A critical review of pharmaceutical galactagogues

Motherhood after Spinal Cord Injury: Breastfeeding, Autonomic Dysreflexia, and Psychosocial Health: Clinical Practice Guidelines

The World Health Organization (WHO) recommends that children be breastfed exclusively for the first 6 months of age. This recommendation may prove challenging for women with spinal cord injury (SCI) who face unique challenges and barriers to breastfeeding due to the impact of SCI on mobility and physiology. Tailored provision of care from health care professionals (HCPs) is important in helping women navigate these potential barriers. Yet, HCPs often lack the confidence and SCI-specific knowledge to meet the needs of mothers with SCI. An international panel of clinicians, researchers, consultants, and women with lived experience was formed to create an accessible resource that can address this gap. A comprehensive survey on breastfeeding complications, challenges, resources, and quality of life of mothers with SCI was conducted, along with an environmental scan to evaluate existing postpartum guidelines and assess their relevance and usability as recommendations for breastfeeding after SCI. Building on this work, this article provides evidence-based recommendations for HCPs, including but not limited to general practitioners, obstetricians, pediatricians, physiatrists, lactation consultants, nurses, midwives, occupational therapists, and physiotherapists who work with prospective and current mothers with SCI.

Acupoint-tuina therapy promotes lactation in postpartum women with insufficient milk production who underwent caesarean sections

Breast milk is recognized and strongly recommended by the World Health Organization (WHO) as the optimal feeding for all babies. Breastfeeding is associated with better nutritional and non-nutritional outcomes when compared to formula feeding, and has proven health benefits to both infants and their mothers. This clinical research is to examine the feasibility and efficacy of Acupoint-Tuina therapy in treating postpartum women who underwent C-sections and suffered from insufficient milk production.The patients in the control group received standard medical care, while the patients in the Tuina group received Tuina therapy during the next 48 hours in addition to standard care, given once daily for 2 days. To evaluate the efficacy of Tuina therapy, patients of both groups were assessed for surface temperature of breasts, volume of breasts, volume of breast milk production, serum PRL level, and uterus recovery at various time points.Tuina therapy significantly increased the milk production when compared to the control group, for as much as 13-fold and 10-fold of that in the control group on the third and fourth postpartum days. In addition, Tuina therapy also significantly increased the full breast enlargement and the serum PRL level change, and decreased the breast surface temperature rise. Last but not the least, Tuina therapy also accelerated the post-surgery recovery of uterus.During the early postpartum days, Tuina therapy increases the milk production and promotes other physiological changes supporting lactation for postpartum women with C-section delivery and insufficient breast milk production. The novel intervention is warranted for further investigation and validation.

Breastfeeding: A Review of Its Physiology and Galactogogue Plants in View of Traditional Persian Medicine

INTRODUCTION

The beneficial effects of breastfeeding for the infant and mother are well recognized. Many natural products are reputed to be galactogogue agents in major Traditional Persian Medicine (TPM) textbooks. The aim of this study is to review those medicinal plants that are reported to be effective in increasing breast milk in TPM and to compare the data from TPM texts with the findings of modern pharmacological and clinical research.

MATERIALS AND METHODS

Data on the medicinal plants used to increase breast milk were obtained from major TPM textbooks. A detailed search in PubMed, Science Direct, Scopus, Google Scholar, and Web of Science databases was performed to confirm the effects of medicinal plants mentioned in TPM on lactation in view of the identified pharmacological actions.

RESULTS

Foeniculum vulgare, Anethum graveolens, Pimpinella anisum, Nigella sativa, and Vitex agnus-castus are among the most effective galactogogue TPM plants. Many pharmacologically relevant activities have been reported for these herbs.

CONCLUSION

The use of traditional knowledge can pave the way toward finding effective phytopharmaceuticals for increasing breast milk.

