailored to suit the woman's situation and improve efficacy. For example, the herbalist may include galactagogue herbs:
* with nervine properties when stress is suspected to be a significant factor
* directed at increasing functional breast tissue when lack of glandular tissue is suspectedwith hormonal-balancing effects when conditions such as hypothyroidism or PCOS are present
* that improve insulin sensitivity when impaired glucose tolerance is suspected
Common problems with galactagogue clinical trial methodology
While there are a growing number of small clinical trials assessing the efficacy of herbal galactagogues, the results of these studies need to be assessed cautiously. Many studies have methodological limitations (ABM 2011, Anderson 2007, Mortel 2013). Common problems with clinical trials assessing galactagogues include:
* inadequate control for other factors that influence milk production such as: access to breastfeeding support, feeding frequency, birth interventions, maternal hormonal factors, pre-term and late pre-term birth, parity, past breastfeeding experience, use of breastmilk substitutes, and infant-related challenges affecting breastmilk removal
* lack of clear and or acceptable definitions of diagnostic labels such as lactational insufficiency and delayed lactogenesis
* difficulties with determining a reliable endpoint variable with which to measure that accurately reflects breastmilk production, for example: expressed breastmilk volumes do not necessarily represent the milk volume available in the breast; assessment based on infant weights may not reflect the amount of milk available in the breast especially when infant-related challenges exist; and use of percentage increase rather than milk volume absolutes can be misleading if daily milk volumes are small
* poor description of herbal extract characteristics and dosage, and failure to confirm the botanical identity and quality of the study herb material
* general methodological limitations such as inadequate randomisation, allocation concealment and control measures
In addition to attending to the points listed above, studies investigating the efficacy of galactagogues need to ensure that all participants receive consistent, high quality breastfeeding management and support (Anderson 2007) and that clinically relevant outcomes such as short-and long-term infant growth, need for supplementation and breastfeeding duration are measured (ABM 2011, National Library of Medicine. 2012a).
Considerations for galactagogue dosage forms (tinctures, herbal teas and solid dosage forms)
A number of factors may affect the dosage form selected by herbalists including: safety, affordability, quality issues, ability to individualise the prescription and convenience for the patient.
Herbal tinctures allow for individualised prescriptions and are relatively convenient for the patient. However the consequence of exposing mothers and babies to alcohol needs to be considered. Maternal blood alcohol levels achieved from approximately 1.5 standard drinks can disrupt the feeding and sleeping patterns of breastfeeding infants and inhibit the MER (by inhibiting oxytocin release from the pituitary) (Giglia 2010, Mennella 2001). Repeated intake may impair milk supply by reducing milk removal.
The alcohol delivered in a 5ml dose of tincture will vary according to the prescription. A 5ml dose of a 50% alcohol tincture will contain approximately 2g of alcohol (assuming a specific gravity of 0.8) and deliver approximately 20% of a standard drink. By comparison a 10ml dose of a 65% alcohol tincture would deliver approximately 56% of a standard drink. Some mothers may be consuming alcoholic beverages and so tinctures then represent an additional source of alcohol. And some mothers may take more than the recommended dose of prescribed tinctures.
