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A precious opportunity: supporting women with concerns about their breastmilk supply.

Plants in the form of foods and herbal preparations have been ingested to aid lactation across continents for many centuries (Bruckner 1993, Dioscorides 64CE, Salmon 1710). Within a contemporary context, many women continue to seek out herbal solutions when they are concerned about their milk supply. This therapeutic encounter can be a precious opportunity to provide breastfeeding support and protect the breastfeeding relationship, as perceived insufficient milk supply is one of the most common reasons for premature cessation of breastfeeding (Colin 2002, Gatti 2008). Premature cessation of breastfeeding is associated with many health risks to mothers and babies. Hence the herbalist requires a comprehensive understanding of lactation and the capacity to co-manage with a team of practitioners and support services to enable them to provide the best care for women who have concerns about their milk supply. Herbal galactagogues have the potential to add to the comprehensive management of lactation insufficiency. This review will discuss the causes of lactational insufficiency and explore the use of galactagogues within this context.

Background

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

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.

Conclusion

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.

Resources

Australian Breastfeeding Association--information and support service providing peer support to mothers and health professional continuing education. Helpline 1800 686 268: https://www.breastfeeding.asn.au/

Humphrey S. 2003. The Nursing Mothers Herbal. Fairview Press, Minnesota: ISBN-10: 1-57749-118-1

Humphrey S. 2010. Breastfeeding and Botanical Medicine. In Romm, A. Botanical Medicine for Women, Churchill Livingston 978-0-443-07277-2

International Lactation Consultant Association. http:// www.ilca.org/i4a/pages/index.cfm?pageid=3432

Find a certified lactation consultant: http://www. alca.asn.au/4059/Find_a_Consultant/Find_a_Lactation_ Consultant/

World Health Organisation. Infant and Young Child Feeding: Model Chapter for Medical Students and Allied Health Professionals. WHO 2009. Available: http:// whqlibdoc.who.int/publications/2009/9789241597494_ eng.pdf

West D, Marasco L. 2009. The Breastfeeding Mother's Guide to Making More Milk. McGraw-Hill 978-0-07159857-6.

Health-e-learning Breast Ed courses--online courses for health professionals: http://www.health-e-learning. com/courses/breasted

International Breastfeeding Centre--information on lactation aids and many other resources: http://www.nbci. ca/index.php?option=com_content&id=25:lactation-aid&Itemid=17

Acknowledgments

Many thanks to Viola Hemm for her help translating the V. agnus-castus study Mohr H. 1954. [Clinical studies in increase of lactation]. Dtsch Med Wochenschr, 7P:41;1513-6. doi: 10.1055/s-0028-1119903

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Dawn Whitten

Goulds Naturopathica, Hobart, Tasmania

Email: dawn.whitten@gmail.com
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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Geographic Code:8AUTA
Date:Sep 1, 2013
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