Maternal experiences with and sources of information on galactagogues to support lactation: a cross-sectional study

An increase in the marketing and use of herbal galactagogues among breastfeeding mothers in the US has raised the issue of how best to provide support and information on the use of these products, particularly in light of limited availability of certified lactation counselors and continued suboptimal rates of breastfeeding globally. Currently, no cross-sectional data are available on the experiences and attitudes of mothers regarding the use of herbal and pharmaceutical galactagogues for lactation in the US. The findings of an online survey of 188 breastfeeding mothers on experiences with and sources of information on galactagogues are presented. Most mothers (76%) reported that while breastfeeding, they felt as though they were not making enough milk to meet the needs of their child, and yet 54% also indicated that they had not supplemented with formula. A large proportion of respondents reported utilizing galactagogues to increase lactation and finding them useful. The results indicated that most women learned about galactagogues from the Internet or by word of mouth through friends. Lactation consultants were the third-most reported sources of information on these products. While many respondents reported perceiving galactagogues as innocuous, more evidence on safety and efficacy is needed to support women properly who seek out and use them. Large-scale studies of the prevalence of galactagogue use in the US and rigorous evaluation of use globally are needed to ensure that mothers who choose to breastfeed may safely avail themselves of all options when counseling support is insufficient.

Herbal Therapies and Social-Health Policies: Indigenous Ati Negrito Women's Dilemma and Reproductive Healthcare Transitions in the Philippines

The high maternal mortality in the Philippines in the past decades prompted intervention strategies to curb unwanted deaths of mothers and improve health and social conditions of women. Such introductions however have begun to challenge traditional reproductive health practices creating confusion among practitioners and incipient transitions in healthcare. Our aim in this study was to document the herbal therapies practiced by indigenous Ati Negrito women and discuss the implications of social and conventional healthcare intervention programs on reproductive healthcare traditions by conducting semistructured interviews. Fidelity Level index was used to determine culturally important plants (i.e., the most preferred). Review of related studies on most preferred plants and therapies was further carried out to provide information regarding their safety/efficacy (or otherwise). Determination of informants' traditional medicinal knowledge was done using Mann-Whitney U and Kruskal-Wallis tests. A total of 49 medicinal plants used in treating female reproductive health-related syndromes across four categories were recorded. Significant differences in traditional medicinal knowledge were recorded when informants were grouped according to age, education, and number of children. Issues discussed in this research could hopefully raise awareness on changes in healthcare practices in indigenous cultures and on medical safety especially when traditional and conventional medications interact.

The Use, Perceived Effectiveness and Safety of Herbal Galactagogues During Breastfeeding: A Qualitative Study

The World Health Organization recommends breastfeeding as the normal infant feeding method and that infants being breastfed should be regarded as the control group or norm reference in all instances. There are many factors which could contribute to a new mother ceasing breastfeeding early, with the most commonly reported reason being perceived insufficient breast milk supply. The use of herbal galactagogues is increasingly common worldwide. Literature review identified a need for more research in the area of herbal galactagogue use during breastfeeding. Twenty in-depth semi-structured interviews were undertaken with breastfeeding women who used herbal galactagogues, to document use and explore their perceived effectiveness and safety of herbal galactagogues. Several indicators of breastfeeding adequacy were mentioned as participants described their experiences with the use of herbal galactagogues. Confidence and self-empowerment emerged as an over-arching theme linked to positive experiences with the use of herbal galactagogues. Despite the lack of clinical trial data on the actual increase in measured volume of breast milk production, indicators of breastfeeding adequacy boosted participants’ confidence levels and resulted in psychological benefits. This study highlighted the importance of considering the potential psychological benefits of using herbal galactagogues, and how this translates into breastfeeding adequacy.

Predictors of sustained maternal milk feeds in extremely preterm infants

OBJECTIVE

To investigate the predictors of maternal milk feeds (MMFs) in extremely preterm (EPT) infants during neonatal stay.

STUDY DESIGN

Maternal characteristics, obstetrical data and infant characteristics were correlated to MMFs in 97 EPT infants during the first 6 weeks of life and at hospital discharge.