Box 1. Further discussion of Vitex agnus-castus Opinion is divided in relation to the effect of V. agnus-castus (VAC) on lactation, with some authors cautioning against its use and others proposing that low dose VAC may have some benefit, particularly for a subgroup of women. Two older studies are sometimes cited in support of low dose VAC having a galactagogue effect (Weiss 1956). The methodology of these studies has been criticised (National Library of Medicine 2013b, Humphrey 2010). One of the studies appeared to be an unblinded case series, the findings being unclear (National Library of Medicine 2013b). The other study (Mohr 1954) was an inadequately blinded study (n=817) that appeared to correlate VAC (as Agnolyt, Madaus equivalent to approx. 180mg of dried fruit) with greater milk production at 20 days postpartum. The milk volumes reported in the study were however very small, 430ml versus 275ml, suggesting that some of the infants were receiving supplemental formula, which would be a major confounding factor. It would also appear that women in the VAC group may have had lower milk production on days 1 to 3, and a return of menses during the early postpartum period. Some authors propose that the effect of VAC on prolactin may be dose-related. This is based on the findings of a study conducted on healthy men, that found a lower dose (120mg) of a concentrated extract BP1095E1 (16:1 extract; solvent not identified) was associated with prolactin-promoting effects while a higher dose of this same extract (480mg) was associated with prolactin-suppressing effects (Merz 1996). This study does provide an interesting proposition for a u-shaped effect; however two other studies and two case reports detail findings consistent with prolactin suppression in women associated with relatively low-dose VAC extracts. Forty women with hyperprolactinaemia received either 3 months treatment with Agnucaston (3.2mg-4.8mg extract equivalent to 40mg dried VAC) or bromocriptine (a dopamine agonist). Prolactin levels dropped by 44% in the Agnucaston group and 51% in the bromocriptine group, with no significant difference between these treatments (Kilicdag 2004). Another study (n=52) investigated the effects of a VAC extract (Strontan, 3mg of a 10-16:1 ethanolic extract, equivalent to 20mg dried VAC) on women with latent hyperprolactinaemia and found that 3 months' treatment was associated with decreased prolactin release in response to thyroid-releasing hormone (Milewicz 1993). Two case reports (Tamagno 2007, National Library of Medicine 2013b, Gallagher 2008) reported prolactin reduction by 27% after three months treatment with liquid extract of VAC in women with hyperprolactanaemia. The daily dose described in one of these cases was 15 drops of a 1:10 tincture. The potential hormonal actions of VAC promoting progesterone and suppressing prolactin levels (Milewicz 1993) prompt careful consideration of its possible impact on lactation. According to current concepts in lactation physiology, once lactation is established, prolactin's role is permissive rather regulatory, and progesterone no longer suppresses lactation (Riordan 2010), or at least not to the same extent as it does in early lactation. Consequently, the hormonal effects of VAC may be less likely to cause low supply in established lactation and the cautious prescription of this herb may be appropriate in some instances. Further, in the years preceding conception VAC may play a role in preventing lactational insufficiency in women with luteal phase defects, as it is understood that healthy luteal-phase progesterone levels are important for breast development (Robinson 2000, Arbour 2013). However suppression of prolactin and progesterone promotion are likely to have a negative effect on breastmilk production in early lactation and are unlikely to assist with low supply in established lactation. Hence it would appear prudent to avoid this herb in women with low supply and particularly during early lactation. Additionally it is plausible that VAC use during pregnancy (especially the 2nd half) may negatively impact the functional breast development that occurs in part in response to high circulating prolactin.
Alcohol enters (and exits) breastmilk via passive diffusion, entering the breastmilk 30 to 60 minutes following ingestion. It takes approximately two hours to clear one standard drink (10g of alcohol) from the breastmilk.
To what extent lower doses of alcohol, consistent with typical tincture prescriptions, exhibit the detrimental effects discussed above is unclear. According to Burd et al (2012), newborns metabolize alcohol at 80% the rate of adults, suggesting that alcohol accumulation is only likely with frequent dosing with higher-end doses of tinctures. However, there may be inter-individual alcohol-metabolism variability and other factors at play, so the potential for alcohol accumulation needs to be considered.
Alcohol exposure can be reduced by: using a lower dose, a low dosing frequency, and by suggesting mothers take their tincture just after feeding. However any instructions on the timing of the dose in relation to breastfeeding need to be given cautiously as delaying breastfeeding will have a negative effect on breastmilk supply. Additionally a therapeutic dose of herbal galactagogues needs to be obtained.
Herbal teas and decoctions have economic advantages, allow for individualisation and are alcohol-free, but may not appeal to some patients due to their taste and preparation requirements. Some of these factors can be overcome through suggesting practical solutions such as making a large batch of tea to be drunk over the course of one or two days, and careful formulation for palatability. In terms of gram equivalent, the dose of herb required to ensure efficacy of the aqueous preparations is often greater than that required for tincture or solid doses. While they are convenient and alcohol-free, solid dosage forms do not allow for individualized prescriptions and it may be difficult to evaluate the quality of the extracts they contain.
A note on relactation
Many women and health workers are not aware that relactation is possible. Relactation is the recommencement of lactation months or even years after breastfeeding has ceased (Marquis 1998, Seema 1997). Relactation requires regular stimulation of the breast and the support from family and health workers. Relactation is usually easier when less time has elapsed since previous lactation. Adoptive lactation (also called induced lactation) is also possible, where a woman who has never before lactated can stimulate the production of milk (ABM 2011, Gribble 2004, Szucs 2010). This also requires regular stimulation and sometimes the assistance of hormonal medications and galactagogues.