RESULT

High MMFs (>90%) at second week predicted sustained MMFs the first 6 weeks of life; nonuniversity education and non-Nordic origin were unfavorable predictors. The proportion of MMFs the first 6 weeks of life and maternal age were positively associated with MMFs at discharge, whereas overweight was an unfavorable predictor. High MMFs at second week, assisted reproduction technology and employment were predictive factors for exclusive MMFs at discharge.

CONCLUSION

High MMFs at week 2 promote sustained MMFs in EPT infants and exclusive MMFs at discharge. Mothers who are either young, overweight, non-Nordic or without university education may need special interventions to establish successful lactation.

Use of domperidone as a galactagogue drug: a systematic review of the benefit-risk ratio

Breastfeeding is the optimal method for feeding a newborn. However, some mothers may have difficulties lactating. Domperidone is widely used as a galactagogue but to the best of our knowledge has not been approved by any health authority. The objective of this review was to assess the benefit-risk ratio of domperidone for stimulating lactation. The benefit-risk ratio of domperidone as a galactagogue was assessed following a literature search of the PubMed database up to July 2013. Four studies were selected to assess domperidone efficacy and demonstrated an increased milk production. The limited data (60 mother-baby pairs) and the moderate methodological quality of 1 study remain insufficient to conclude on domperidone efficacy. Regarding the safety of domperidone, 7 studies were selected that exposed 113 infants to domperidone through breastfeeding. No adverse effects were observed in 85 infants, and no information was provided for the remaining 28. The limited data available remain in favor of a safe domperidone profile in infants and mothers. However, in large studies focused on gastrointestinal disorders, domperidone is responsible for drug-induced long QT syndrome and sudden cardiac death. The use of domperidone as a galactagogue is worrisome as drug-induced long QT syndrome occurred mostly in women. In these circumstances, an improvement of breastfeeding practices seems to be more effective and safer than the use of an off-label domperidone treatment.

Pharmacological overview of galactogogues

Galactogogues are substances used to induce, maintain, and increase milk production, both in human clinical conditions (like noninfectious agalactias and hypogalactias) and in massification of production in the animal dairy industry. This paper aims to report the state of the art on the possible mechanisms of action, effectiveness, and side effects of galactogogues, including potential uses in veterinary and human medicine. The knowledge gaps in veterinary clinical practice use of galactogogues, especially in the standardization of the lactogenic dose in some pure drugs and herbal preparations, are reviewed.

Perspectives and attitudes of breastfeeding women using herbal galactagogues during breastfeeding: a qualitative study

Background

Some herbal galactagogues have gained reputation and recognition by the public and health professionals as alternative approaches to increase breast milk supply. This study explores the perspectives and attitudes of breastfeeding women towards the use of herbal galactagogues while breastfeeding, their experiences, and why and how they have chosen an alternative option over conventional treatments to enhance breastfeeding performance.

Methods

This exploratory research was conducted through in-depth semi-structured interviews with women living in Perth, Western Australia, who were using one or more herbal galactagogues during breastfeeding. Purposeful and subsequent snowball sampling methods were employed to recruit participants. All interviews, facilitated by an interview guide, were audio-recorded, then transcribed verbatim. Thematic analysis was used to analyse qualitative data to construct themes and subthemes.

Results

The perspectives and attitudes of the 20 participants are classified under three main headings: i) use of herbal medicines during breastfeeding, ii) available herbal medicines resources, and iii) level of breastfeeding support received. Throughout the interviews, participants described how their perseverance and determination to breastfeed, as well as concerns over breastfed infants’ safety with conventional treatments, influenced their choice of therapy. A sense of self-efficacy and autonomy over their own health needs was seen as influential to their confidence level, supported self-empowerment and provided reassurance throughout the breastfeeding journey. There was also a desire for more evidence-based information and expectations of health professionals to provide credible and reliable information regarding the use of herbal medicines during breastfeeding.