While herbal galactagogues can play an important part in supporting women with breastmilk supply issues, it may be the knowledge, attitude, support and referral skills of the herbalist that make the biggest difference to their patients' breastfeeding outcomes. Herbalists, like other health professionals, can play a pivotal role in determining women's likelihood of initiating and continuing to breastfeed. Health professionals' knowledge of lactation physiology; the risks associated with premature breastfeeding cessation and their ability to refer women to specialised practitioners and breastfeeding peer support groups are all key determinants in the successful promotion of breastfeeding.
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Table 1: Risks associated with insufficient breastfeeding for mothers and children (based mostly on data from economically advantaged countries such as Australia, USA, Germany, and the UK) Child Child mortality (all causes) (Bartick 2010, Chen 2004, Ma 2013) SIDS (Byard 2013, Vennemann 2009) Hospitalisation (Quigley 2007, Smith 2002) Lower respiratory tract infection (Quigley 2007) Gastroenteritis (Ma 2013, Quigley 2007) Otitis media (Sabirov 2009) Urinary tract infection (McNiel 2010) Inflammatory bowel disease (Gearry 2010) Coeliac disease (Akobeng 2006, Radlovic 2010) Childhood leukaemia (Bener 2008, Smith 2010) Necrotising enterocolitis (Quigley et al., 2007a; Henderson et al., 2009; Lambert et al., 2007) Maternal child abuse & neglect (Strathearn 2009) Child & adolescent mental health problems (Oddy 2010) ADHD (Chapman 2012) Developmental delay (Quigley 2012, Sacker 2006) Reduced IQ (Kafouri 2013) Depression in adulthood (Peus 2012) Obesity (Shi 2013, Smith 2010) Cardiovascular disease (Ravelli 2000, Smith 2010) Diabetes Type 1&2 (Owen 2006, Patelarou 2012, Taylor 2005) Dental malocclusion (Kobayashi 2010, Sanchez-Molins 2010) Mother Postpartum anaemia (Bodnar 2002, Rioux 2006) Increased anxiety and depression (in mothers with pre-existing postpartum depression and anxiety) (Ystrom 2012) Longer duration gives greater protection against: Ovarian cancer (Danforth 2007, Jordan 2010, Titus-Ernstoff 2010) Breast cancer (Shinde 2010, Stuebe 2009) Vascular calcification (Schwarz 2010) Myocardial infarction (Stuebe 2009) Type 2 diabetes (Schwarz 2010, Stuebe 2005) Metabolic syndrome (Gunderson 2010, Gunderson 2007, Schwarz 2009) Osteoporosis (Chapman 2012, Schnatz 2010, Stuebe 2009) Rheumatoid arthritis (Karlson 2004, Pikwer 2009) Table 2: Signs of insufficient milk intake by baby * Less than 3 stools/day in babies 4 days old or more * after 4-6 wks. not reliable--stool frequency varies Less than 6 wet nappies per day in babies 6 days old or more (less than 5 very wet disposables) * strong odour and or yellow staining Persistent/increasingly painful nipples * pain while breastfeeding Pinched or misshapen nipple immediately after feeding (not so easy to assess--refer to Lactation Consultant) No audible or visible swallowing from the baby (sometimes difficult to assess--refer to Lactation Consultant) Slow weight gain or weight loss * Equal to or greater than 7% weight loss over the first week post birth indicates a need for careful assessment of the breastfeeding dyad and could indicate insufficient breastmilk intake (ABM 2009). Noel-Weiss et al, have suggested that baseline birth weights are better assessed 24 hours post birth to allow initial fluid loss (Noel-Weiss 2011). They found that higher urinary output was associated with greater weight loss over this 24-hour period indicating that weight loss in the first 24 hours is not an accurate indication of intake. Further, increased maternal I.V. fluid may be a factor influencing 24 hour weight loss (Okumus 2011). Weight loss after 24 hours correlates more closely with poor intake. * Not regaining birth weight by 2 weeks. * Weight crossing percentiles downward in first 3 months (it can be normal to cross percentiles downwards after 3 months of age); flat growth curve at any age. Note: breastfed babies should be assessed according to the WHO growth charts which have been constructed using data from babies fed according to the WHO recommendations. Multiple measurements spaced adequately in time are needed to obtain useful data (Riordan 2010). * Weight loss may be due to illness (if this is the case, prescription of breastmilk substitutes will expose the baby to further illness risk). * Caution: weighing errors are very common and occur with poor weighing technique, use of different scales, scale faults and varying timing of weighing--for example in relation to bowel movement or large void. (Sachs 2005). With overly frequent weighing there is a risk