Conclusions

This study has enhanced our understanding of the perspectives and attitudes of breastfeeding women towards the use of herbal medicines, in particular galactagogues, while breastfeeding. The positive attitudes of breastfeeding women identified in this study highlight the need for further research into evaluating the safety and efficacy of commonly used herbal galactagogues, whilst the negative views on breastfeeding education should be taken into consideration when implementing or improving breastfeeding-related health policies.

Safety of the breast-feeding infant after maternal anesthesia

There has been an increase in breast-feeding supported by the recommendations of the American Academy of Pediatrics and the World Health Organization. An anesthesiologist may be presented with a well-motivated breast-feeding mother who wishes to breast-feed her infant in the perioperative period. Administration of anesthesia entails acute administration of drugs with potential for sedation and respiratory effects on the nursing infant. The short-term use of these drugs minimizes the possibility of these effects. The aim should be to minimize the use of narcotics and benzodiazepines, use shorter acting agents, use regional anesthesia where possible and avoid agents with active metabolites. Frequent clinical assessments of the nursing infant are important. Available literature does suggest that although the currently available anesthetic and analgesic drugs are transferred in the breast milk, the amounts transferred are almost always clinically insignificant and pose little or no risk to the nursing infant.

Systematic review of the efficacy of herbal galactogogues

Exclusive breastfeeding has been linked to many positive health outcomes, yet its widespread adoption as the primary mode of providing nutrition to infants remains challenging. The most common reported reason for early breastfeeding cessation is perception of inadequate milk production. To augment breast milk production, a substantial number of women turn to herbal galactogogues despite the limited scientific evidence of their efficacy and safety. We conducted a systematic review of published literature to evaluate the efficacy of herbal galactogogues. PubMed was searched from inception to October 2012 using an iterative search process that proceeded from broad categories to specific herbs. Manuscript references were also reviewed. Only experimental studies with objective outcome measures were included. Six trials met our search criteria. Using an adapted version of the CONSORT checklist, each trial was evaluated for potential sources of bias in design and reporting. Shatavari, torbangun, fenugreek, milk thistle, and a Japanese herbal medication were the 5 herbal preparations studied. Five trials found an increase in breast milk production. Several limitations exist that affect the validity of the trial results, including small sample size, insufficient randomization methods, poorly defined eligibility criteria, use of poly-herbal interventions, and variable breastfeeding practices among enrolled subjects. Given the insufficiency of evidence from these trials, no recommendation is made for the use of herbs as galactogogues. Well-designed and well-conducted clinical trials that address the above limitations are necessary to generate a body of evidence as a basis for recommendations regarding herbal galactogogues.

Systematic review of breastfeeding and herbs

OBJECTIVES

Despite popular and historical use, there has been little modern research conducted to determine the safety and efficacy of herb use during breastfeeding. The purpose of this study was to systematically review the clinical literature on herbal medicine and lactation.

METHODS

The databases PubMed, CAB Abstracts, Cochrane Central Register of Controlled Trials, HealthSTAR, Cumulative Index to Nursing and Allied Health Literature, and Reprotox were systematically searched for human trials from 1970 until 2010. Reference lists from relevant articles were hand-searched.

RESULTS

Thirty-two studies met the inclusion criteria. Clinical studies were divided into three categories: survey studies (n=11), safety studies (n=8), and efficacy studies (n=13). Six studies were randomized controlled trials. The most common herbs studied were St. John's wort (Hypericum perforatum L.) (n=3), garlic (Allium sativum L.) extract (n=2), and senna (Cassia senna L.) (n=2). Studies were very heterogeneous with regard to study design, herbal intervention, and outcome measures. Overall, poor methodological quality predominated among the studies.

CONCLUSIONS

Our review concludes that further research is needed to assess the prevalence, efficacy, and safety of commonly used herbs during breastfeeding.