that variations do not reflect true weight change. Adapted from (Hurst 2007) *Referral to an International Board Certified Lactation Consultant and other relevant health professionals is recommended if any of these signs are observed; Table 3: Causes of lactation insufficiency Poor lactation Early postpartum care: management * separation of mother and baby (most common) * lack of skin-to-skin contact * delayed 1st feed; decreased frequency of feeds * supplementary feeds given Ongoing care: * scheduled feeds (not frequent or long enough) * not feeding according to babies cues * supplementary feeds given * lack of appropriate support to identify and resolve challenges Infant-related * Poor latch challenges * poor early lactation management (common) * cleft palate * tongue tie (ankyloglossia) and top-lip-tie * prematurity (and late pre-term birth) * Down's syndrome * neurological issues and lower motor-tone sedation consequences to drugs used during labour * Heart defect Hormonal or * Effect of birth interventions drug effects * including sedation of infant (see above) (less common) * effects to mother: including stress and altered oxytocin response (these effects are compounded if mother and baby separated and deprived of skin-to-skin contact * Thyroid disease * Insulin resistance (polycystic ovary syndrome (PCOS), gestational diabetes, diabetes mellitus) * [up arrow] Progesterone (retained placenta; contraceptives; pregnancy) * [up arrow] Glucocorticoids (stressful labour; administered in premature labour; administered to treat asthma during pregnancy) * Obesity (may lower prolactin response; may also impact latch) * Pituitary disease (uterine haemorrhage pituitary shock) * Other drugs (progestins, oestrogens, alcohol, nicotine, pseudoephedrine, dopamine agonists) Structural * Insufficient glandular tissue, previously (unusual) estimated to occur in 0.01% of women *, may be on the rise due to an increase in hormone-related factors. Many women who receive poor breastfeeding management are erroneously told they have insufficient glandular tissue. * Nipple abnormality Structural due * Severed 4th intercostal nerve (interferes with to surgery or milk ejection reflex) trauma * Breast reduction and augmentation (may affect supply--but with appropriate support many women successfully breastfeed) (Amir 2006, Riordan 2010) *Many texts incorrectly quote a figure of 5% referencing a 1938 BMJ article, or a secondary reference originating from this source (Riordan 2010). However in this article the 5% figure includes cleft palate and other infant-related challenges that hinder lactation success (Spence 1938). With the rise in the use of assisted reproductive technology (ART), there is the potential for an associated rise in the incidence of true insufficient glandular tissue, as some health conditions that pose as fertility obstacles are associated with insufficient glandular tissue. However one recent study found that many of the determinants of poor breastfeeding outcomes in a population of ART users were modifiable and could be overcome by ensuring consistent breastfeeding advice (Hammarberg 2011). Table 4: Infant feeding cues Early cues Change in breathing pattern Opening and closing mouth Stirring Turning head Seeking/ Rooting Mid cues Stretching Increased physical movement Hand to mouth Late cues Crying Agitated movements Turning red Adapted from (Riordan 2010) Table 5: Information on some core herbal galactagogues from the Western herbal materia medica Core Actions * / Daily Dosage Traditional Galactagogues suggestion/ Cautions Information Pimpinella Actions that may There are many anisum support galactagogue references to the (aniseed) effect: use of F. vulgare Carminative in traditional texts Foeniculum Selective Oestrogen (Bruckner 1993, Cook vulgare** Receptor Modulator? 1869, Dioscorides (fennel) May increase functional 64CE, Lloyd 1808): breast tissue F. vulgare references: Daily dosage Decocted in barley suggestions: water to "draw down 5-30g crushed seed as the milk" (Dioscorides infusion (higher end of 64CE). dosage when used as a "From a very early simple) period of medical 6-8ml of a 1:2 tincture history, fennel seed in divided doses has been credited (weekly dose 40-60ml) with the power Cautions: of increasing the Internal use of the secretion of milk, essential oils of either of (galactagogue.) these herbs may not be ... leading physicians of safe during lactation due many countries ascribe to the presence of the to it excellent power potential toxin estragole. in this direction. The Infusions of F. vulgare infusion of the seed seed within the may be used without recommended dosage limitation." (Cook range are unlikely 1869) to deliver excessive "The leaves or seed amounts of estragole boiled in barley water (Raffo 2011). Additionally and drank are good there is some evidence for nurses, to increase that other constituents their milk and make it present in F. vulgare more wholesome for infusions may inactivate the child." (Culpeper estragole (Gori 2012). 