Use of herbals as galactagogues

With a substantial number of women using herbal products to augment their milk production, this article will review available literature illustrating efficacy and adverse effects of using these products. Embase, PubMed, and EBSCO (all databases) were searched from inception to June 2011 using terms such as ‘‘galactagogue,’’ ‘‘galactogogue,’’ ‘‘herbal,’’ and ‘‘botanical’’ and the search was subsequently narrowed to specific herbals by name. Additional articles were obtained from article reference lists. Supplemental information was obtained with Natural Standard. All abstracts retrieved were evaluated for relevance and germane articles were included. Numerous lactation-stimulating herbals have been identified in the literature with varying degrees of evidence,mostly anecdotal. Use of torbangun, milk thistle, and fenugreek may correlate with increased milk supply. Evidence regarding adverse effects, pharmacodynamic properties, and pharmacokinetic effects remains scarce. Despite the fact that postpartum women may turn to herbal galactagogues, scant clinical evidence exists to justify their effectiveness. Further clinical trials are needed in order to substantiate these findings.

Effect of domperidone on insufficient lactation in puerperal women: a systematic review and meta-analysis of randomized controlled trials

Background. There is a controversy within the medical community regarding the role of domperidone as a galactagogue and the drug has been removed from the US market owing to safety concerns. Objective. To perform a systematic review and meta-analysis of the available data assessing the effect of domperidone on breast milk production in women experiencing insufficient lactation. Study Selection. Randomized controlled trials (RCTs) examining the effect of domperidone on breast milk production of puerperal women were eligible for inclusion. Data Analysis. Absolute and relative changes from baseline were calculated for individual studies and pooled using a random effects model. Results. Three RCTs including 78 participants met the inclusion criteria. All showed a statistically significant increase in breast milk production following treatment with domperidone. The analysis of pooled data demonstrated a statistically significant relative increase of 74.72% (95%  CI = 54.57; 94.86, P < 0.00001) in daily milk production with domperidone treatment compared to placebo. No maternal or neonatal adverse events were observed in any of the trials. Conclusions. Evidence from a few small RCTs of moderate to high quality suggests that domperidone produces a greater increase in breast milk supply than placebo.

Effects of domperidone on augmentation of lactation following cesarean delivery at full term

OBJECTIVE

To evaluate the effects of domperidone on breast milk production in women who underwent cesarean at full term.

METHODS

Women who underwent uncomplicated full-term cesarean were randomly assigned to receive domperidone or placebo for 4 consecutive days post partum. Breast milk was collected twice daily via electric breast pump. Baseline milk production was determined by measuring the volume of milk collected on the 1st postpartum day, before initiation of study medication (day 0). The daily volume of milk collected was compared between groups. Adverse treatment-related effects were recorded.

RESULTS

The study was completed by 22 women in the domperidone group and 23 in the placebo group. Compared with day 0, mean increases in milk volume per participant collected on days 1, 2, 3, and 4 were significantly higher in the domperidone (13.6 ± 23.2 mL, 68.5 ± 71.9 mL, 144.5 ± 122.3 mL, and 191.3 ± 136.1 mL) than in the placebo (2.5 ± 4.6 mL, 24.5 ± 26.5 mL, 72.1 ± 55.6 mL, and 91.4 ± 60.3 mL) group. Minor adverse effects were reported by 7 women in the domperidone group.

CONCLUSION

Postpartum treatment with domperidone can augment breast milk production after full-term cesarean, with minimal adverse effects.

Breastfeeding self-efficacy and the use of prescription medication: a pilot study

Objective. To examine the association of self-efficacy, perception of milk production, and lactating women's use of medication prescribed to increase breast milk in a cohort of 18–40-year-old mothers over six months. Methods. Mothers (n = 76) attending community clinics completed the Breastfeeding Self-Efficacy Scale and the Humenick/Hill Lactation Scale, a measure of perceived milk production, three times. Results. Domperidone, a dopamine antagonist, was used by 28% of participants. On average, those using domperidone had lower self-efficacy scores than those not using it (P < 0.05) and were more likely to have used formula (Pearson chi-square test statistic  = 6.87, df = 1, P < 0.05). Breastfeeding self efficacy and perception of milk production were positively correlated. Conclusion. Breastfeeding assessment conducted prior to prescription of galactogogues is recommended for mothers and healthy term babies. Following Baby-Friendly hospital protocols and increasing self-efficacy for lactating women may be most effective in sustaining breastfeeding. Risks and benefits of various galactogogues are discussed.