1653). P. anisum may P. anisum references: occasionally be Aniseed cookies substituted with the are a traditional gift potentially toxic Illicum for new mothers in anisatum (Japanese star the Netherlands to anise). ensure "bountiful milk" (Humphrey, 2003). "breeds milk" (Salmon 1710). Trigonella Actions that may support Reportedly used foenum- galactagogue effect: in ancient Egypt graecum Demulcent as a galactagogue (fenugreek) Diaphoretic (Toppo 2009). Nutritive There are Hypoglycaemic (depending ethnobotanical on dose and delivery) references to Daily dosage suggestions: its use as a 3.5-10g ground seed galactagogue in ingested Sudan, Africa, 15-40g whole seed as Iraq, Egypt, and infusion (less if seed Argentina (Bingel crushed or ground) 1991). 6-10ml of a 1:2 tincture in divided doses (weekly dose 40-70ml) Cautions: Possible peanut and other Fabaceae allergen cross sensitivity (ABM 2011, Faste 2009) Rodent study suggests fenugreek may reduce conversion of thyroid hormone T4 to T3 (Panda 1999) Monitor blood glucose levels in patients taking hypoglycaemic agents, herb may have an additive effect (Note: this only applies with the ingestion of high doses of the ground seed). Diarrhoea and maple syrup odour of sweat and urine are the most common reported adverse effects (ABM 2011). Huggins (Accessed 2011), who reportedly has experience with more than 1200 lactating women using fenugreek, reports: * observing two or three cases of diarrhoea resolved with reduced dose or discontinuation of herb * two asthmatic mothers reported aggravated asthma symptoms * no reported side effects in infants. Both Marasco and Humphrey report occasional diarrhoea in infants that resolves with discontinuation of the tea (Humphrey 2003, Marasco 2009). Silybum Actions that may Mary's milk said to marianum support galactagogue have splashed on the (St Mary's effect: leaves. thistle, May improve insulin Traditionally seen variegated sensitivity (Suksomboon as a food for thistle) 2011) breastfeeding Hepatoprotective mothers the whole Daily dosage plant being boiled suggestions: after the spikes were >420mg silymarin (Di removed (Grieve Pierro 2008) 1931). Ingestion of 15g of ground seed the whole herb would ingested have facilitated the Extrapolating from absorption of actives absorption studies on with poor water- phospholipid silymarin solubility. preparations (Abrol 2005, Song 2008), suggests a potential for co-prescription of lecithin to improve bioavailability of silymarin from the ground seeds. Cautions: Asteraceae allergymonitor blood glucose levels in patients taking hypoglycaemic agents, herb may have an additive effect Galega Actions that may support Several references to officinalis galactagogue effect: its traditional use as (goats Rue) Diaphoretic a galactagogue on May improve insulin goats and cows in sensitivity France (Bruckner 1993, May increase functional Remington 1918, Sayre breast tissue 1917) Daily dosage suggestions: Suggested root for Recommendations vary: Galega from Greek: 5-30g/day of the dried Gala = milk, agein = to leaves and flowers given as drive (Bruckner 1993). infusion "stimulate the 6-10ml of a 1:2 tincture in lactiferous vessels to divided doses (weekly dose an increased secretion 40-70ml) during the period of Note: this herb is subject lactation" (Lloyd 1898), to quality issues which though this is followed can have marked effect on by a reference to its efficacy (author's clinical lack of use at the time. observation). Ensure high quality starting material with at least good organoleptic indicators of quality and a low proportion of stem. Cautions: Humphrey (2003) cautions against use of the fresh plant. Monitor blood glucose levels in patients taking hypoglycaemic agents; herb may have an additive effect. Verbena Actions that may support "a remedy for sore officinalis galactagogue effect: breasts" (Culpeper (vervain) Thymoleptic 1653). Nutritive Daily dosage suggestions: 5-10g as infusion (bitter) 3-7ml of a 1:2 tincture in divided doses (weekly dose 20-50) Cautions: None known Cnicus Actions that may support Referred to as a galac- benedictus galactagogue effect: tagogue by Sayre (1917) (blessed Thymoleptic in his USA Pharmacognosy thistle) Anxiolytic Text, where it also Digestive bitter tonic states that the cold Diaphoretic infusion is a bitter Emmenagogue (could tonic and the hot suggest oxytocic effect) infusion a diaphoretic Daily dosage suggestions: and emetic in larger 6g dried leaves as infusion doses. 3-8ml of a 1:2 tincture in Perhaps if the galacta- divided doses (weekly dose gogue effect is linked 20-55ml) to the diaphoretic action Infusions or tinctures may a hot infusion may be be more effective than more effective. solid dosage forms. "It slowly promotes Cautions: nearly all the Avoid in pregnancy, strong secretions" (Cook 1869) emmenagogue (Not sure if breastmilk is included in his list of secretions). According to Weed (1986), it is "Famed for its ability to increase milk supply" and it "... removes suicidal feelings and lifts depression". Core Contemporary Information Clinical Trial Data Galactagogues Pimpinella P. anisum and F. vulgare Two human studies anisum contain trans-anethole investigating herbal (aniseed) which has structural complexes containing similarity to dopamine fennel were found (see Foeniculum and is theorised to act below). Their bearing on vulgare** as a dopamine receptor the potential impact of (fennel) antagonist (Bruckner, 1993). fennel is limited. One study found F. vulgare One older unblinded leaf had considerably Bulgarian study (n=5) greater concentrations of observed an increase in trans-anethole and lower milk volume after 10 days concentrations of estragole treatment with a herbal than the fruit (Miguel formula containing fennel 2010). One report describes compared to baseline. four cases of premature Many details of the study thelarche and raised are unavailable (Nikolov oestrodial levels in chil- 1951) Via (National Lib- dren who had received F. rary of Medicine 2013a). vulgare tea (one five-month Turkyilmaz et al., com- old and three children under pared outcomes for women the age of 6). The dose and drinking Humana[R] tea, characteristics of the tea reported to contain were not supplied. Thelarche fennel extract (600mg per resolved and oestradiol essential oil (20mg per levels returned to normal day) as well as 6 other range 3 to 6 months after herbal ingredients and ceasing the tea (Turkyilmaz three nonherbal ingre- 2008). Further investiga- dients, to "apple tea" tion into the potential and no treatment (n=66). effect of F. vulgare on Humana[R] tea group had: serum oestrogen is * higher mean volume of warranted too. expressed breastmilk One small study found at 3 days postpartum lactating cows treated with 73.2ml compared to a combination of F. vulgare 38.8ml (apple tea) and and Nigella sativa seed 31.1ml (no tx), P<0.05 (information on dose and * lower mean infant weight preparation not available) loss in the first week had greater mean milk yield 5.7% compared to 6.6% compared to controls after 1 (apple tea) and 8.3% week (15.4%) and 24 days (no tx), P<0.05 (16.9%) treatment (P<0.003). * faster regain of their (Torabi Gudarzi 2008). birth weight 6.7 days compared to 7.3 days (apple tea) and 9.9 days (no tx), P<0.05 (Turkyilmaz 2011). Trigonella Huggins (Lactation Three small clinical foenum- Consultant claiming trials have delivered graecum to have observed the mixed results and had me- (fenugreek) response of 1200 women thodological limitations. over a 6 year period) In an open-label study reports that "nearly (n=10), the 24-hour mean all" women who took breastmilk volumes of fenugreek report an women after one increase in milk production no-treatment week were within 24-72 hours of compared to volumes after taking the herb. The one week of fenugreek dosage prescribed in her supplementation (1830mg clinic is 1200 to 1800mg of encapsulated ground seed encapsulated ground seed tds). Mean 24-hour tds. She recommends breastmilk volumes were discontinuation of herbal significantly greater treatment when milk after 1-week fenugreek production is at sufficient treatment (mean daily level and maintaining volume 464ml) compared to supply through adequate 1-week no-treatment breast stimulation and (207ml) P=0.004 (Swafford emptying of the breast. 2000). Of note is that the dosage Another study found no recommended by Huggins significant differences is greater than the dose in pump volume or that appears to have been prolactin levels between used in some of the small women given placebo or clinical studies. fenugreek (3 capsules of A survey of lactation unreported quantity/ consultants in the USA extract per day) for 21 found that 49% of days postpartum (Reeder the 124 respondents 2011). reported using fenugreek In a third study, two to "promote lactation" cycles of 30 day (Schaffir 2012). fenugreek treatment (600mg One small study on the of ground seed three effect of fenugreek on times daily) was compared lactating goats suggested to two other active that