ABM Clinical Protocol #9: Use of galactogogues in initiating or augmenting the rate of maternal milk secretion (First Revision January 2011)

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Recombinant human prolactin for the treatment of lactation insufficiency

CONTEXT

Lactation insufficiency has many aetiologies including complete or relative prolactin deficiency. Exogenous prolactin may increase breast milk volume in this subset. We hypothesized that recombinant human prolactin (r-hPRL) would increase milk volume in mothers with prolactin deficiency and mothers of preterm infants with lactation insufficiency.

DESIGN

Study 1: R-hPRL was administered in an open-label trial to mothers with prolactin deficiency. Study 2: R-hPRL was administered in a randomized, double-blind, placebo-controlled trial to mothers with lactation insufficiency that developed while pumping breast milk for their preterm infants.

PATIENTS

Study 1: Mothers with prolactin deficiency (n = 5). Study 2: Mothers of premature infants exclusively pumping breast milk (n = 11).

DESIGN

Study 1: R-hPRL (60 μg/kg) was administered subcutaneously every 12 h for 28 days. Study 2: Mothers of preterm infants were randomized to receive r-hPRL (60 μg/kg), placebo or r-hPRL alternating with placebo every 12 h for 7 days.

MEASUREMENTS

Change in milk volume.

RESULTS

Study 1: Peak prolactin (27·9 ± 17·3 to 194·6 ± 19·5 μg/l; P < 0·003) and milk volume (3·4 ± 1·6 to 66·1 ± 8·3 ml/day; P < 0·001) increased with r-hPRL administration. Study 2: Peak prolactin increased in mothers treated with r-hPRL every 12 h (n = 3; 79·3 ± 55·4 to 271·3 ± 36·7 μg/l; P < 0·05) and daily (101·4 ± 61·5 vs 178·9 ± 45·9 μg/l; P < 0·04), but milk volume increased only in the group treated with r-hPRL every 12 h (53·5 ± 48·5 to 235·0 ± 135·7 ml/day; P < 0·02).

CONCLUSION

Twice daily r-hPRL increases milk volume in mothers with prolactin deficiency and in preterm mothers with lactation insufficiency.

Oxytocin: the great facilitator of life

Oxytocin (Oxt) is a nonapeptide hormone best known for its role in lactation and parturition. Since 1906 when its uterine-contracting properties were described until 50 years later when its sequence was elucidated, research has focused on its peripheral roles in reproduction. Only over the past several decades have researchers focused on what functions Oxt might have in the brain, the subject of this review. Immunohistochemical studies revealed that magnocellular neurons of the hypothalamic paraventricular and supraoptic nuclei are the neurons of origin for the Oxt released from the posterior pituitary. Smaller cells in various parts of the brain, as well as release from magnocellular dendrites, provide the Oxt responsible for modulating various behaviors at its only identified receptor. Although Oxt is implicated in a variety of "non-social" behaviors, such as learning, anxiety, feeding and pain perception, it is Oxt's roles in various social behaviors that have come to the fore recently. Oxt is important for social memory and attachment, sexual and maternal behavior, and aggression. Recent work implicates Oxt in human bonding and trust as well. Human disorders characterized by aberrant social interactions, such as autism and schizophrenia, may also involve Oxt expression. Many, if not most, of Oxt's functions, from social interactions (affiliation, aggression) and sexual behavior to eventual parturition, lactation and maternal behavior, may be viewed as specifically facilitating species propagation.