fenugreek treatment treatment arms Moloco+B12 increased growth (vitamin B12 and placenta hormone, growth hormone extract) or a traditional being one of the hormones Bataknese medicinal involved in lactation soup containing Coleus (Alamer 2005). amboinicus (syn. Plec- tranthus amboinicus). At no point was the 24-hour infant breastmilk intake of the fenugreek group different from that of the Moloco+B12. The 24-hour breastmilk intake of the infants in the traditional Bataknese soup group was signifi- cantly greater than both the other active treat- ments. (Damanik et al., 2006). One major limita- tion of this study (and possibly the study by Reeder) is the failure to use a dose that repre- sented clinical practice i.e. equal to or greater than 1200mg of encapsu- lated ground herb. Additionally one study (see above for descrip- tion of study on Humana[R] tea) reported to deliver a daily fenugreek dose of 300mg per day (National Library of Medicine 2011, Turkyilmaz 2011), a dose unlikely to contribute to the potential galactagogue effects of the tea. Silybum The galactagogue effect may One human placebo- marianum occur via dopamine receptor controlled study (St Mary's antagonism according to (randomised or thistle, (Capasso et al., 2009). investigator blinding variegated This is based on findings was not reported) thistle) of a rat study where 14-day investigated the effect treatment with micronized of 63 days treatment with silymarin extract BIO-C[R] micronized silymarin was associated with a dose extract BIO-C[R] 420mg dependent increase in serum per day on women prolactin levels. (n=50) diagnosed with The dopamine D2 receptor low milk supply, defined agonist bromocriptine given as producing less than at an oral dose of 1mg/kg 700ml breastmilk per significantly reduced the day (Di Pierro 2008). high serum prolactin levels Milk production was in the BIO-C[R] treated assessed over a 24-hour group. period by weighing The researchers propose infants before and after that dopamine D2 receptor feeding, and measuring antagonism may be at least milk pumped after each a partial mechanism for the feed to quantify milk effect of BIO-C[R] on retained in the breast. female rat prolactin levels. 24-hour breastmilk Another study (randomised production was assessed controlled) was conducted on day 0, 30 and 63. on 30 dairy cows treated After 30 with 10g of silymarin days the treatment group extract reported to contain had a mean observed 49.1% silybin (Tedesco 2004) increase in breastmilk From 10 days prior to ex- volume of 64.4% and pecting calving date until the placebo group of 15 days postpartum 15 of 30 22.5% (P<0.01). After cows were given silymarin 63 days the treatment extract. Treated cows and placebo group had reached their average a mean increase from lactation peak 1 week prior baseline of 85.9% and to control cows and main- 32.1% respectively tained a higher milk yield (P<0.01). throughout lactation. Milk yield of treated cows was greater than controls on day 21 and 30 by 14.6% and 15% respectively (P<0.05). Galega Three older studies were officinalis identified (Heiss 1968, (goats Rue) Nikolov 1951, Typl 1961) and due to language restrictions information was obtained from LactMed (National Library of Medicine 2012b). Many aspects pertaining to the quality of these studies were not available including information on breastfeeding support given and technique for measuring breastmilk production. Heise (1968) investigated the effect of 15ml of a 5% G. officinalis infusion given three times daily for 10 days followed by a 5-day control period on 5 breastfeeding mothers. No effect on milk volume or fat content was observed. The dose given in this study is quite unclear and information on blinding and randomistaion is not available. The study population is very small. Nikolov (1951) conducted an uncontrolled study on G. officinalis extract (dose and extract characteristics unavai- lable) given to 336 women whose milk production was thought to be lower than normal. Increased milk output of 30 to 60% was reported. Typl (1961) conducted an unblinded controlled study (n=100) of women given G. officinalis extract (dose and extract characteristics unavai- lable) or no treatment from day 3 to 5 postpar- tum. Milk output increased by 125% in the goats rue group and 75% in the no treatment group. According to LactMed (National Library of Medicine 2012b) the milk volumes varied widely and differences were not statistically significant. Verbena No studies identified. officinalis (vervain) Cnicus No studies identified. benedictus (blessed thistle) * Actions that may relate to or support its use as a galactagogue; ** Also consider other carminatives of the Apiaceae family such as Anethum graveolens (dill) and Coriandrum sativum (coriander); tx = treatment(Amir 2006, Riordan 2010) * Many texts incorrectly quote a figure of 5% referencing a 1938 BMJ article, or a secondary reference originating from this source (Riordan 2010). However in this article the 5% figure includes cleft palate and other infant-related challenges that hinder lactation success (Spence 1938). With the rise in the use of assisted reproductive technology (ART), there is the potential for an associated rise in the incidence of true insufficient glandular tissue, as some health conditions that pose as fertility obstacles are associated with insufficient glandular tissue. However one recent study found that many of the determinants of poor breastfeeding outcomes in a population of ART users were modifiable and could be overcome by ensuring consistent breastfeeding advice (Hammarberg 2011). Table 6: Supportive galactagogues Supportive galactagogues Specific information Urtica dioica (nettle) Nutritive Althaea officinalis Root Nutritive, moistening (marshmallow root) Medicago sativa (alfalfa) Nutritive Lavandula angustifolia Nervine, thymoleptic, carminative (lavender) May be useful when MER is diminished Chamomilla recutita (German Nervine, carminative chamomile) May be useful when MER is diminished Nepeta cataria (catnip) Nervine, thymoleptic May be useful when MER is diminished Asparagus racemosus Nervine, female reproductory tonic (shatavari) Note: A. racemosus considered endangered in its native habitat and is subject to over-harvesting pressures, in part due to its popularity in the west (Bopana 2007). Sustainable sources are available and market pressure from practitioners may provide an incentive for manufacturers to ensure the sustainability of their raw materials. Hibiscus sabdariffa (rosella) Diuretic, mild hypotensive Humulus lupulus (hops) Strong nervine traditionally used when MER impaired. Use low dose only (up to 1g per day in divided doses). Avoid over-sedating mother and baby. Rubus idaeus (raspberry leaf) Reported to have initial galactagogue effect followed by anti-galactagogue effect when used for longer than two weeks (Humphrey 2003). Postpartum uterine tonic, uterine astringent MER = milk ejection reflex (Bruckner, 1993; Humphrey, 2003; Humphrey, 2010) Table 7: Potential anti-galactagogues Herb Supporting information and potential mechanism Salvia officinalis (sage) Long consistent tradition of use as an anti-galactagogue Ephedra spp. (ephedra) Contains pseudoephedrine Anecdotal reports and one small clinical study indicate that the drug pseudoephedrine may suppress lactation, possibly in part through prolactin suppression (Aljazaf 2003) Mucuna pruriens Contains L-Dopa (Brauckmann 2010) (Velvet Bean) therefore may diminish prolactin release Vicia faba Contains L-Dopa (Brauckmann 2010) (broad bean, fava bean) therefore may diminish prolactin release Caution: A principal in V. faba can trigger haemolytic anaemia and hyperbilirubinaemia in babies with Glucose 6-phosphate dehydrogenase (G6PD) deficiency (Ahmed 2013, Riordan 2010). Mentha spp Low to moderate dose of Mentha spp. as (peppermint, spearmint) tea or extract is unlikely to cause anti- galactagogue effect. High dose peppermint and or use of the essential oil may have an anti-galactagogue effect. Some women have reported reduction in milk-supply after eating peppermint essential oil or menthol-containing candies and or using tooth pastes with these ingredients (Marasco 2009). Petroselinum crispum Traditionally seen as a herb/food that (parsley) lowers milk supply. Women report reduction in breastmilk supply after consuming large amounts such as would be obtained from eating tabouleh (Humphrey 2003). Small intake is unlikely to impact lactation. Culpeper discusses its use topically for engorgement (Culpeper 1653). Vitex agnus-castus Theoretical anti-galactagogue via (chaste Tree) dopaminergic action and potential to suppress prolactin (see Box 1). There is however, divided opinion amongst herbalists regarding its effect on lactation. There appears to be some traditional evidence for use (Dioscorides 64CE, Humphrey 2010). Caution: May cause early return of menses which may deprive mothers of some of the health benefits associated with lactational amenorrhea and also deprive them of delayed fertility. (Dugoua 2008, Humphrey 2003) Note: This is not an exhaustive list, some reactions may be idiosyncratic--observe for individual reactions to herbal preparations.
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|Publication:||Australian Journal of Herbal Medicine|
|Date:||Sep 1, 2013|
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